The prevalence of concurrent and overlapping surgeries came to light for the first time for many Americans in 2015, when The Boston Globe's famed Spotlight Team reported on the practices at Boston-based Massachusetts General Hospital.
Since then, the debate over the controversial practice has affected policies at hospitals across the country.
In a recent viewpoint article in JAMA, Michelle Mello, PhD, a health law scholar with Stanford Law School, and Edward Livingston, MD, a physician who is also deputy editor of JAMA, discussed the overlapping surgery debate and what hospitals should do to regulate the practice.
First, they drew a line in the sand between overlapping and concurrent surgeries.
They called overlapping surgeries a "common" practice in which the start time of one surgery overlaps with the end of another for the same primary surgeon. Meanwhile, concurrent surgeries occur when "'critical parts' of operations for which the primary surgeon is responsible occur during the same time" and said "there is a general agreement that concurrent surgery is ethically unacceptable and is prohibited for teaching hospitals" by Medicare, they wrote.
Studies have shown that overlapping surgeries don't differ much from non-overlapping surgeries — overlapping surgeries usually took longer on average, but that extended length was not associated with any negative effect on patient outcomes.
"Overall, the modest evidence base does not suggest that overlapping surgery is unsafe, but rather that the practice is not trusted, at least by individuals considering the practice in the abstract without the benefit of an established patient-surgeon relationship," the authors wrote.
Hospitals should do the following to build trust among patients whose surgeries may overlap with another case.
1. Full disclosure. Hospitals need to fully inform patients of overlapping surgery scheduling practices well before the surgery is scheduled. This disclosure should include the likelihood that the operation will involve an overlap, a description of who will perform which parts of the operation and what their qualifications are," as well as what the patient can do if they object to the overlap, according to the authors.
2. Clear definitions. During an overlapping surgery, the main surgeon completes the "critical portions" of the surgery but may be absent during the start or end of the procedure. While the American College of Surgeons has a broad definition of what critical portions are — "those stages when essential technical expertise and surgical judgment are necessary to achieve an optimal patient outcome" — Drs. Mello and Livingston say hospitals need to get more specific. "[T]he definition of the critical portion should be established by a multidisciplinary committee within the hospital" instead of leaving it up to surgeons to define what "critical" means.
3. Oversight. Hospitals need to ensure surgeons really are present for critical parts of procedures, the authors wrote. This can be achieved by having surgeons clock in and out of the OR so there is a record of when they are there — this is now the law in Massachusetts, according to the authors.
Following these three steps "can do much to ensure that abuses of overlapping scheduling do not further undermine public trust in the practice of surgery," they concluded.