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What’s New in the Patient Safety World

April 2022

Overlapping Surgery Back in Focus

 

 

The issue of overlapping surgery was back in the news recently with the announcement that Massachusetts General Hospital paid $14.6 million to settle a whistle-blower suit over such surgeries (Saltzman 2022). This settlement went to insurers for presumed improper billing. It actually was the third payment made by the MGH regarding the overlapping surgeries. In 2019 the MGH settled for $13 million with a physician who challenged double-booked surgeries (Saltzman 2019a). That surgeon had been fired by the MGH in 2015 for allegedly violating patient confidentiality, but he always believed he had been dismissed for raising safety concerns about colleagues who performed two operations at once. MGH also offered him his old job back to settle his wrongful termination lawsuit (which he declined) and agreed to honor him with a hospital safety initiative in his name. The third settlement was with former Boston Red Sox pitcher Bobby Jenks to settle a claim that he suffered a career-ending spine injury when a surgeon at the MGH operated on his back while overseeing another operation at the same time (Saltzman 2019b). According to Saltzman, the three out-of-court settlements total $32.7 million.

 

As part of the current settlement, the Mass General Brigham healthcare system agreed to change its consent forms to include the wording "My surgeon has informed me that my surgery is scheduled to overlap with another procedure she/he is scheduled to perform. I understand that this means my surgeon will be present in the operating room during the critical parts of my surgery but may not be present for my entire surgery." (Putka 2022).

 

The controversial practice first received national attention in 2015 when the Boston Globe Spotlight team published a series on it (Abelson 2015). We’ve taken a strong position against overlapping surgery, beginning with our November 10, 2015 Patient Safety Tip of the Week “Weighing in on Double-Booked Surgery”.

 

Over the years, there have been many articles and studies defending the practice (see our Patient Safety Tips of the Week for March 12, 2019 “Update on Overlapping Surgery” and December 3, 2019 “Overlapping Surgery Back in the News”). Most have looked at mortality rates and complication rates in large databases and concluded that there is no statistical difference between cases with or without an overlap. We have pointed out that complications due to overlapping surgery are still quite rare, so statistics from any large databases will “dilute out” those cases that did have complications. Those of us involved in patient safety have all seen instances in which overlapping surgery was a contributing factor to or root cause of an adverse event.

 

Our December 19, 2017 Patient Safety Tip of the Week “More on Overlapping Surgery” had our detailed comments on the following considerations for overlapping surgery:

 

We hope you’ll go back to that column (and all our columns listed below) to see our arguments against the practice of overlapping surgery. However, even though we personally would not consent to undergo overlapping surgery, we are pragmatic and understand the practice is not likely to go away any time soon. Therefore, we developed our “Overlapping Surgery Checklist” to help guide you in planning for safe implementation.

 

Part of our job in teaching hospitals is to train surgeons and other physicians to be able to practice independently. That obviously requires graded autonomy. Since the onset of the COVID-19 pandemic there has been a reduction in the number of elective surgeries performed at many hospitals, reducing the learning opportunities for surgical residents and fellow. So now, more than ever, we need to foster graded surgical autonomy. A recemt study from the VA health system (Oliver 2021) showed that surgical procedures performed by residents alone were not associated with any changes in all-cause mortality or composite morbidity compared with those performed by attending surgeons alone or by residents with the assistance of attending surgeons. The accompanying editorial (Stulberg 2021) notes that lack of attending surgeon scrubbed and resident autonomy are not equivalent. It notes that, outside of technical assistance, attending faculty may also coach residents regarding next steps or provide advice to avoid missteps.

 

But the issue comes down to transparency. If a patient is expecting that the attending surgeon will be performing the entire surgery or at least be present in the OR for the entire surgery, the informed consent must clearly specifiy anything to the contrary.The revised MGH informed consent wording should convey the appropriate message to the patient, assuming the patient has the opportunity to discuss the details and implications of the attending surgeon’s absence from any portion of the surgery or procedure.

 

 

See our previous columns on double-booked, concurrent, or overlapping surgery:

 


And our “Overlapping Surgery Checklist

 

 

References:

 

 

Saltzman J. Mass. General pays $14.6 million to settle whistle-blower suit over concurrent surgeries. Hospital’s third major payment related to surgeons doing two operations at once. Boston Globe 2022; February 18, 2022

https://www.bostonglobe.com/2022/02/18/business/mass-general-pays-146-million-settle-suit-it-defrauded-governments-by-leaving-surgeries-unsupervised-trainees/

 

 

Saltzman J. MGH settles for $13m with doctor who challenged double-booked surgeries. Boston Globe 2019; November 7, 2019

https://www.bostonglobe.com/business/2019/11/07/mgh-settles-with-dismissed-surgeon-over-criticism-operating-practices/x4R2S7JkvTjpTBvvVRzabO/story.html

 

 

Saltzman J. Former Red Sox pitcher settles claim with doctor, MGH for $5.1 million. Boston Globe 2019; May 8, 2019

https://www.bostonglobe.com/metro/2019/05/08/former-red-sox-pitcher-receive-millions-settle-allegations-botched-back-surgery-mass-general/sWrhc1D1RKnugmrJTNB50K/story.html

 

 

Putka S. Mass General 'Not an Outlier' in Double-Booked Surgeries — The teaching hospital resolves lawsuit, changes patient consent forms. MedPage Today 2022; February 24, 2022

https://www.medpagetoday.com/special-reports/exclusives/97350

 

 

Abelson J, Saltzman J, Kowalcyzk L, Allen S. Clash in the Name of Care. Boston Globe October 26, 2015

http://apps.bostonglobe.com/spotlight/clash-in-the-name-of-care/story/

 

 

Oliver JB, Kunac A, McFarlane JL, Anjaria DJ. Association Between Operative Autonomy of Surgical Residents and Patient Outcomes. JAMA Surg 2021; Published online December 22, 2021

https://jamanetwork.com/journals/jamasurgery/fullarticle/2787397

 

 

Stulberg JJ, Adams SD, Kao LS. Lack of Attending Surgeon Scrubbed and Resident Autonomy Are Not Equivalent. JAMA Surg 2021; Published online December 22, 2021

https://jamanetwork.com/journals/jamasurgery/article-abstract/2787401

 

 

 

 

 

 

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