The practice of concurrent, or simultaneous, surgery has largely been hidden from public knowledge until recently, and current guidelines regulating the practice fall short in protecting and serving patients in crucial ways. Simultaneous surgery occurs when one surgeon, with the help of assistants, performs two surgeries on two different patients in different operating rooms at the same time. A series of articles published last year in The Boston Globe propelled the practice into public consciousness. In response to the ensuing outcry the American College of Surgeons revised their guidelines with respect to simultaneous surgeries.
The medical community hopes this will put the controversial matter to rest. The revised guidelines stress both informed patient consent and the necessity of ensuring that surgeons are present during “critical elements” of any surgery. Importantly, these guidelines leave the decision regarding what exactly constitutes “critical elements” completely in the hands of the operating surgeon. While I applaud the emphasis on informing patients, these guidelines are not nearly enough, and fall short in two crucial ways.
Truly Informed Consent
Informed consent has been the standard of care for American physicians for decades. Unfortunately, we continue to be surprisingly bad at it.
Recent research shows that only a small minority of patients—just 9 percent in one study—receive adequate information from their medical team to make truly informed decisions. I suspect that explaining to patients that their surgeon will be operating on other patients while the patient is undergoing his or her surgery will be even more difficult and less successful. Euphemisms, incomplete information, and oblique discussions will be the norm. This is an issue that deeply concerns patients: in one study, when patients were given a realistic scenario in which a resident would act as the operative surgeon without direct staff supervision, only 18 percent said they would give consent.
Additionally, the recommended timing of this discussion is completely absent from these guidelines. Telling patients on the day of their surgery—which is often when consent is obtained—that their surgeon will be absent from the operating room and busy working on different patients for parts of their procedure is terribly unfair. At that point, patients are emotionally prepared to proceed with surgery, work arrangements have been made, and family members are all assembled. This is not the time to present potentially disconcerting new information and ask patients to accept it.
When surgery is first discussed, surgeons should tell patients if they practice simultaneous surgery, and explain what this will mean in the operating room. Elective surgery schedules are typically developed weeks or months in advance of the surgery date, so forewarning patients promptly would give them adequate time to consider the idea and ask questions. It would also give them time to find another surgeon if they are uncomfortable with the practice of simultaneous surgery.
Defining Critical Elements
According to the American College of Surgeons guidelines, each surgeon should decide, acting in their sole discretion, which components of each surgery are “critical elements” worthy of their attendance in the operating room. Such a standard is subject to all sorts of confounding variables. A physician’s mood, the demands of the daily surgery schedule, or even the insurance status of a patient may affect how a surgeon views the critical parts of any one surgery. The fear this standard engenders is that what a surgeon considers to be “critical” in a procedure performed on his partner’s mother may be different from what is considered “critical” for the average patient operated on at the end of a long day.
Asking surgeons, by themselves, to define “critical” components of any patient’s surgery is completely upside down. Patients take all the risk and bear all the expense of a surgical procedure; therefore, they—through their payors or representatives—should define the standard for a surgeon’s participation in any patient’s surgery.
To use current parlance, the standard should be patient-centered, easily understood and discussed, and agreeable to the patients undergoing surgery. This type of standard would be identical to what we expect from other professionals. Lawyers, for instance, adhere to federal and state legal standards about how they practice and financial advisors adhere to fiduciary standards imposed upon them by regulators. These standards are easily understood, not just by professionals, but by everyone participating in the process — they are transparent and build trust between members of the public and the professionals who serve them. Because of such standards, Americans know exactly what they can expect in their dealings with these professionals.
Currently Medicare and other insurers fully reimburse for simultaneous surgery when the surgeon is present for only those parts of the procedure that that surgeon deems critically important. In order to reduce the influence of such subjective variables as time of day, the patient’s insurance status, or other demands upon members of the operative team, this decision should not be left to the surgeon. Instead, payers or other patient representatives should be the ones defining which elements of a surgery are critical, and patients should know exactly what to expect while unconscious in the operating room.
For example, CMS might expect a surgeon to be in the operating room from the time she moves beyond the subcutaneous tissues until only these tissues are left to close. Everyone in the operating room would understand such a standard and know what to expect, including the surgeon, assistants, the anesthesiologist, operating room nurses, and, most importantly, the patient who places his life in the care of others.
Justice Benjamin Cardozo said it well in 1914 in the case that made informed consent the law of the land: “Every human being of adult years and sound mind has a right to determine what shall be done with his own body,” and this extends to the right to make judgments over who shall perform surgery and under what conditions. A patient-centered, transparent standard for simultaneous surgery is surely the way forward. It will increase patient trust in their operating team and keep the team on the same page; it will simplify informed consent discussions for patients; and it will ensure that all patients know exactly what to expect when they are unconscious and vulnerable. Payers and regulators, working with the medical community, should adopt such standards expeditiously.
