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Editor's Note
February 26, 2019

Overlapping Surgery and Perioperative Outcomes

JAMA. 2019;321(8):772. doi:10.1001/jama.2019.1123

By the time surgeons complete residency or fellowship training, they must be able to independently perform surgery. This can only occur if surgeons have graded responsibility, meaning that surgical residents must be able to do various parts of an operation on their own until they have mastered the skills necessary to function completely independently. One way this is done is by allowing overlapping surgery—operations in which someone other than the attending surgeon performs part of the operation. In this issue of JAMA, Sun and colleagues report outcomes for overlapping surgery to show that this mechanism, which is essential for training surgical residents, is generally safe.1 Mortality and complications were approximately the same for operations that had substantial overlap (more than 1 hour of the procedure from the time of incision) as compared with no overlap. However, there was a signal that outcomes (mortality and complications) might be worse for high-risk patients, a scenario that makes intuitive sense. This work appealed to me because it answered an important, unresolved question: Is surgery safe as practiced in academic environments that balance the needs of safe patient care with those required to train the next generation of surgeons? The answer appears to be yes.

This study does not address risks associated with concurrent surgery in which the attending surgeon is not present during a part of the operation considered critical.2 Major complications attributable to concurrent surgery have been highlighted by the news media,3 yet whether this practice is safe or acceptable remains unresolved and is not addressed in the current study. How that should be addressed was outlined in JAMA previously2,3 and requires a precise definition of the critical part of the operation that requires the presence of the attending surgeon. That definition should be determined by an independent body of clinicians familiar with the operating room environment and monitoring to ensure that the attending surgeon is in the operating room during that time.3

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Article Information

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

Conflict of Interest Disclosures: None reported.

References
1.
Sun  E, Mello  MM, Rishel  CA,  et al.  Association of overlapping surgery with perioperative outcomes  [published February 26, 2019].  JAMA. doi:10.1001/jama.2019.0711Google Scholar
2.
Mello  MM, Livingston  EH.  Managing the risks of concurrent surgeries.  JAMA. 2016;315(15):1563-1564. doi:10.1001/jama.2016.2305PubMedGoogle ScholarCrossref
3.
Mello  MM, Livingston  EH.  The evolving story of overlapping surgery.  JAMA. 2017;318(3):233-234. doi:10.1001/jama.2017.8061PubMedGoogle ScholarCrossref
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