Concurrent Surgery Gets the Spotlight Treatment

The editor of the Boston Globe’s investigative reporting unit discusses his team’s landmark story that raises questions about the practice of concurrent surgeries and patient safety.

The debate over the safety of concurrent surgeries was ongoing when The Boston Globe’s team of investigative reporters tapped into it, says the paper’s Spotlight Team editor Scott Allen.

The Globe’s October 2015 series looked at complex orthopedic surgeries at Massachusetts General Hospital and beyond, raising questions about safety, clinical oversight, and informed consent. MGH bristled at the suggestion that patients could be harmed as a result of the way overlapping surgery is practiced. “Nothing could be further from the truth,“ it declared on the website it set up in response to the Globe‘s reporting.

Still, the report has triggered government inquiries and a review of the practice by the American College of Surgeons.

Allen, head of the news team that is now the stuff of Hollywood legend, spoke with me recently about what hospitals and health systems can take away from “Clash in the Name of Care.”

HLM: How did this story come about?

Allen: Concurrent surgery is something that is well known within the hospital community and among surgeons. It’s something that doesn’t come as a great surprise, but many members of the general public had no idea prior to us publishing this story.

We covered a court case that had nothing to do concurrent surgery. But, in the course of the oral arguments, there was a sidebar discussion about the way the plaintiff handled a case where the surgeon had three different cases going at once. The reporter who covered the case was [health writer] Liz Kowalczyk and it stuck in her mind.

The case involved a trauma surgery where the resident was mixing the cement to begin a hip replacement, and when it was time for the surgeon to do the surgery, the surgeon wasn’t there. [The resident’s] got the cement and she’s wondering where [the surgeon] is and she doesn’t dare to do the procedure on her own. So the anesthesiologist goes looking for the surgeon... The anesthesiologist testified that never in her career had she had to leave the OR to find the surgeon who was supposed to be the attending.

We started doing some research on it and found extremely good sources because there was a very lively debate inside MGH and we tapped into that debate. That’s how we were able to do the story. This is complex material and it can be extremely difficult for lay reporters to go toe-to-toe with surgeons if you haven’t also got extremely good sources who can explain every bend in the road. And we did.

HLM: Is it possible to do concurrent surgery safely?

Allen: People certainly said that. I don’t hold myself out—nor does the team —as experts in how surgery should or shouldn’t be done… In the name of efficiency, it makes a lot of sense for the surgeon to get to the closing, turn it over to one of the residents or fellows and go to the next room where the opening has already occurred for the next surgery.

It is easy to understand how that sort of staggering [of workflow] make sense from an efficiency standpoint and doesn’t jeopardize the patient’s well-being in any way. You have people working at their appropriate level of responsibility from start to finish.

What we were talking about were complex spinal surgeries that could be overlapping by four, five, seven hours. And the surgeon needed to be simultaneously mindful of both cases and go back and forth between rooms to check in on his other patient.

There was the risk that if something came up, he could not be at the second place when he was needed. [This] was a scenario that most alarmed surgeons around the country when we shopped around for the state of opinion on double surgery… Those are the ones that really scared people and they were the ones that would have required the most delicate calibration and planning for them to work. That’s where a lot of the debate was focused, and that’s where the critics at MGH focused—poorly planned, substantial overlap, simultaneous responsibility for two cases.

HLM: On its web page addressing your series, MGH says the practice is “in compliance with federal and state guidelines” and was reviewed and deemed safe by ”several external organizations.”

Allen: That’s what they said, but there were several things that convinced us that it was not a satisfactory response. It had not quieted the internal critics at all… For a long time, the report was kept so closely, that even people involved in patient safety had not seen the report.

We asked, probably ten times, if we could see it or get a summary of it and it was all lawyer/client privilege. They would not release it at all. They eventually released to their top people. It was never given to JCHO (The Joint Commission). It was never given to us, and it wasn’t given to the internal parties to the debate over double booking. It was never in any way summarized or provided to anybody, which to us was a major hole in transparency and accountability.

HLM: Can you talk about the kind of policies other hospitals have regarding concurrent surgery?

Allen: In hospitals that have not had a big, internal dispute about this, there is a pretty good chance they don’t have a well-articulated policy on concurrent surgery. To the extent they have one, it is just the Medicare guidelines. That is their de facto policy.

Medicare has pretty much never enforced the double-booking policy, so whether you follow it or not, there has been very little enforcement. So, what you had was a situation that was ripe for abuse. I’m not accusing any individual—but the potential was there.

HLM: CMS requires that “the teaching surgeon must be present during the critical or key portions of both operations. Therefore, the critical or key portions may not take place at the same time.“

Allen: There is no set of standards on what constitutes the “critical part“ of any surgery. So the individual surgeon who is doing the double-booked procedures is telling you what is the critical part of each surgery. That’s pretty obviously an enormous loophole. It’s undefined and it is up to the person doing the double-booking to decide what’s important.

HLM: What has your team learned about patient consent for concurrent surgery?

Allen: [Concurrent surgery] is not common knowledge among the general public and it not common knowledge among patients. The informed consent form is an important document. But, the fact of the matter is, patients sign those documents without fully understanding them. They don’t read them closely; they trust their doctors.

The obligation is larger than what you put into the forms… The obligation is to affirmatively tell the patient: This is the way we practice here. If you are not comfortable with that, you shouldn’t do it.

If you are a surgeon and you are going to be out of the room while the case is still active, the patient ought to know that. The last thing the patient is thinking before going unconscious is: I’m entrusting my life to this surgeon. If he is not going to be there part of the time, I should at least know that and have assurance that in no way am I going to be harmed.