PART 2. “Massachusetts Surgeons will have to document each time they enter and leave the operating room, and who took over in their absence… amid controversies over doctors who perform more than one surgery at a time…

Over twenty years ago a general surgeon at one of our community hospitals left the OR to operate at a competing hospital and told a nurse to close the incision. He claimed OR nurses could train and be certified as “closers”. Problem was the nurse hadn’t been certified and we did not have hospital privileges for this competency. The nurse was fired and the surgeon fought disciplinary action although up to the Board of Trustees. Recollection is that he had been suspended from the medical staff, by me for over six months and that became his penalty as well as a long period of probation.

There are many areas in the hospital where it may be hard for a patient to discern who is actually providing care: an attending or a resident? An anesthesiologist or a nurse anesthetist? an orthopedic (foot) surgeon or a podiatrist for ankle surgery?; a primary care physician or a nurse practitioner?

PART 1 before new Part 2.

ASSIGNMENT: You are the CMO of your local teaching and the CEO wants to know if you should prohibit double-booking? And you are instructed to make sure patients know who is treating them, so what do you do?

PART 1. December 5, 2017. Should surgeons be allowed to operate in more than one OR at a time?

“Dr. Kirkham Wood arrived in the operating room at Massachusetts General Hospital before 7 one August morning with a schedule for the day that would give many surgeons pause.

Wood, chief of MGH’s orthopedic spine service at the time and a nationally renowned practitioner in his specialty, is a confident, veteran surgeon. He would need all of his talent and confidence this day, and then some, as he planned to tackle two complicated spinal surgeries over the next many hours — two patients, two operating rooms, moving back and forth from one to the other, focusing on the challenging tasks that demanded his special skills, leaving the other work to a general surgeon, who assisted briefly, and two surgeons in training.

In medicine it is called concurrent surgery, and the practice is hardly unique to Wood or MGH. It is allowed in some form at many prestigious hospitals, limited or banned at many others. Hospitals that permit double-booking consider it an efficient way to deploy the talents of their most in-demand specialists while reducing wasted operating room time.” (A)

‘Known as “running two rooms” – or double-booked, simultaneous or concurrent surgery – the practice occurs in teaching hospitals where senior attending surgeons delegate trainees – usually residents or fellows – to perform parts of one surgery while the attending surgeon works on a second patient in another operating room. Sometimes senior surgeons aren’t even in the OR, but are seeing patients elsewhere.

The decision about whether to allow the practice is left to hospitals, which are primarily responsible for policing it. Medicare billing rules permit it as long as the attending surgeon is present during the critical portion of each operation – and that portion is defined by the surgeon. And while it occurs in many specialties, double-booking is believed to be most common in orthopedics, cardiac surgery and neurosurgery.”  (B)

American College of Surgeons – Overlapping Operations- Statements on Principles (C)

“Overlap of two distinct operations by the primary attending surgeon occurs in two general circumstances.

The first and most common scenario is when the key or critical elements of the first operation have been completed, and there is no reasonable expectation that the primary attending surgeon will need to return to that operation. In this circumstance, a second operation is started in another operating room while a qualified practitioner performs noncritical components of the first operation—for example, wound closure—allowing the primary surgeon to initiate the second operation. In this situation, a qualified practitioner must be physically present in the operating room of the first operation.

The second and less common scenario is when the key or critical elements of the first operation have been completed and the primary attending surgeon is performing key or critical portions of a second operation in another room. In this scenario, the primary attending surgeon must assign immediate availability in the first operating room to another attending surgeon.

The patient needs to be informed in either of these circumstances. The performance of overlapping procedures should not negatively affect the seamless and timely flow of either procedure.””

“The Centers for Medicare and Medicaid Services does allow surgeons to bill for concurrent surgeries under certain circumstances but requires that the attending physician is “present during all critical and key portions of both operations.”

Surgeon Matthew Indeck, president of the American College of Surgeons’ central Pennsylvania chapter, said he “certainly would not support

[concurrent]

cases being done in distant hospitals” or keeping a patient under anesthesia longer than necessary.

But he acknowledged that a line delineating what’s appropriate and what isn’t “is very fuzzy.”” (D)

“……transparency and patient consent. Wrong is the only way to describe the fact that secretaries, nurses, anesthesiologists, residents, and fellows knew but the patient did not. If you defend double-booking, tell the patient. Sometimes I wonder why doctors don’t see themselves as patients. To us, the experienced professional, medical, and surgical practice is rote. It’s hardly so to the person being wheeled onto a narrow table on which they will be cut open. Would any surgeon-patient consent to this practice?” (E)

“Swedish Health has decided to largely prohibit its doctors from conducting overlapping surgeries, responding to the concerns of patients who were troubled by the practice…

Under the new policy, implemented Monday, surgeons must be present for the “substantial majority” of each surgical procedure. They are not required to be present for the very end of the case — closing the surgical incision once the planned procedure is completed — as that can be delegated to a qualified fellow assisting on the case.

Some smaller aspects at the beginning of a surgery, such as the harvesting of healthy blood vessels that would later be used in a coronary-artery bypass surgery, can also be delegated while the attending surgeon is out of the room, according to the policy. There is also flexibility for unexpected emergencies.

Staff will document the times surgeons enter and exit the operating room — something that didn’t previously appear in the records of many surgical patients.” (F)

“Patients whose hip surgeries were performed by surgeons overseeing two operations at once were nearly twice as likely to suffer serious complications as those whose doctors focused on one patient at a time, according to a large Canadian study, the first research to show that overlapping surgery can pose health risks.

The study of more than 90,000 hip operations at some 75 hospitals in Ontario also found that the longer the duration of overlap between surgeries, the more likely patients were to suffer a serious complication within a year, including infections and a need for follow-up surgery.

“If your surgeon is in multiple places, there’s an increased risk of having a complication,” Dr. Bheeshma Ravi, a hip surgeon at Sunnybrook Health Sciences Centre in Toronto and lead author of the study to be published Monday in JAMA Internal Medicine, told the Globe. “I think that just makes sense.”” (G)

PART 2. July 29, 2019

“Surgeons will have to document each time they enter and leave the operating room, and who took over in their absence, under a rule approved Wednesday by the (Massachusettes) state medical board amid controversies over doctors who perform more than one surgery at a time…

Massachusetts is the first state to approve such requirements, according to board members. A spokesman for the Federation of State Medical Boards, which represents the nation’s 70 state medical and osteopathic regulatory boards, said it was unaware of any other states with similar regulations… (A)

“Beginning next month, all surgeons in Massachusetts will be required to document every time they enter or leave the operating room, and for how long, for any reason. That’s according to a new rule passed Wednesday by the Massachusetts Board of Registration in Medicine. Along with documenting their entry or exit, surgeons will also be required to identify the names of any participating “physician extenders” including residents, fellows, and physicians assistants…

Candace Lapidus Sloane, chairwoman of the medical board, told The Globe, “As a doctor and as a patient, I know that when you undergo a serious surgery, or your loved one undergoes a serious surgery, you find the best doctor you can. You’re going there for that surgeon’s skill. And if it’s not going to be that surgeon [who actually does the operation], the patient has a right to know.” Basically, it comes down to getting what you’re paying for, right?

The only opposition to the rule, as stated by The Globe, was from the Massachusetts Medical Society which deemed it too hard to identify all “physician extenders” because, especially at teaching hospitals, things can switch in an instant. But at that point, the patient should be informed and it should be their prerogative to move forward with the procedure or not.” (B)

“The issue was catapulted into public consciousness in October 2015 by an exhaustive investigation of concurrent surgery at Harvard’s famed Massachusetts General Hospital by The Boston Globe. The validity of the story has been vehemently disputed by hospital officials who defend their care as safe and appropriate…

Patients who signed standard consent forms said they were not told their surgeries were double-booked; some said they would never have agreed had they known…

Critics of the practice, who include some surgeons and patient-safety advocates, say that double-booking adds unnecessary risk, erodes trust and primarily enriches specialists. Surgery, they say, is not piecework and cannot be scheduled like trains: Unexpected complications are not uncommon.

All patients “deserve the sole and undivided attention of the surgeon, and that trumps all other considerations,” said Michael Mulholland, chair of surgery at the University of Michigan Health System, which halted ­double-booking a decade ago. Surgeons might leave the room when a patient’s incision is being closed, Mulholland said. A computerized system records the doctor’s entry and exit…

Some surgeons say they are troubled by the resemblance of double-booking to a practice known as “ghost surgery,” in which patients learn, usually after something goes wrong, that someone other than the surgeon they hired performed their operation…

Rickert and others advise patients who want to avoid overlap to ask detailed questions well in advance and to put their request in writing and on the consent form.

“If you say, ‘I want only you to do the surgery,’ doctors will typically do it,’” Rickert said. “They want the business.”

He also recommends asking, “Are you going to be in the room the entire time during my surgery?” and then repeating that statement in front of the OR nurses the day of surgery. “If the doctor’s not willing to say yes, vote with your feet.”

If a surgeon says he or she will be “present” or “immediately available,” a patient should ask what that means. It may mean that the surgeon is somewhere on a sprawling hospital campus but not in — or even near — your operating room. (C)

“I certainly knew that for many procedures, residents might be involved,” said Arthur Caplan, a professor of bioethics at NYU School of Medicine. (NYU Langone Medical Center does not permit concurrent surgery.) “But I was a little taken aback that the attending surgeon was not in the room.” (D)

“A recent trial resulting in a $2 million malpractice verdict pulled back the curtain on a Syracuse orthopedic surgeon’s routine of doing 14 operations in a single day.

A state Supreme Court jury in Syracuse unanimously found Dr. Brett Greenky and his practice, Syracuse Orthopedic Specialists, negligent July 2 for his handling of a hip replacement surgery performed six years ago. The lawsuit says the operation permanently injured Dorothy G. Murphy, 63, who is still limping, using a cane and in pain. She is a former Camillus resident who now lives in Florida.

The trial shined a light on a controversial hospital practice in which a doctor leaves the operating room after completing the most critical part of an operation to start surgery on another patient in a second room.

Murphy was the sixth of Greenky’s 14 patients on Sept. 9, 2013 at St. Joseph’s Hospital Health Center…

During the trial Robert Lahm, Murphy’s attorney, likened Greenky’s surgical approach to an “assembly line.” A copy of Greenky’s schedule for that day shows most of the operations were total knee and hip replacements.

Patients were staggered across two operating rooms. Greenky would cut open a patient, put in an implant, close up part of the incision, then leave before the operation was over to start surgery on another anesthetized patient in a second room. Meanwhile, a resident physician in training or physician assistant closed the previous patient’s wound and applied a dressing.

Sometimes Greenky does overlapping surgery in three operating rooms. In a deposition, he said he performs about 600 knee and hip replacements annually and each operation takes, on average, 45 minutes…

Murphy said she cannot understand why surgeons performing complex operations are allowed to work more than 14 hours a day when bus drivers are prohibited by federal regulations from driving more than 10 hours.” (E)

“A judge has ordered Massachusetts General Hospital to release a secret 2011 report written by a lawyer whom the hospital hired to investigate its practice of letting some surgeons oversee more than one operation at a time.

Suffolk Superior Court Judge Rosemary Connolly said that — pending a possible appeal — the hospital must share an unredacted copy of the report with an orthopedic surgeon fired by Mass. General in 2015 after he complained about concurrent surgeries…

Burke, who now practices at Beth Israel Deaconess Hospital in Milton, worked for Mass. General for 35 years until he was dismissed in August 2015. The hospital said he was fired for improperly releasing patient records, with names redacted, to the Globe. Burke contends he was sacked because he blew the whistle on what he considered a serious patient-safety issue.

In 2011, the hospital hired a former US attorney, Donald Stern, to investigate Burke’s complaints to Mass. General officials about concurrent surgeries, also known as double-booking. The hospital never made the report public, but Dr. Peter Slavin, the hospital’s president, told the Globe in 2015 that Stern “found no basis to support Dr. Burke’s concerns.”

Burke’s attorneys have repeatedly requested the report. But Mass. General’s lawyers have insisted it contains legal advice from Stern to the hospital and is protected by attorney-client privilege.

The judge rejected that argument. She said Mass. General hired Stern to conduct an internal review, not to provide legal advice. She also noted that the hospital shared the report with a public relations firm, Rasky Baerlein Strategic Communications, which it hired to respond to the Globe’s inquiries.

And, the judge wrote, the hospital allowed the report to be stored on a computer server at Simmons College, which employed a dean who headed Mass. General’s Board of Trustees.

“MGH has used the report as both sword and shield,” Connolly wrote.

“The mounting evidence all leads to the conclusion that even if sections of the Stern report were once privileged, they no longer are,” she continued.

In addition to ordering the hospital to turn over the report, the judge directed it to provide all drafts of the document and backup materials.

Ellen J. Zucker, Burke’s lead counsel, was pleased. “In the end, based on MGH’s own words and conduct, this is not a close call,” Zucker said.

A hospital spokeswoman declined to comment.” (F)

Prequels

Every clinician with a doctoral degree has earned the respect to be called doctor.

Do you want to be treated by a stranger when you are admitted to the hospital? Every practicing physician should have hospital privileges.

Have you met your interventional pathologist or interventional neurologist or interventional oncologist?

It’s like the Wild, Wild West, the (physician specialty) turf wars….

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