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July 18, 2017

The Evolving Story of Overlapping Surgery

Author Affiliations
  • 1Stanford Law School and Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California
  • 2Deputy Editor, JAMA
  • 3Department of Surgery at the UT Southwestern School of Medicine, Dallas, Texas
  • 4Northwestern University, Evanston, Illinois
JAMA. 2017;318(3):233-234. doi:10.1001/jama.2017.8061

In December 2015, a Boston Globe investigation of Massachusetts General Hospital (MGH) sparked investigations into concurrent and overlapping surgery. Overlapping surgery refers to operations performed by the same primary surgeon such that the start of one surgery overlaps with the end of another. A qualified practitioner finishes noncritical aspects of the first operation while the primary surgeon moves to the next operation. This is distinct from concurrent surgery, in which “critical parts” of operations for which the primary surgeon is responsible occur during the same time. There is general agreement that concurrent surgery is ethically unacceptable and is prohibited for teaching hospitals under the Medicare Conditions of Participation. Overlapping surgery is common, ranging from having trainees open and close incisions to delegating all aspects of the operation except the critical parts.

Recent Developments

In February 2017, the Seattle Times exposed the unusually high volume of neurosurgical operations and reportedly poor outcomes at Swedish Neuroscience Institute. The top 2 neurosurgeons each billed more than $75 million in 2015. Clinical staff who raised concerns about a range of troubling practices, including scheduling, were ignored. The news reports prompted federal and state investigations and the resignations of the hospital's neurosurgery chief and chief executive officer.

There have also been reports of retaliatory actions against clinicians who raised concerns about scheduling practices. Allegations lodged by reporting clinicians at Swedish Neuroscience Institute, MGH, and University Hospital in New York, if true, could implicate state and federal whistleblower statutes. In May 2017, the first lawsuit brought by a surgical whistleblower was resolved in favor of the clinicians who had raised concerns.

Reports about overlapping surgery inspired the Senate Committee on Finance, which oversees Medicare, to intervene because of the potential for unlawful Medicare billing. After analyzing policies submitted by 20 academic medical centers, the Senate committee’s 2016 report1 addressed patient safety and informed consent at length. It deemed many hospitals’ overlapping surgery policies and consent practices inadequate; endorsed the notion that surgical departments, not individual surgeons, define the critical parts of operations; recommended that patients be informed about what overlapping scheduling entails for their case and asked to affirmatively consent to it; and urged hospitals to document surgeons’ operating room (OR) entry and exit times and actively monitor compliance with policy. The committee also suggested that additional federal oversight was warranted, including extending Medicare’s rules to nonteaching hospitals and enhancing federal audit capabilities. Although the committee acknowledged that “the frequency and consequences of the practice of concurrent or overlapping surgeries remains unknown,” it nevertheless concluded that “the absence of data does not mean there is no risk” and “the need to ensure patient safety and informed consent” requires action now.1

Anticipating the need to head off regulatory action, the American College of Surgeons (ACS) stated that although concurrent surgery is “inappropriate,” overlapping surgery is permissible if the primary surgeon or another attending is “immediately available,” “qualified practitioners” perform the noncritical parts, the scheduling does not “negatively affect the seamless and timely flow of either procedure,” and the patient is informed.2 Disclosure should include what types of qualified practitioners will participate in the patient’s operation and what their roles will be.

The Evidence Base

Because of the controversy’s public nature, studies have been launched to evaluate the safety of overlapping surgery. Six peer-reviewed studies have been published, all retrospective, single-institution studies.38 The studies consistently identified differences between overlapping and nonoverlapping cases only in procedure time. Although overlapping cases took longer on average, they were rarely associated with less favorable rates of complications, readmissions, returns to the OR, mortality, or discharge to home or associated with length of stay. One study reported a lower rate of discharge to home.6 Another reported longer length of stay for some types of overlapping cases,8 but 2 found overlapping cases had better rates of 30-day unplanned return to the OR and better inpatient and 30-day mortality.5,8

These studies suggest that overlapping surgery is not associated with increased risk of patient harm, but these observational studies have important limitations. Some studies have better risk adjustment than others—an important issue because case-mix differences exist between comparison groups. Studies may be underpowered to detect rare outcomes. The generalizability of findings beyond the small number of institutions and surgeons studied is unknown. Three of the 6 studies come from the same hospital.46 All but 1 took place in academic medical center facilities where trainees were available, and the other3 took place in an ambulatory surgery center that handles low-risk cases. Only 2 studies included data from more than 5 surgeons.4,8

No study captured the primary surgeon’s actual time in the OR or time performing the procedure or examined which parts of the operation were defined as critical and whether the primary surgeon performed them. Furthermore, most studies used a definition of overlap, such as one second or one minute, that does not distinguish among cases with different amounts of overlap. Including cases with a trivial amount of overlap would bias results toward the null, and it is of interest to know whether more overlap matters.

A recent study, evaluating the perceptions of 1454 patients of overlapping surgeries,9 found that most respondents were unfamiliar with the practice: only 4% had seen a news story about it; 69% expressed opposition to the practice, although more than 50% said they would support it for low-risk operations, if an emergency occurred in another OR, or if the surgeon or resident is highly experienced with the procedure. Respondents had varying impressions of what constituted the “critical parts” of an operation. In addition, 44% indicated they would not have chosen that surgeon had they known that he or she was scheduling overlapping surgeries, and 78% would wait up to a month longer to have a nonoverlapping surgery.

Overall, the modest evidence base does not suggest that overlapping surgery is unsafe, but rather that the practice is not trusted, at least by individuals considering the practice in the abstract without the benefit of an established patient-surgeon relationship.

Addressing the Trust Gap

Patients and regulators may distrust overlapping surgery because of 3 factors: plausibility of risk, lack of transparency, and conflict of interest. First, even absent of evidence of harm, overlapping scheduling is a practice that could involve a higher risk of complications. Although patients may accept that trainees will participate in their operation, they may not envision that trainees will handle challenging portions without an attending surgeon in the OR. Second, disclosures about scheduling during informed consent processes tend to be vague, if they occur at all. This lack of transparency allows patients and regulators to assume the worst, whereas a full explanation of what overlapping scheduling means in practical terms and how the hospital ensures safety could assuage many patients’ concerns. For instance, explaining why overlapping scheduling is done, including the vital role it plays in training, may allay suspicions that it is motivated only by a desire to maximize revenue. The third problem is the conflict of interest that arises from allowing individual surgeons or surgery departments to determine when an overlap is acceptable. The ACS statement indicates that the primary attending surgeon should define what the critical parts of the operation are. Under pressure to generate revenue, the surgeon and department may consciously or unconsciously permit secondary interests to interfere with their judgments.

Restoring public trust in overlapping surgery requires several actions. First, stronger, prospective observational studies and randomized studies should be performed. Second, patients must be fully informed about scheduling practices well ahead of surgery. This disclosure should include the likelihood that the operation will involve an overlap, a description of who will perform which parts of the operation and what their qualifications are, and the patient’s options if he or she objects to the scheduling. Patients have the right to decide to have surgery at another hospital or at a later time. Third, hospitals must ensure that surgeons are fulfilling the responsibility they have to patients to personally perform the critical parts of an operation. Abdication of this responsibility constitutes noncompliance with federal billing regulations. More importantly, it exposes patients to unacceptable risk.

Neither the ACS nor the Senate committee effectively addressed the problem of who decides which parts of the operation are critical. The ACS called for business as usual, leaving the determination up to surgeons and offering a content-free definition to guide them: the critical parts are “those stages when essential technical expertise and surgical judgment are necessary to achieve an optimal patient outcome.” Giving surgeons authority to unilaterally declare what the critical parts of an operation are does not work, as evidenced by the repeated episodes of billing fraud, retaliation against whistleblowers, and loss of public trust. The Senate committee recognized the problem but recommended another flawed approach, having surgical departments decide. This choice does not recognize the inherent conflict of interest that departments have and ignores evidence that many departments have declined to address this issue and that some have gone so far as to harass clinicians who question scheduling practices.

As previously proposed, the definition of the critical portion should be established by a multidisciplinary committee within the hospital.10 Additionally, surgeons should clock in and out of the operating room so there is a record of when they were present, a system now required in Massachusetts. Hospitals’ policies should also adopt a strict definition of what it means to be “immediately available” to rejoin an operation if complications occur, and ensure that clinicians who report concerns about violations of the policy are protected. After staff are educated about the policy, adherence must be documented and actively monitored. These steps can do much to ensure that abuses of overlapping scheduling do not further undermine public trust in the practice of surgery.

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Article Information

Corresponding Author: Edward H. Livingston, MD, JAMA, 330 N Wabash Ave, Chicago, IL 60611 (edward.livingston@jamanetwork.org).

Published Online: June 28, 2017. doi:10.1001/jama.2017.8061

Conflict of Interest Disclosures: Both authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest, and none were reported.

US Senate, Committee on Finance. Concurrent and overlapping surgeries: additional measures warranted. https://www.finance.senate.gov/download/finance-concurrent-surgeries-report. Published December 6, 2016. Accessed June 1, 2017.
American College of Surgeons. Statements on principles. https://www.facs.org/about-acs/statements/stonprin#preamble. Revised April 12, 2016.Accessed June 1, 2017.
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Mello  MM, Livingston  EH.  Managing the risks of concurrent surgeries.  JAMA. 2016;315(15):1563-1564.PubMedArticle