Another article targeting simultaneous surgery

[cpants]

Right....but this is the position you are supporting. Supporting the patients right to choose whether they want trainees involved is, de facto, putting the burden of medical training and learning onto the poor and vulnerable and underserved. Eliminating that right would ALLEVIATE the burden on the poor by spreading it out more uniformly.

I'm not suggesting this as a good reason that patients dont have the right to refuse trainees (because I've got lots of other good reasons, as stated) but by your own reasoning it should be a good reason for YOU to oppose patients rights to refuse trainees. The right to refuse trainees is a practice that, in reality if not in theory, harms the poor.

I'm not sure that you can claim it harms the poor. If anything, the research suggests that having trainees involved IMPROVES patient outcomes.

If we respect patients' autonomy it is absolutely their right to refuse trainee involvement. It's not their right to have surgery performed by me without trainee involvement, though. Typically, the patient will still want to proceed after a well-thought out response about how surgery is a team sport and the attending will be present or performing the critical portions. You have to know how to finesse it, which I agree is a paternalistic gray area. If not, there's the door--happy to refer you to the private hospital across town.

Trauma is a special case, obviously, but probably one where trainee involvement is rarely a sticking point or even discussed. This is much more of an issue at somewhere like Lennox Hill on the upper west side where rich guys are seeking out Dr. Samadi to perform the world's best prostatectomy.

Back to the original topic. With regard to running 2+ rooms.

This comes right from CMS.gov:

In order to bill for surgical, high-risk, or other complex procedures, the teaching physician must be present during all critical and key portions of the procedure and be immediately available to furnish services during the entire procedure.

If Samadi is performing robo prostates while the residents do his TURPs all day in another room, he meets neither of the standards of "present during critical and key portions" or "immediately available to furnish services". What happens if the patients in both rooms start bleeding at once?

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[vhawk]

Again you are making the mistake of conflating "respecting patients autonomy" with "patients autonomy is the only principle that matters and overrules every other ethical concern." This is not the case. Patients that refuse trainee involvement but still expect to receive medical care from doctors who were trained on human patients are stealing from those prior patients and harming future patients. Why does their autonomy trump those concerns? Because those past and future patients aren't very likely to sue you?

But to be fair I'm not arguing that it should be illegal or anything. Simply that it is immoral for patients to do so and not ethically justified. Prohibiting it is, in the real world, almost certainly not worth the hassle. But if it becomes more common we would have to consider it and it would be perfectly ethical to do so.

Also that physicians who accommodate these patient demands are basically scabs haha.

 

[cpants]

Again you are making the mistake of conflating "respecting patients autonomy" with "patients autonomy is the only principle that matters and overrules every other ethical concern." This is not the case. Patients that refuse trainee involvement but still expect to receive medical care from doctors who were trained on human patients are stealing from those prior patients and harming future patients. Why does their autonomy trump those concerns? Because those past and future patients aren't very likely to sue you?

But to be fair I'm not arguing that it should be illegal or anything. Simply that it is immoral for patients to do so and not ethically justified. Prohibiting it is, in the real world, almost certainly not worth the hassle. But if it becomes more common we would have to consider it and it would be perfectly ethical to do so.

Also that physicians who accommodate these patient demands are basically scabs haha.

Autonomy isn't the only ethical principle in medical ethics, but it is one of the most important ones. It does trump most other concerns in these situations.

So if I get my surgery at one of the thousands of hospitals without surgical residencies I am "stealing from those prior patients and harming future patients"? That's a stretch. Most surgery is not done in a training environment.

The surgeon-patient relationship, with some exceptions, is a two-way street requiring the consent of both parties. If the patient insists that they don't want my team participating, I can refer them elsewhere, terminating our relationship.

 

[vhawk]

Autonomy isn't the only ethical principle in medical ethics, but it is one of the most important ones. It does trump most other concerns in these situations.

So if I get my surgery at one of the thousands of hospitals without surgical residencies I am "stealing from those prior patients and harming future patients"? That's a stretch. Most surgery is not done in a training environment.

Stealing from past patients, absolutely, harming future ones, probably not. I mean it depends a little on WHY you are getting care there. If it is explicitly to avoid providing an educational benefit to trainees then sure.

The surgeon-patient relationship, with some exceptions, is a two-way street requiring the consent of both parties. If the patient insists that they don't want my team participating, I can refer them elsewhere, terminating our relationship.

What if you cant? This is again one of those cop out ethical solutions that only works because someone else is willing to do something for you to alleviate your burden. But what if there wasnt any other surgeon willing to operate without residents either, for example? I mean, most of those surgeons specifically took an oath preventing them from accomodating that patient, right? Lets say every surgeon in your area took their sworn oath seriously and wouldn't treat that patient without residents. Now what?

Doesnt it worry you a little bit that your ethical principles and solutions only work because the problem they are trying to solve...isnt that widespread of a problem?

And again your "they can find another doctor" solution disproportionately harms the disadvantaged and underserved.

 

[LongDucDong]

Again you are making the mistake of conflating "respecting patients autonomy" with "patients autonomy is the only principle that matters and overrules every other ethical concern." This is not the case. Patients that refuse trainee involvement but still expect to receive medical care from doctors who were trained on human patients are stealing from those prior patients and harming future patients. Why does their autonomy trump those concerns? Because those past and future patients aren't very likely to sue you?

But to be fair I'm not arguing that it should be illegal or anything. Simply that it is immoral for patients to do so and not ethically justified. Prohibiting it is, in the real world, almost certainly not worth the hassle. But if it becomes more common we would have to consider it and it would be perfectly ethical to do so.

Also that physicians who accommodate these patient demands are basically scabs haha.

I am still only a student, and certainly do not have the experience any of you have with regards to actual patient concerns. That being said, your assertion that a patient who refuses trainees would be unduly benefitting from the sacrifice and risk of prior patients who did allow trainees seems completely true. The simple fact that an attending surgeon can perform a particular procedure, i.e. an appendectomy, is directly attributable to him/her having once been a trainee themselves. Without trainee involvement, any particular procedure would cease to exist beyond one generation because there is no crop of upcoming physicians being trained. This patient who refuses trainee involvement (to avoid personal risk, I assume) is benefitting from prior patients' risk and depriving future generations of well trained physicians. It seems that part of the inherent "risk" of any procedure is that there may be trainees involved, because the involvement of trainees is necessary for the continued existence of any procedure. Indeed, trainees do not need to be involved in every procedure in order for it to continue and be passed on to future generations, but where do we draw the line? And who gets the "benefit" of no trainees while others have to assume risk in order to assure the continued existence of medical knowledge and ability? What if a patient is allocated to be the "risk-taker" and something goes wrong?

 

[vhawk]

I am still only a student, and certainly do not have the experience any of you have with regards to actual patient concerns. That being said, your assertion that a patient who refuses trainees would be unduly benefitting from the sacrifice and risk of prior patients who did allow trainees seems completely true. The simple fact that an attending surgeon can perform a particular procedure, i.e. an appendectomy, is directly attributable to him/her having once been a trainee themselves. Without trainee involvement, any particular procedure would cease to exist beyond one generation because there is no crop of upcoming physicians being trained. This patient who refuses trainee involvement (to avoid personal risk, I assume) is benefitting from prior patients' risk and depriving future generations of well trained physicians. It seems that part of the inherent "risk" of any procedure is that there may be trainees involved, because the involvement of trainees is necessary for the continued existence of any procedure. Indeed, trainees do not need to be involved in every procedure in order for it to continue and be passed on to future generations, but where do we draw the line? And who gets the "benefit" of no trainees while others have to assume risk in order to assure the continued existence of medical knowledge and ability? What if a patient is allocated to be the "risk-taker" and something goes wrong?

yes

 

[bannie22]

Ok so enlighten me. From my understanding surgeons only have to be "present during the critical portion" in order to bill for it.
So is it illegal if they are NOT present for the rest of the surgery?
If it is not illegal, then why is it a problem to have rooms running simultaneously?

 

[ProfMD]

Ok so enlighten me. From my understanding surgeons only have to be "present during the critical portion" in order to bill for it.
So is it illegal if they are NOT present for the rest of the surgery?
If it is not illegal, then why is it a problem to have rooms running simultaneously?

In order to bill, the attending needs to be "present for the critical portions." The rest of the time, the attending needs to be "immediately available" or arrange for another qualified attending to be immediately available.

The problem is not with the legality, but with ensuring quality care. Generally speaking, patients don't go to a board certified specialist just to have the resident / fellow do the case with little supervision. In addition, it opens up the attending to legal problems should something go wrong. Finally, trainees are there to learn from attendings, not blunder around and figure it out on their own.

 

[Arcan57]

Stealing from past patients, absolutely, harming future ones, probably not. I mean it depends a little on WHY you are getting care there. If it is explicitly to avoid providing an educational benefit to trainees then sure.

What if you cant? This is again one of those cop out ethical solutions that only works because someone else is willing to do something for you to alleviate your burden. But what if there wasnt any other surgeon willing to operate without residents either, for example? I mean, most of those surgeons specifically took an oath preventing them from accomodating that patient, right? Lets say every surgeon in your area took their sworn oath seriously and wouldn't treat that patient without residents. Now what?

Doesnt it worry you a little bit that your ethical principles and solutions only work because the problem they are trying to solve...isnt that widespread of a problem?

And again your "they can find another doctor" solution disproportionately harms the disadvantaged and underserved.

I understand the focus on trainees, but there are also surgeons that are performing simultaneous surgeries that aren't using trainees. I think if you can present the patient with data on patient outcomes using the team that's going to be working on the patient, that inspires some trust. If random surgical assistant is going to be doing 80% of the operation because trusted 2nd assist is out sick, that seems like something that a patient would have the legitimate right to know. The attending surgeon is responsible for the outcome which I think limits irresponsible behavior. There are however plenty of instances where you can be sufficiently incentivized to accept small risks repeatedly that are going to lead to worse outcomes eventually. Given human nature, I'd be suprised if there has never been a simultaneous surgery where the attending wasn't completely comfortable when they handed off to the trainee/assistant and walked out of the room but had talked themselves into thinking it was ok.

 

[vhawk]

I'm not sure that you can claim it harms the poor. If anything, the research suggests that having trainees involved IMPROVES patient outcomes.

OK so then it's DEFINITELY unethical to let people refuse trainee involvement right? You are going to intentionally and knowingly give a patient substandard care just because they ask for it?

You are fighting the wrong fight here.

If we respect patients' autonomy it is absolutely their right to refuse trainee involvement.

You omitted a word here. If we respect patients autonomy ABSOLUTELY, it is absolutely their right to refuse trainee involvement.

It's not their right to have surgery performed by me without trainee involvement, though.

And just a few short pixels later you realize why that "absolutely" was omitted. We disregard patient autonomy all the time. It is an important value. But it is not an absolute one.

Typically, the patient will still want to proceed after a well-thought out response about how surgery is a team sport and the attending will be present or performing the critical portions. You have to know how to finesse it, which I agree is a paternalistic gray area. If not, there's the door--happy to refer you to the private hospital across town.

Trauma is a special case, obviously, but probably one where trainee involvement is rarely a sticking point or even discussed. This is much more of an issue at somewhere like Lennox Hill on the upper west side where rich guys are seeking out Dr. Samadi to perform the world's best prostatectomy.

Back to the original topic. With regard to running 2+ rooms.

This comes right from CMS.gov:


If Samadi is performing robo prostates while the residents do his TURPs all day in another room, he meets neither of the standards of "present during critical and key portions" or "immediately available to furnish services". What happens if the patients in both rooms start bleeding at once?

What happens if a patient starts bleeding in a single room, the attending is there, but he has a stroke? You will always be able to craft a doomsday scenario like this. How often will that happen? It will be exceedingly rare, and what you will do is call for help and whoever is around will come and help, and the outcome will be bad. Outcomes are bad when bad things happen. Crafting policies based on worst case scenario is childish and something politicians do.

 

[vhawk]

I understand the focus on trainees, but there are also surgeons that are performing simultaneous surgeries that aren't using trainees. I think if you can present the patient with data on patient outcomes using the team that's going to be working on the patient, that inspires some trust. If random surgical assistant is going to be doing 80% of the operation because trusted 2nd assist is out sick, that seems like something that a patient would have the legitimate right to know. The attending surgeon is responsible for the outcome which I think limits irresponsible behavior. There are however plenty of instances where you can be sufficiently incentivized to accept small risks repeatedly that are going to lead to worse outcomes eventually. Given human nature, I'd be suprised if there has never been a simultaneous surgery where the attending wasn't completely comfortable when they handed off to the trainee/assistant and walked out of the room but had talked themselves into thinking it was ok.

Of course. Those are all good points. There are plenty of ugly motivations and morally and ethically unacceptable actions on the concurrent surgery side as well. I'm not even saying I think concurrent surgery is an acceptable practice. I'm simply pointing out that is opponents focus only on one side and don't consider the costs of prohibiting concurrent surgery....as is entirely typical. No one ever considers the downsides of their position.

 

[vhawk]

In order to bill, the attending needs to be "present for the critical portions." The rest of the time, the attending needs to be "immediately available" or arrange for another qualified attending to be immediately available.

The problem is not with the legality, but with ensuring quality care. Generally speaking, patients don't go to a board certified specialist just to have the resident / fellow do the case with little supervision. In addition, it opens up the attending to legal problems should something go wrong. Finally, trainees are there to learn from attendings, not blunder around and figure it out on their own.

So then it should be trivially easy to show that the quality of care suffers in situations like this right?

But I think we both know you won't be able to show that because to some extent you are in the same position as the work hour restriction people were. You think it's just self evidently obvious that this must be harming patients, but in reality it probably isn't except in an anecdotal way and it would be very hard to show, and whatever the equivalent of "handoffs" in this situation are, would obfuscate the results.

 

[ProfMD]

So then it should be trivially easy to show that the quality of care suffers in situations like this right?

But I think we both know you won't be able to show that because to some extent you are in the same position as the work hour restriction people were. You think it's just self evidently obvious that this must be harming patients, but in reality it probably isn't except in an anecdotal way and it would be very hard to show, and whatever the equivalent of "handoffs" in this situation are, would obfuscate the results.

I am not saying there is demonstrated harm with concurrent surgery in the majority of cases. In fact, concurrent surgery probably, in the majority of cases, does not harm the patient.

I am saying several things:
1) Patients expect the surgeon they meet in clinic to be the surgeon performing the operation, or at least the "critical portion." Whether you agree with it or not, this is what they want. I must say, I can't blame them.
2) As a trainee once myself, I appreciated learning from attendings, not poking around in someone's body myself trying to figure it out on the fly. My residents these days appreciate as well (or so they tell me).
3) If something goes wrong, and it can be demonstrated that a trainee was doing something without supervision, the responsible attending will have a tough time explaining him/herself in court. This is just a legal fact. May not happen often, but it does happen.
4) I don't run concurrent surgeries, mostly for reasons #1 and #2.

 

[vhawk]

I am not saying there is demonstrated harm with concurrent surgery in the majority of cases. In fact, concurrent surgery probably, in the majority of cases, does not harm the patient.

I am saying several things:
1) Patients expect the surgeon they meet in clinic to be the surgeon performing the operation, or at least the "critical portion." Whether you agree with it or not, this is what they want. I must say, I can't blame them.
2) As a trainee once myself, I appreciated learning from attendings, not poking around in someone's body myself trying to figure it out on the fly. My residents these days appreciate as well (or so they tell me).
3) If something goes wrong, and it can be demonstrated that a trainee was doing something without supervision, the responsible attending will have a tough time explaining him/herself in court. This is just a legal fact. May not happen often, but it does happen.
4) I don't run concurrent surgeries, mostly for reasons #1 and #2.

Right and when that something that goes wrong occurs early on in a new surgeons operative experience, there is no one to have to "have a tough time explaining" anything even though this outcome can be seen as being in part caused by increasingly strict supervision guidelines. The harms caused by concurrent surgery are more easily seen than the harms caused by restrictions on concurrent surgery but availability heuristic is a bias not a viable argument strategy.

When a less skilled surgeon performs an operation and has a complication this too can be seen as an indirect consequence of the prohibition on concurrent surgery but these errors won't get lain at the feet of concurrent surgerys critics.

Concurrent surgerys critics arguments are based on "common sense" but they are also based on an inherently biased way of viewing the situation due to the facts that the harms of concurrent surgery are more available to the imagination than its benefits, and similarly the harms of restrictions concurrent surgery are less available to the imagination than its benefits. This is very similar to the position of the work hour restriction people. In such settings I don't think it's too much to ask for a little data before making sweeping changes with unknown unintended consequences.

And what little data there is does not suggest concurrent surgery harms patients.

 

[ProfMD]

Right and when that something that goes wrong occurs early on in a new surgeons operative experience, there is no one to have to "have a tough time explaining" anything even though this outcome can be seen as being in part caused by increasingly strict supervision guidelines. The harms caused by concurrent surgery are more easily seen than the harms caused by restrictions on concurrent surgery but availability heuristic is a bias not a viable argument strategy.

When a less skilled surgeon performs an operation and has a complication this too can be seen as an indirect consequence of the prohibition on concurrent surgery but these errors won't get lain at the feet of concurrent surgerys critics.

Concurrent surgerys critics arguments are based on "common sense" but they are also based on an inherently biased way of viewing the situation due to the facts that the harms of concurrent surgery are more available to the imagination than its benefits, and similarly the harms of restrictions concurrent surgery are less available to the imagination than its benefits. This is very similar to the position of the work hour restriction people. In such settings I don't think it's too much to ask for a little data before making sweeping changes with unknown unintended consequences.

And what little data there is does not suggest concurrent surgery harms patients.

I'm not sure why you are arguing with me since we don't actually disagree.

I do think the opposition to concurrent surgery is overblown. Still doesn't change the fact that I don't do it for my own reasons. Nor does it make my points any less valid.

Also doesn't change the fact that medicolegally your last day as a resident and your first day as an attending you are treated differently. Overnight you just become "qualified" in the eyes of patients, hospitals, insurers, and lawyers. Right or wrong, this is the way it is.

 

[Arcan57]

Of course. Those are all good points. There are plenty of ugly motivations and morally and ethically unacceptable actions on the concurrent surgery side as well. I'm not even saying I think concurrent surgery is an acceptable practice. I'm simply pointing out that is opponents focus only on one side and don't consider the costs of prohibiting concurrent surgery....as is entirely typical. No one ever considers the downsides of their position.

I don't think no one considers the downside, I think that once you've weighed the issues in your mind and have decided that you don't toss out arguments that contradict your position into the discussion.

Our hospital system just passed guidelines on concurrent surgeries that are consistent with the ACS position. All the community surgeons had 0 problems, the academic Trauma chief was very concerned about the guideline's suggestion that the involvement of other surgeons be disclosed. Given that many of the benefits of concurrent surgery (allowing more patients access to skilled surgeons due to increased availability) are not effected by disclosure and that the consent form already lists trainees and assistants being involved, this seems an odd point to protest. That being said, the surgeon that was objecting had shown themselves to be dedicated advocate of improving patient care so maybe there's something in the guidelines that's particularly hard to implement in academic centers?

 

[ProfMD]

I don't think no one considers the downside, I think that once you've weighed the issues in your mind and have decided that you don't toss out arguments that contradict your position into the discussion.

Our hospital system just passed guidelines on concurrent surgeries that are consistent with the ACS position. All the community surgeons had 0 problems, the academic Trauma chief was very concerned about the guideline's suggestion that the involvement of other surgeons be disclosed. Given that many of the benefits of concurrent surgery (allowing more patients access to skilled surgeons due to increased availability) are not effected by disclosure and that the consent form already lists trainees and assistants being involved, this seems an odd point to protest. That being said, the surgeon that was objecting had shown themselves to be dedicated advocate of improving patient care so maybe there's something in the guidelines that's particularly hard to implement in academic centers?

We also recently instituted guidelines at my place. Basically followed the same ACS guidelines you are, amounting to disclosure to the patient. No one objected and there have not been any issues.

 

[vhawk]

I don't think no one considers the downside, I think that once you've weighed the issues in your mind and have decided that you don't toss out arguments that contradict your position into the discussion.

Our hospital system just passed guidelines on concurrent surgeries that are consistent with the ACS position. All the community surgeons had 0 problems, the academic Trauma chief was very concerned about the guideline's suggestion that the involvement of other surgeons be disclosed. Given that many of the benefits of concurrent surgery (allowing more patients access to skilled surgeons due to increased availability) are not effected by disclosure and that the consent form already lists trainees and assistants being involved, this seems an odd point to protest. That being said, the surgeon that was objecting had shown themselves to be dedicated advocate of improving patient care so maybe there's something in the guidelines that's particularly hard to implement in academic centers?

I agree that the issue of consent is a separate one and not related to the costs and benefits of concurrent surgery specifically. I think we as a medical establishment collectively lose our minds when the topic of consent comes up and we have incredibly naive views on it, but that isnt specific to concurrent surgery. It just got brought up as a jumping off point for me since its a topic I care about a lot.

As to your first point, I dont see how to distinguish, then, the difference between someone who doesnt consider the downside and someone who just never ever states or concedes any of the downside (but has carefully considered it in the privacy of their mind, dont you worry).

 

[vhawk]

I'm not sure why you are arguing with me since we don't actually disagree.

I do think the opposition to concurrent surgery is overblown. Still doesn't change the fact that I don't do it for my own reasons. Nor does it make my points any less valid.

Also doesn't change the fact that medicolegally your last day as a resident and your first day as an attending you are treated differently. Overnight you just become "qualified" in the eyes of patients, hospitals, insurers, and lawyers. Right or wrong, this is the way it is.

ok. Ipse dixit isnt that interesting on a discussion board though.

 

[ProfMD]

ok. Ipse dixit isnt that interesting on a discussion board though.

Do I need to offer proof that patients/hospitals/lawyers/insurers view attendings differently than trainees from a respect/credentialing/legal/billing standpoint? I think it is safe to assume that these differences between trainees and attendings are self-evident to anyone who works in medicine.

 

[TypeADissection]

This whole discussion of whether patients have the right to refuse care by residents is interesting. Fortunately, in my experience at least, it is rare. I have certainly had patients ask if I would be the one to do the surgery. In these cases I reassure them that I will be there for the critical portion (honestly determined based on the case). In most (if not all) of the situations where this has come up, the case was sufficiently complex where I was going to do it anyway. If I promise a patient that I will do the critical portion myself, I stick to that promise, of course. I do explain to the patient that most of what I do is made much easier with 2 people and the resident will be assisting me.

Regarding whether an attending needs to leave in order to maximize resident learning, I have mixed feelings. I can understand the arguments others have made, but this was not my experience as a resident. I did have some attendings who were very hands off and would come in late in the case. However, I had others who were truly excellent at just standing there and assisting, saying nothing, there to either answer questions, bail me out of small trouble, and keep me out of big trouble. The latter was a good balance of resident education and patient safety.

The reality is, however, that no experience as a trainee truly prepares you for being an attending. Even if the attending is not in the room, knowing he or she is out there, somewhere, gives you a degree of confidence as a resident that you do not have in your first year or so in practice.

As my attending will often say, "The best part of being out in practice is that there is no one looking over your back telling you what to do. The worst part of being out in practice is that...there is no one looking over your back telling you what to do." It's so true. I actually love and appreciate the fact that I get to practice surgery under someone else's name right now. And that's why those first 3-5 years when we're done is so important in our growth as a surgeon. Get reckless or arrogant and I'm gonna hurt some people and my career. As Kevin Hart said, "Stay in your lanes."

 

[droliver]

The surgeon in the story was acting unethically and clearly committing billing fraud. An attending physician supervising residents should be IN the operating room from skin to skin on elective cases.

 

[cpants]

OK so then it's DEFINITELY unethical to let people refuse trainee involvement right? You are going to intentionally and knowingly give a patient substandard care just because they ask for it?

You are fighting the wrong fight here.

You omitted a word here. If we respect patients autonomy ABSOLUTELY, it is absolutely their right to refuse trainee involvement.

Of course it is ok to intentionally give a patient substandard care just because they ask for it. You have a very paternalistic mindset. 50 years ago when you went to the doctor, they might not even discuss your diagnosis with you....take two of these and call me in the morning. These days we tell patients what they have and what their options are. The patient choosing a less effective treatment based on his personal preferences happens all the time.

And just a few short pixels later you realize why that "absolutely" was omitted. We disregard patient autonomy all the time. It is an important value. But it is not an absolute one.

We don't, or at least shouldn't, disregard patient autonomy all the time. Me refusing to operate on someone who refuses trainee-involvement does not violate the patient's autonomy. It is an expression of my own autonomy.

What happens if a patient starts bleeding in a single room, the attending is there, but he has a stroke? You will always be able to craft a doomsday scenario like this. How often will that happen? It will be exceedingly rare, and what you will do is call for help and whoever is around will come and help, and the outcome will be bad. Outcomes are bad when bad things happen. Crafting policies based on worst case scenario is childish and something politicians do.

Just to be clear here...you think it is fine for an attending surgeon to book two full rooms of surgery, not set foot in one of the rooms all day while his residents do the cases, and mislead the patients into thinking that the attending is doing their operation? That's what we are talking about here. I am a proponent of increasing resident autonomy as they progress through training, including the attending not being in the room at times. That's a totally different scenario than the one presented in this thread.

This has nothing to do with resident education and everything to do with money. I'm sure Samadi's residents hate this because you would need to use a senior level resident with endoscopic skills good enough to run the endoscopic room, effectively pulling an upper level resident out of level-appropriate learning cases. I'm trying to think what the gen surg equivalent would be --- something like your surg onc guy books 2 rooms: 8 lumpectomies in one room which the chief resident gets to do independently while the intern scrubs in and drives camera for 2 lap colectomies in his other room. Both residents get shafted out of a learning experience, while the surgeon doubles his pay.

 

[vhawk]

Of course it is ok to intentionally give a patient substandard care just because they ask for it. You have a very paternalistic mindset. 50 years ago when you went to the doctor, they might not even discuss your diagnosis with you....take two of these and call me in the morning. These days we tell patients what they have and what their options are. The patient choosing a less effective treatment based on his personal preferences happens all the time.



We don't, or at least shouldn't, disregard patient autonomy all the time. Me refusing to operate on someone who refuses trainee-involvement does not violate the patient's autonomy. It is an expression of my own autonomy.

It's obviously both. You've decided your autonomy trumps theirs. That's fine. I agree. It's just more evidence that patient autonomy is not a trump card. This is such a weird argument to make. Nearly every example of a physician disregarding and violating a patients autonomy could be seen as "an expression of his/her own autonomy."

Just to be clear here...you think it is fine for an attending surgeon to book two full rooms of surgery, not set foot in one of the rooms all day while his residents do the cases, and mislead the patients into thinking that the attending is doing their operation?

Up to the word mislead, I'd give a qualified yes. In reality the answer is "it depends." It depends on the cases and the residents.

That's what we are talking about here. I am a proponent of increasing resident autonomy as they progress through training, including the attending not being in the room at times. That's a totally different scenario than the one presented in this thread.

There wasn't a single scenario presented in this thread. There was an active discussion involving multiple scenarios.

This has nothing to do with resident education and everything to do with money. I'm sure Samadi's residents hate this because you would need to use a senior level resident with endoscopic skills good enough to run the endoscopic room, effectively pulling an upper level resident out of level-appropriate learning cases. I'm trying to think what the gen surg equivalent would be --- something like your surg onc guy books 2 rooms: 8 lumpectomies in one room which the chief resident gets to do independently while the intern scrubs in and drives camera for 2 lap colectomies in his other room. Both residents get shafted out of a learning experience, while the surgeon doubles his pay.

Ok.

 

[akwho]

I saw concurrent surgeries being used in a very time/resource efficient way at my medical school.

Two complex multi-level TLIF's with O-arm guidance scheduled to start within 30 minutes of each other. Team in room #1: Spine Fellow and MS4. Team in room #2: Chief resident (R7) and resident (R3). Attending to bounce between next door operating rooms. Simple posterior approach. Attending scrubs room #1 and hustles team through approach (30-min), O-arm guidance set up by fellow (45min), while attending bounces to room #2 to help finish approach. Chief resident sets up O-arm guidance in room #2 (1-hour) while team performs TLIF and hardware placement in room#1. Once the critical portions are finished attending bounces to room #2 to put in hardware with chief resident while team #1 closes.

Multiply this by two for morning and afternoon cases, and you have twice the number of cases the usual spine surgeon is able to do by efficient use of his resources. He was there for all critical portions (hardware placement) and available for all immediate complications (scrubbed next door, capable assistants in each room). The fellow, resident and medical student all got to participate in the case and assist with level appropriate portions of the procedure. The team was a well oiled machine while I was on. Patients received excellent care from an experienced high volume surgeon who was able to increase his training/experience in the most difficult portions of the case by using trainee assistance.

I would caution blanket rejection of simultaneous surgery, it certainly has it's place in training institutions.

 

[akwho]

Sounds great, except this is exactly what ran into problems in Boston and Seattle.

One glitch or complicated operation or poorly operating fellow/chief, and this whole "machine" falls apart.

End result is an anesthetized patient sitting around waiting for extended periods of time until the attending is available or, worse, a complication occurring in one room without the attending who's capable of fixing it available.

The motivation is money, not education. It's unprofessional and increasingly hard to defend.

How'd you know where I trained??

Glitches, complicated surgeries, and poorly operating surgeons are present in a non-simultaneous surgery as well. Until there is data showing that the rate of those increases due to simultaneous surgeries this discussion is theoretical. All I can tell you is what I saw: simultaneous surgery with excellent patient outcomes and a well run team. Perhaps some surgeons are capable of running two rooms as well as other surgeons are capable of running one.

I don't pretend to know what my attending's motivations were. It could be money. It could be a huge backlog of uninsured and Medicaid patients that wouldn't get their emergent, urgent or semi-urgent surgeries without our team running two rooms because no private spine surgeon would do those cases. It could be he wanted the spine fellow to get more cases and trusted him midway through his fellowship.

As long as:
1) The outcomes are equivalent and
2) Patients are informed of simultaneous surgery during informed consent

Then I think it's shortsighted to be against simultaneous surgeries, but I'm still a lowly resident and I still have much to learn about the world. Thank you all for this interesting discussion.

 

[Gastrapathy]

Is "the attending will be present for all critical parts of the procedure" buried in the fine print informed consent?

 

[altoid25]

pretty relevant to this topic.

 

[vhawk]

Ha the first author on that paper was a med school classmate of mine

 

[vhawk]

Sounds great, except this is exactly what ran into problems in Boston and Seattle.

One glitch or complicated operation or poorly operating fellow/chief, and this whole "machine" falls apart.

End result is an anesthetized patient sitting around waiting for extended periods of time until the attending is available or, worse, a complication occurring in one room without the attending who's capable of fixing it available.

The motivation is money, not education. It's unprofessional and increasingly hard to defend.

You are basically just stating that, for PR reasons, simultaneous surgery is held to an absurdly higher standard than non-simultaneous surgery, and its a standard that is unlikely to be perfectly met. I'm sure you are correct, but I guess I dont find that argument very interesting. Its the argument against going for it on 4th down more often in the NFL....its gotta be right every time or the fans/media will crucify you.

 

[Gastrapathy]

Let me guess. The paper concluded that there is absolutely nothing wrong with simultaneous surgery and claimed only altruistic reasons for the practice.

 

[mimelim]

It's 9pm. I'm opening a second room right now because frankly we have multiple sick patients that need operations and everyone, both staff and patients will be in their beds sooner by doing so. And yes, when waiting for a patient to be intubated at 9pm I'm on SDN. -.-

 

[thedrjojo]

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R2303CP.pdf

 

[Slack3r]

I don't pretend to know what my attending's motivations were. It could be money.

If I were a betting man...

 

[Trauma Surgeon]

For those interested in the subject

http://jamanetwork.com/journals/jam...MAPublishAheadofPrint&utm_campaign=28-06-2017

Cheers!

 

[vhawk]

Its a pretty good article summarizing the situation and outlining the problems. Unfortunately, it is light on solutions, and the solutions it does have are, well lets just say I'm underwhelmed. The main actionable solution that they suggest is to have a multidisciplinary body within each hospital decide which portions of each procedure qualify as the "critical portions." This is guaranteed to be a joke and has almost no chance of helping patients. I fully understand the limitations in allowing individual surgeons to decide which portions are critical. Its the worst solution you can imagine....aside from all other solutions that have been suggested.