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Concurrent Surgery and Informed Consent

Concurrent Surgery and Informed Consent Few patients know what it is like to perform surgery, train residents, or be in an operating room (OR). This is understandable; during most operative cases, patients are sedated or anesthetized, and the modern OR is sealed to casual observers for multiple reasons including infection control and privacy. Television often portrays the OR dramatically and rarely depicts the careful but routine manner in which surgical teams conduct patient care. This translates to information asymmetry, where we as surgeons know much and our patients know little about what will happen during their operation. Most surgeons are aware of and personally participate in concurrent surgical procedures at some point during their training or professional careers, and the “team” approach to surgical care has a long tradition in anesthesiology and on the wards. Although this is a controversial topic, those in favor of running concurrent ORs argue that it is safe and efficacious when properly planned.1 Until the Spotlight report in The Boston Globe2 drew attention to this practice, we may not have realized how surprising and upsetting this practice is to patients. The reason patients find this uncomfortable is founded in the question, “If my surgeon is out of the room, who’s operating on me?” This concern echoes a debate in the 1970s and 1980s surrounding “ghost surgery,” the highly unethical practice of intentionally and secretly substituting one surgeon for another. At the time, a number of surgeons (eg, Foster3) provided sound arguments for a distinction between resident training and “ghost surgery”: during training, the attending surgeon still holds responsibility and oversight for the procedure, even if his or her hands are not cutting and suturing. Yet, the public may not be convinced, and our patients likely expect that we perform the entire operation—unless they are informed otherwise. This information provided to patients is often not adequate to support informed decision making. Standard consent form language and “University Hospital” signs provide only a vague acknowledgment that trainees are present. Furthermore, some surgeons avoid explicit descriptions of trainee involvement out of concern for undermining patient confidence in their operation, and others go even further by intentionally misleading patients regarding trainee participation.4 This subterfuge inappropriately favors paternalism over patient autonomy and is unnecessary in modern surgery. Resident involvement elevates care by bringing additional knowledge and viewpoints, providing direct assistance during cases (including relieving the attending to take breaks), and questioning clinical decisions when appropriate.5 Such essential training provides society with future surgeons.1,3 Rather than avoid this, we should continue to educate the public about the benefits of our practices and be forthright with our patients. This honesty starts with the informed consent process. The “reasonable person” standard used by many jurisdictions guides us to disclose information that is material to a patient’s decision to undergo surgery. This applies not just to the procedure itself, but how it will be performed by a particular surgeon at a particular institution. We can interpret the widespread outcry following the Boston Globe Spotlight report2 as evidence that at least some of the public feels that surgeon presence during the entire procedure is material to their decisions about entrusting their care to particular surgeons. This holds true even if we do not have evidence or belief that our absence during select portions of a procedure alters outcomes.1 Thus, we have a duty to inform patients about how we will manage their operations and to amend “widespread misconceptions”3 about care at academic hospitals. Others have suggested a requirement to inform patients if trainees will be assisting or handling portions of a case.4,6 Our duty to inform also includes informing patients if we will leave the room while the case is under way. If cases will overlap (Figure, B-C), we need to explicitly explain the logistical and clinical implications of this practice, particularly the possibility that an unexpected event in a second OR may delay our arrival or return to the first OR (meaning additional unnecessary anesthetic time or, rarely, the possible need for substitution of another qualified surgeon to complete the case). The degree of acceptability of simultaneous cases (Figure, D) is narrow, and it would be inappropriate and unethical to ask a patient to consent to a procedure where the surgeon knew a priori that he or she would be unable to meaningfully participate (Figure, E). The only 2-room scenario that guarantees that the surgeon can be present during the entire operation is staggered ORs, which may be institutionally unfavorable owing to inefficient use of OR and other staff time (Figure, A). Figure. Concurrent Operating Rooms (ORs) View LargeDownload The planned schedule has implications for informed consent. A, Staggered cases are less efficient with surgeon time, but eliminate the risk of critical portions of cases occurring at the same time. B and C, When cases overlap, there is a risk that an unexpected event in one room will keep the surgeon longer than expected. D and E, Simultaneous cases may not be appropriate except in very select circumstances and deserve scrutiny to ensure patient care is not being compromised. With better data on when and for how long critical portions of cases are likely to occur, intelligent schedules could be designed to minimize the risk of concurrent critical portions. Informed consent also includes a discussion of direct benefits. Concurrent surgery allows timely access to specialized or sought-after surgeons who otherwise may have unacceptable backlogs. Surgeon time is a scarce resource that may rightly be maximized in a society concerned with improving access and controlling health care costs. If procedures can be accomplished with high quality using trainees or other assistants as extenders, then it is acceptable to offer patients concurrent surgery to have an operation by a particular surgeon within a given timeframe. Surgeons operating concurrently have a duty to plan appropriately to ensure they are available for all critical portions and can provide appropriate cross-coverage for noncritical portions if necessary. This planning helps prevent case delays and wasted resources related to surgeons not being immediately present when critical portions occur. Because there are no strict definitions for what constitutes the “critical portion” of a procedure, it is incumbent on the surgeon to seek input from the patient, determine these portions in their best interest, and discuss this strategy during informed consent. Patient, case, and team factors may modify which portions are critical, and this is an area ripe for further study. Surgeons also must manage their trainees. This means knowing the abilities of the residents and fellows who will be handling the noncritical portions to ensure that patients are appropriately cared for. A surgeon who does not know their assistants may inappropriately leave a trainee to a task for which they have not yet attained competency.7 Resident or fellow assistance is not always consistent, either in availability or skill level, and these factors must be considered when planning the operative day. The way such factors affect the timing of critical and noncritical aspects of surgical procedures is an avenue of necessary research. The recent controversy about concurrent surgery has highlighted issues of informed consent regarding surgeon presence and trainee involvement. While the debate continues regarding the limits and optimal strategies for concurrent surgery, the duty to respect our patients’ autonomy remains unchanged. We can and should be open and transparent about how we manage surgical procedures and allow our patients to make informed decisions about entrusting themselves to our care. Back to top Article Information Corresponding Author: Alexander Langerman, MD, SM, Department of Otolaryngology and Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, 1215 21st Ave S, 7209 Medical Center E, South Tower, Nashville, TN 37215 (alexander.langerman@vanderbilt.edu). Published Online: March 17, 2016. doi:10.1001/jamasurg.2016.0511. Conflict of Interest Disclosures: None reported. References 1. Beasley GM, Pappas TN, Kirk AD. Procedure delegation by attending surgeons performing concurrent operations in academic medical centers: balancing safety and efficacy. Ann Surg. 2015;261(6):1044-1045.PubMedGoogle ScholarCrossref 2. Abelson J, Saltzman J, Kowalczyk L, Allen S. Clash in the name of care. The Boston Globe. October 25, 2015. https://apps.bostonglobe.com/spotlight/clash-in-the-name-of-care/story/. Accessed February 22, 2016. 3. Foster JH. Who does an operation? Arch Surg. 1981;116(6):743.PubMedGoogle ScholarCrossref 4. McAlister C. Breaking the silence of the switch: increasing transparency about trainee participation in surgery. N Engl J Med. 2015;372(26):2477-2479.PubMedGoogle ScholarCrossref 5. Sur MD, Schindler N, Singh P, Angelos P, Langerman A. Young surgeons on speaking up: when and how surgical trainees voice concerns about supervisors’ clinical decisions. Am J Surg. 2016;211(2):437-444.PubMedGoogle ScholarCrossref 6. Jones JW, McCullough LB. Consent for residents to perform surgery. J Vasc Surg. 2002;36(3):655-656.PubMedGoogle ScholarCrossref 7. Nuland SB. Mistakes in the operating room: error and responsibility. N Engl J Med. 2004;351(13):1281-1283.PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Surgery American Medical Association

Concurrent Surgery and Informed Consent

JAMA Surgery , Volume 151 (7) – Jul 1, 2016

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Publisher
American Medical Association
Copyright
Copyright © 2016 American Medical Association. All Rights Reserved.
ISSN
2168-6254
eISSN
2168-6262
DOI
10.1001/jamasurg.2016.0511
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Abstract

Few patients know what it is like to perform surgery, train residents, or be in an operating room (OR). This is understandable; during most operative cases, patients are sedated or anesthetized, and the modern OR is sealed to casual observers for multiple reasons including infection control and privacy. Television often portrays the OR dramatically and rarely depicts the careful but routine manner in which surgical teams conduct patient care. This translates to information asymmetry, where we as surgeons know much and our patients know little about what will happen during their operation. Most surgeons are aware of and personally participate in concurrent surgical procedures at some point during their training or professional careers, and the “team” approach to surgical care has a long tradition in anesthesiology and on the wards. Although this is a controversial topic, those in favor of running concurrent ORs argue that it is safe and efficacious when properly planned.1 Until the Spotlight report in The Boston Globe2 drew attention to this practice, we may not have realized how surprising and upsetting this practice is to patients. The reason patients find this uncomfortable is founded in the question, “If my surgeon is out of the room, who’s operating on me?” This concern echoes a debate in the 1970s and 1980s surrounding “ghost surgery,” the highly unethical practice of intentionally and secretly substituting one surgeon for another. At the time, a number of surgeons (eg, Foster3) provided sound arguments for a distinction between resident training and “ghost surgery”: during training, the attending surgeon still holds responsibility and oversight for the procedure, even if his or her hands are not cutting and suturing. Yet, the public may not be convinced, and our patients likely expect that we perform the entire operation—unless they are informed otherwise. This information provided to patients is often not adequate to support informed decision making. Standard consent form language and “University Hospital” signs provide only a vague acknowledgment that trainees are present. Furthermore, some surgeons avoid explicit descriptions of trainee involvement out of concern for undermining patient confidence in their operation, and others go even further by intentionally misleading patients regarding trainee participation.4 This subterfuge inappropriately favors paternalism over patient autonomy and is unnecessary in modern surgery. Resident involvement elevates care by bringing additional knowledge and viewpoints, providing direct assistance during cases (including relieving the attending to take breaks), and questioning clinical decisions when appropriate.5 Such essential training provides society with future surgeons.1,3 Rather than avoid this, we should continue to educate the public about the benefits of our practices and be forthright with our patients. This honesty starts with the informed consent process. The “reasonable person” standard used by many jurisdictions guides us to disclose information that is material to a patient’s decision to undergo surgery. This applies not just to the procedure itself, but how it will be performed by a particular surgeon at a particular institution. We can interpret the widespread outcry following the Boston Globe Spotlight report2 as evidence that at least some of the public feels that surgeon presence during the entire procedure is material to their decisions about entrusting their care to particular surgeons. This holds true even if we do not have evidence or belief that our absence during select portions of a procedure alters outcomes.1 Thus, we have a duty to inform patients about how we will manage their operations and to amend “widespread misconceptions”3 about care at academic hospitals. Others have suggested a requirement to inform patients if trainees will be assisting or handling portions of a case.4,6 Our duty to inform also includes informing patients if we will leave the room while the case is under way. If cases will overlap (Figure, B-C), we need to explicitly explain the logistical and clinical implications of this practice, particularly the possibility that an unexpected event in a second OR may delay our arrival or return to the first OR (meaning additional unnecessary anesthetic time or, rarely, the possible need for substitution of another qualified surgeon to complete the case). The degree of acceptability of simultaneous cases (Figure, D) is narrow, and it would be inappropriate and unethical to ask a patient to consent to a procedure where the surgeon knew a priori that he or she would be unable to meaningfully participate (Figure, E). The only 2-room scenario that guarantees that the surgeon can be present during the entire operation is staggered ORs, which may be institutionally unfavorable owing to inefficient use of OR and other staff time (Figure, A). Figure. Concurrent Operating Rooms (ORs) View LargeDownload The planned schedule has implications for informed consent. A, Staggered cases are less efficient with surgeon time, but eliminate the risk of critical portions of cases occurring at the same time. B and C, When cases overlap, there is a risk that an unexpected event in one room will keep the surgeon longer than expected. D and E, Simultaneous cases may not be appropriate except in very select circumstances and deserve scrutiny to ensure patient care is not being compromised. With better data on when and for how long critical portions of cases are likely to occur, intelligent schedules could be designed to minimize the risk of concurrent critical portions. Informed consent also includes a discussion of direct benefits. Concurrent surgery allows timely access to specialized or sought-after surgeons who otherwise may have unacceptable backlogs. Surgeon time is a scarce resource that may rightly be maximized in a society concerned with improving access and controlling health care costs. If procedures can be accomplished with high quality using trainees or other assistants as extenders, then it is acceptable to offer patients concurrent surgery to have an operation by a particular surgeon within a given timeframe. Surgeons operating concurrently have a duty to plan appropriately to ensure they are available for all critical portions and can provide appropriate cross-coverage for noncritical portions if necessary. This planning helps prevent case delays and wasted resources related to surgeons not being immediately present when critical portions occur. Because there are no strict definitions for what constitutes the “critical portion” of a procedure, it is incumbent on the surgeon to seek input from the patient, determine these portions in their best interest, and discuss this strategy during informed consent. Patient, case, and team factors may modify which portions are critical, and this is an area ripe for further study. Surgeons also must manage their trainees. This means knowing the abilities of the residents and fellows who will be handling the noncritical portions to ensure that patients are appropriately cared for. A surgeon who does not know their assistants may inappropriately leave a trainee to a task for which they have not yet attained competency.7 Resident or fellow assistance is not always consistent, either in availability or skill level, and these factors must be considered when planning the operative day. The way such factors affect the timing of critical and noncritical aspects of surgical procedures is an avenue of necessary research. The recent controversy about concurrent surgery has highlighted issues of informed consent regarding surgeon presence and trainee involvement. While the debate continues regarding the limits and optimal strategies for concurrent surgery, the duty to respect our patients’ autonomy remains unchanged. We can and should be open and transparent about how we manage surgical procedures and allow our patients to make informed decisions about entrusting themselves to our care. Back to top Article Information Corresponding Author: Alexander Langerman, MD, SM, Department of Otolaryngology and Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, 1215 21st Ave S, 7209 Medical Center E, South Tower, Nashville, TN 37215 (alexander.langerman@vanderbilt.edu). Published Online: March 17, 2016. doi:10.1001/jamasurg.2016.0511. Conflict of Interest Disclosures: None reported. References 1. Beasley GM, Pappas TN, Kirk AD. Procedure delegation by attending surgeons performing concurrent operations in academic medical centers: balancing safety and efficacy. Ann Surg. 2015;261(6):1044-1045.PubMedGoogle ScholarCrossref 2. Abelson J, Saltzman J, Kowalczyk L, Allen S. Clash in the name of care. The Boston Globe. October 25, 2015. https://apps.bostonglobe.com/spotlight/clash-in-the-name-of-care/story/. Accessed February 22, 2016. 3. Foster JH. Who does an operation? Arch Surg. 1981;116(6):743.PubMedGoogle ScholarCrossref 4. McAlister C. Breaking the silence of the switch: increasing transparency about trainee participation in surgery. N Engl J Med. 2015;372(26):2477-2479.PubMedGoogle ScholarCrossref 5. Sur MD, Schindler N, Singh P, Angelos P, Langerman A. Young surgeons on speaking up: when and how surgical trainees voice concerns about supervisors’ clinical decisions. Am J Surg. 2016;211(2):437-444.PubMedGoogle ScholarCrossref 6. Jones JW, McCullough LB. Consent for residents to perform surgery. J Vasc Surg. 2002;36(3):655-656.PubMedGoogle ScholarCrossref 7. Nuland SB. Mistakes in the operating room: error and responsibility. N Engl J Med. 2004;351(13):1281-1283.PubMedGoogle ScholarCrossref

Journal

JAMA SurgeryAmerican Medical Association

Published: Jul 1, 2016

Keywords: informed consent,communication,education, medical, graduate,ethics, medical,internship and residency,intraoperative care,operating room,patient care team,truth disclosure,surgery specialty,health care decision making,surgeons

References