The Ethics of Overlapping Surgery: Do Patients Have the Right to Know?

Nearly 3 years after the Boston Globe Spotlight Team shed light on the controversial practice of overlapping surgery,¹ many questions still remain surrounding the ethics of the method, including: Do patients have the right to know?

The Globe report, which ultimately led to the firing of Dennis W Burke, MD, a well-respected orthopedic surgeon who worked at Massachusetts General Hospital for 35 years, sparked conversation among physicians and the public alike.

“[Overlapping surgery] is a very sensitive topic,” Brent A Ponce, MD, an orthopedic surgeon affiliated with the University of Alabama at Birmingham Hospital, told Medical Bag. “Sensitive for the fact that, without question, we took the position upon graduating to do no harm and part of that oath is making sure the patient is first and foremost. But we also don’t work in a vacuum.”  

When considering whether overlapping surgery should be allowed, many variables are at play, he said: economic issues and financial pressures, especially at academic hospitals, are among the many factors.

However, Dr Ponce noted, there is the potential for many legal implications to pop up as well — the most important to consider is informed consent. According to the American College of Surgeons (ACS) “Statements on Principles,” if a surgeon will be performing overlapping surgery, the patient must be informed. These guidelines were changed in April 2016, following the Globe report.

“The simple act of a surgeon not completing a surgery, or moving off to another table where their expertise and level of experience is required, doesn’t necessarily represent an ethical improbity or legal problem,” James Giordano, PhD, MPhil, Chief of the Neuroethics Studies Program and professor in the departments of neurology and biochemistry at Georgetown University Medical Center, told Medical Bag, “but rather one of procedure, and whether or not the patient was informed of this procedure, and whether or not they understand that in a teaching hospital this is very often what happens.”

Even after the patient is informed, there is no guarantee that they understand that their surgeon will not be present during the entirety of their procedure.

Often, the informed consent conversations between a surgeon and patient aren’t thorough, James B Rickert, MD, an orthopedic surgeon and president of the Society for Patient Centered Orthopedics in Bedford, Indiana, who is opposed to simultaneous surgery, told Medical Bag.

“The consent discussions are usually lacking in detail and clarity, so patients don’t fully know the details,” Dr Rickert said. “When a patient places their life in the hands of a surgeon, that surgeon has a duty to be personally involved throughout the procedure.”

There are also the legal considerations that must be accounted for, particularly if a patient is injured or faces a complication while the surgeon is operating on another patient. However, in a retrospective cohort study led by Dr Ponce, published in the Annals of Surgery,³ he and his colleagues found that patients who were exposed to overlapping surgery did not have an increased risk for negative outcomes, including mortality, complications, and readmissions, in most cases.

The study included 15,106 cases across 13 different specialties at an unidentified tertiary academic center in the southeast. Their patient pool was unique because most other published papers on the topic focus on a single specialty. Several limitations existed, including that the authors chose to use a definition of overlapping surgery that is not the current definition used by the ACS, but is rather a definition used in prior literature.

Dr Ponce and his colleagues concluded that “the calls for reform on overlapping surgery policy due to patient safety concerns are possibly overreactive,” citing the Spotlight team’s report.

Following the report, the main changes to the ACS guidelines on overlapping surgery were outlining 2 scenarios in which overlapping surgery may happen. For both cases, the ACS states that the procedures should not “negatively impact the seamless and timely flow of either procedure.”

Instead of focusing on changing policy, Dr Ponce suggests it is important for physicians “to police their own.”

“Otherwise external forces will tell us how to practice medicine and that’s needed, but at the same time it needs to be done in the balance of taking care of the patient and not simply taking care of a statistic and checking off a box,” he said.

References

1. Abelson J, Saltzman J, Kowalczyk L, Allen S. Clash in the name of care. Boston Globe. http://apps.bostonglobe.com/spotlight/clash-in-the-name-of-care/story/. Accessed March 28, 2019.
2. American College of Surgeons. Statements on Principles. https://www.facs.org/about-acs/statements/stonprin. Updated April 12, 2016. Accessed March 28, 2019.
3. Ponce BA, Wills BW, Hudson PW, e Outcomes with overlapping surgeries at a large academic medical center. Ann Surg. 2019;269(3):45-470.

This article originally appeared on Medical Bag