Concurrent Surgery (Boston Globe Spotlight article Targeting MGH)

[maxxor]

http://apps.bostonglobe.com/spotlight/clash-in-the-name-of-care/story/

What do you guys think about this article? It's excruciatingly long, but also brings up many issues with modern medical / surgical care. It's also unfair because it's this mega "j'accuse" and then does the "MGH cannot comment because of HIPAA" thing as if that's an admission of guilt.

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[Winged Scapula]

Comment on Facebook from a friend of mine who is a anesthesiologist there:

Don't let the Boston Globe lie to you about care at the leading hospital in the country ... they're only interested in selling papers. The Globe DOES NOT care about the people of Massachusetts. It put together a ridiculous story on a highly select few cases that it knew the hospital could not comment on (because of HIPAA) ... shameful, cheap, revolting! If you care about the people of Massachusetts, ban the Globe - even the Inquirer shows better integrity these days!

 

[Pir8DeacDoc]

I sort of doubt the old guy would be so bent out of shape and basically lose his job if there wasn't something going on.. Like most things, where there's smoke there's probably fire. The question is whether it's a campfire or forest fire.

 

[Winged Scapula]

I actually thought it was pretty well written. Certainly very thoroughly researched with documentation to back them up.

TBH I haven't read it, just thought I'd post a response from someone who works there that I trust (bias aside).

 

[Gastrapathy]

More interesting than the article are the emails published on the website. You can see Dr Burke getting more and more frustrated as his concerns are dismissed. The hospital was the one hiding behind HIPAA and attorney privilege and it worked. The state declined to investigate because he wouldn't violate HIPAA. So, finally, he went to the press. I'm good with that.

 

[Dr.LeoSpaceman]

I think this is absoultely an issue in high-volume, tertiary care centers.

I can tell you that at our institution they have a "1 attending per OR" rule, so that you cannot book concurrent cases. However what does happen is that Well Known Attending X will book 3 full rooms, and have junior faculty (could be non-ACGME fellows, or actural clinical faculty) run those rooms. In these cases it's not safety that's my biggest concern. It's the ethical issue of what the patient is being told prior to the operation. I also don't buy the "better use of time" argument. It's certainly a better use of the surgeon's time because they can then avoid having to book another long operative day. From an actual OR utilization standpoint, I'm skeptical. More often than not, I suspect the actual operations take longer than they otherwise would since there are (sometimes prolonged) periods of waiting for an attending.

 

[OtoHNS]

From an ENT perspective, running 2 concurrent rooms was standard practice for both Head & Neck and Pedi attendings during my residency. I never found it to cause any major issues during my 4 years of being a resident.

 

[deleted547339]

As a nonsurgeon, I'm a little surprised it's an issue. I'm an EM resident. As we progress through training, we get less and less supervision. Why should that be any different in the OR? I don't have an attending in the same room when I'm placing a chest tube or central line.

I understand the gravity of surgery, but I have buddies in ortho who do entire cases and only have the attending pop in and pop out when they need them - this seems totally appropriate.

 

[doc05]

As a nonsurgeon, I'm a little surprised it's an issue. I'm an EM resident. As we progress through training, we get less and less supervision. Why should that be any different in the OR? I don't have an attending in the same room when I'm placing a chest tube or central line.

I understand the gravity of surgery, but I have buddies in ortho who do entire cases and only have the attending pop in and pop out when they need them - this seems totally appropriate.

except that patients seek out specific renowned MGH surgeons, not residents. I doubt that's the case in the ER.

 

[vhawk]

except that patients seek out specific renowned MGH surgeons, not residents. I doubt that's the case in the ER.

Eh. I mean thats true but thats also a good argument against resident/fellow involvement in the case. Those patients come to Big Hospital X and it isnt so that I can sew their pancreatic anastamosis...but thats what happens. And we dont explicitly tell them about it. Every big shot attending I've worked with has said something like "Its a teaching hospital, they are there to assist and be taught" or "I cant do the operation by myself I need them there to help." Which is certainly true, but its also probably not exactly what the patient wants to know. I'm sure the attending would do it better than me, and over the course of my entire training I've probably caused more leaks or hernias or whatever than if the attending did every step of every case.

But whats the alternative? We gotta be trained. And part of training is autonomy. And part of being that big shot attending is being busy, and running multiple rooms, and having demands on your time. So if the patient has a problem with that, then I suppose one response might be "Ok you are right, we shouldnt do that. Sorry you can no longer have your operation done by Dr. Johnson, she doesnt have time in her schedule, its gonna have to be junior faculty." Is that better for them? Maybe, and maybe its at least more honest. I just dont think its so straightforward.

As a fellow I've definitely run rooms by myself, starting cases, ending cases, doing essentially entire cases, under my attendings name. I've never done anything I wasn't comfortable doing, and plenty of times I've just sat and waited because I was at a critical point and I was very cognizant that this was "his" patient and not mine and if anyone was gonna **** it up it was gonna be him. Is the patient being disserved by this?

 

[deleted547339]

Eh. I mean thats true but thats also a good argument against resident/fellow involvement in the case. Those patients come to Big Hospital X and it isnt so that I can sew their pancreatic anastamosis...but thats what happens. And we dont explicitly tell them about it. Every big shot attending I've worked with has said something like "Its a teaching hospital, they are there to assist and be taught" or "I cant do the operation by myself I need them there to help." Which is certainly true, but its also probably not exactly what the patient wants to know. I'm sure the attending would do it better than me, and over the course of my entire training I've probably caused more leaks or hernias or whatever than if the attending did every step of every case.

But whats the alternative? We gotta be trained. And part of training is autonomy. And part of being that big shot attending is being busy, and running multiple rooms, and having demands on your time. So if the patient has a problem with that, then I suppose one response might be "Ok you are right, we shouldnt do that. Sorry you can no longer have your operation done by Dr. Johnson, she doesnt have time in her schedule, its gonna have to be junior faculty." Is that better for them? Maybe, and maybe its at least more honest. I just dont think its so straightforward.

As a fellow I've definitely run rooms by myself, starting cases, ending cases, doing essentially entire cases, under my attendings name. I've never done anything I wasn't comfortable doing, and plenty of times I've just sat and waited because I was at a critical point and I was very cognizant that this was "his" patient and not mine and if anyone was gonna **** it up it was gonna be him. Is the patient being disserved by this?

That's what I wanted to say, just more eloquent.

 

[Pir8DeacDoc]

There will always be debates about how much or how little a resident/fellow gets involved at teaching facilities. I think, if done properly, everyone can come out a winner. But we have a duty to let patients know what is happening to them when they are in the OR. One of my head and neck attendings (cases most likely to be super long and requires multiple surgeons) always told patients I would be involved in the case and parts I would do by myself, parts we would do together, and parts he would do by himself. I think as long as you are upfront with patients they are usually ok with the process. Leaving them hanging out in the OR for long periods of time or not tailoring the case to be level appropriate isn't acceptable.

 

[Thanatos]

http://apps.bostonglobe.com/spotlight/clash-in-the-name-of-care/story/

What do you guys think about this article? It's excruciatingly long, but also brings up many issues with modern medical / surgical care. It's also unfair because it's this mega "j'accuse" and then does the "MGH cannot comment because of HIPAA" thing as if that's an admission of guilt.

Interesting to say the least......in particular this guy had a bad outcome and he's sore about it and looking for an explanation which I think is normal. He's found his scapegoat and is going to press it, a lot of people would I think.

The bigger issue (and what we've been kicking around at work all week) is what does this mean for how we do things going forward. I'm at a place where we routinely run two rooms (on a thoracic service so thats the flavor of my commentary), the typical set up is a big room (esophagectomy, VATS lobe, etc) and a "small" room (egd, bronch, stents, pegs, meds, etc) and the boss will bounce back and forth between the two rooms. They're good at setting these things up.....the attending will run over and do a bronch/med or a peg while i'm repositioning the esophagectomy for example.

I can see how the lay person is concerned that the attending is not in the room performing every move....at the same time I think they have a poor understanding in general of how these things work and maybe we just need to educate them on these things. Closing skin doesn't take the attending....in fact if they stick around and help you can tell which one's they closed because they tend to look worse! That being said I'm not going to staple across the pulmonary artery without the boss scrubbed in, that would be crazy.

We run multiple rooms for efficiency reasons, it can take hours to close, wake up, clean the room, roll back with the next case, position, drape, etc......if the masses demand the attending in the room from the stretcher wheels in to out we can certainly do it.....but the here's the trade off:

the wait time to get your surgery booked is going way up, and all so an attending can watch anesthesia put you to sleep, nurses put the foley in, and me sew in your drains....I don't think thats a good trade off.

 

[Pir8DeacDoc]

I think most of us on here understand the situation.. It can definitely make a lot of sense to run multiple rooms. But doing it and not discussing things with the patient isn't kosher. If you have nothing to hide why hide?

 

[Vandalia]

I don't know that this is anything new. Decades ago it was fairly well known that the high profile cardiothoracic surgeons would essentially run an assembly line doing CABGs, with the attending surgeon doing the actual grafts moving between rooms and the house staff/fellows doing the exposure, harvest, and closures on different patients at the same time. If my memory is correct - and it may well be faulty - and the rumors true, there was nothing unusual about such a CT attending surgeon having 3-4 patients under anesthesia at any one time.

Perhaps it was just urban legend, but it was frequently cited legend.

 

[brown_cow]

I think those of us at academic centers can attest that concurrent surgery or at least overlapping rooms is a common phenomenon.

I would argue that our Anesthesia colleagues which work to make these two room situations feasible have insight but also a biased opinion on what is appropriate. One point that stuck out in this article was the Attending Anesthesiologist writing his concerns for two difficult cases to run in parallel, this sticks out too me as insight into what may not be appropriate.

Food for thought. Anesthesia Attending providers frequently supervise two rooms (residents) or three rooms (CRNAs). If parallel rooms supervising residents is subject to such scrutiny, would you argue this system is any different? CRNAs are viewed as near-independent practitioners but an Attending is "available immediately".

When two simultaneous incidents arise more often than not another Anesthesia Attending is available immediately float over and cover. I would argue the same goes for surgical services, a Surgical Attending from the same service is pulled in from a neighboring OR in an emergency.

 

[dienekes88]

I don't know that this is anything new. Decades ago it was fairly well known that the high profile cardiothoracic surgeons would essentially run an assembly line doing CABGs, with the attending surgeon doing the actual grafts moving between rooms and the house staff/fellows doing the exposure, harvest, and closures on different patients at the same time. If my memory is correct - and it may well be faulty - and the rumors true, there was nothing unusual about such a CT attending surgeon having 3-4 patients under anesthesia at any one time.

Perhaps it was just urban legend, but it was frequently cited legend.

There's a difference, though. That is a stagger room (hypothetically, no two patients are cross clamped at the same time) in an operation with a fairly predictable timeline compared with what is described as allegedly simultaneous surgery in the article. One of the difficulties is that most people (including other physicians and surgeons) don't know the conduct of these operations. Maybe it is actually reasonable to expect the critical portions of the operation to occur at different times throughout the day. Maybe it isn't. I guess you'd have to be a spine surgeon to judge.

 

[SLUser11]

Food for thought. Anesthesia Attending providers frequently supervise two rooms (residents) or three rooms (CRNAs). If parallel rooms supervising residents is subject to such scrutiny, would you argue this system is any different? CRNAs are viewed as near-independent practitioners but an Attending is "available immediately".

When two simultaneous incidents arise more often than not another Anesthesia Attending is available immediately float over and cover. I would argue the same goes for surgical services, a Surgical Attending from the same service is pulled in from a neighboring OR in an emergency.

Not the same.

Sort of silly to insinuate that it is.

Also, aside from the inherent difference in the tasks required, as someone pointed out there is a big difference between service line physicians (e.g. EPs and anesthesiologists) and sought-out specialists.

OTOH, as surgeons we've all benefitted from a bit of deception when it comes to resident autonomy. I'm sure residents would vote unanimously against us asking the patient prior to every case what degree of autonomy we should give the resident. In general, patients are unaware of how much of their surgery and subsequent patient care is done by trainees. We also know, deep down in our hearts, that certain surgeries would go better and ultimately have better outcomes if done solely by the specialist....but we need PRACTICE so we can be the next generation's specialists. We have to be a bit utilitarian in our approach to justify our means.

 

[vhawk]

Right. There isnt an obvious better alternative. To get a little off topic, its the same reason I find it unethical and immoral to refuse to allow residents to be involved with your care if you are a patient, and my plan as attending surgeon would be to try to educate and if failing that refuse to operate on patients who won't allow trainees. Its a completely understandable thing for a patient to want but its also scummy and basically just stealing from other patients.

 

[OtoHNS]

Right. There isnt an obvious better alternative. To get a little off topic, its the same reason I find it unethical and immoral to refuse to allow residents to be involved with your care if you are a patient, and my plan as attending surgeon would be to try to educate and if failing that refuse to operate on patients who won't allow trainees. Its a completely understandable thing for a patient to want but its also scummy and basically just stealing from other patients.

If a patient doesn't want any residents or students involved in their care, there are plenty of non-academic hospitals out there.

 

[mimelim]

I don't know that this is anything new. Decades ago it was fairly well known that the high profile cardiothoracic surgeons would essentially run an assembly line doing CABGs, with the attending surgeon doing the actual grafts moving between rooms and the house staff/fellows doing the exposure, harvest, and closures on different patients at the same time. If my memory is correct - and it may well be faulty - and the rumors true, there was nothing unusual about such a CT attending surgeon having 3-4 patients under anesthesia at any one time.

Perhaps it was just urban legend, but it was frequently cited legend.

This still happens where I'm at and at our neighboring institutions. While certain restrictions have come about, nobody bats an eyelash over having multiple rooms open.

 

[Pir8DeacDoc]

I don't think anyone is advocating polling patients for what degree of resident involvement they want. But it is fair to make it clear this is a teaching hospital and parts of your pre op, operative, and post operative care will be handled by trainees. If you aren't ok with that, then feel free to seek care somewhere else. Lots and lots of non-teaching hospitals

 

[SLUser11]

If a patient doesn't want any residents or students involved in their care, there are plenty of non-academic hospitals out there.

That's easy to say if you are a weathered attending with more business than you want or can handle, but what about when you are starting out, building a practice, and possibly in competition with some people across town? Academics is much more similar to the community than it used to be....we have to say "yes" to most things, are held to RVU targets, and have to compete for cases. If you pull the stuff mentioned above, which sounds honorable but often comes off to the patient as rude, you won't just lose that patient....you could lose a referring physician, or worse....then that patient decides to go online and trash you on 1 of thousands of unregulated doctor rating websites......

If you are a service line physician, it's easier to stand up to people...if you are a faceless attending in "trauma" or "surgery" then perhaps you can get away with it, but if you are a specialist, and the patient drove 5 hours to come see you, and you basically threaten them with no care if they want to ensure that you do the case.....who's winning? The residents never see the case, and you look like a jerk.

 

[Pir8DeacDoc]

Have you ever had that discussion with a patient and them decline care? It's all in the delivery. You can be honest with people and not threaten them but still get the point across. Most everyone coming to a teaching hospital gets it. At least that was my experience

 

[SLUser11]

Have you ever had that discussion with a patient and them decline care? It's all in the delivery. You can be honest with people and not threaten them but still get the point across. Most everyone coming to a teaching hospital gets it. At least that was my experience

No, they never decline care. That sort of makes my point, though....when I do that, I'm essentially threatening them with no care, and they feel pressured to comply.

I'm not saying I've never had that conversation, because I have. However, this is definitely an ethical grey area, and an inherent conflict of interest. The patient wants the best possible care from the most capable person, meanwhile the resident wants the most possible autonomy.

On a reverse note, I forgot to mention how the residents punish attendings for withholding autonomy, which leads to pressure on the attending from the other direction....if you don't let the resident go nuts, you can lose respect/loyalty/coverage/favor, etc. Often, the attendings that receive teaching awards (voted on by the residents) are by no means the most talented or most dedicated...they are the ones who simply get out of the resident's way and let them work independently...I would opine that this is hardly "teaching" and leads to the blind leading the blind, and poor care for everyone, present and future.

I subscribe to the Zwisch Model (http://bulletin.facs.org/2015/08/teaching-in-the-or-new-lessons-for-training-surgical-residents), but the resident's attention span is not always long enough to graduate to "dumb help" and beyond. Even though they've never done the case at hand, and have not researched the steps or listened to my words on positioning, technique, etc, they expect to do the whole thing skin to skin.....they often can't appreciate the subtle differences between patients/cases that make one a teaching case and the other a "watch and learn" case. So, even if it's the first time you've done a Lap colectomy with them, and they've never seen a medial to lateral dissection (or researched it), if you tell them to assist, they tend to pout, and give very poor assistance, and then label you in a negative way.

/end soapbox

 

[VisionaryTics]

No, they never decline care. That sort of makes my point, though....when I do that, I'm essentially threatening them with no care, and they feel pressured to comply.

I'm not saying I've never had that conversation, because I have. However, this is definitely an ethical grey area, and an inherent conflict of interest. The patient wants the best possible care from the most capable person, meanwhile the resident wants the most possible autonomy.

On a reverse note, I forgot to mention how the residents punish attendings for withholding autonomy, which leads to pressure on the attending from the other direction....if you don't let the resident go nuts, you can lose respect/loyalty/coverage/favor, etc. Often, the attendings that receive teaching awards (voted on by the residents) are by no means the most talented or most dedicated...they are the ones who simply get out of the resident's way and let them work independently...I would opine that this is hardly "teaching" and leads to the blind leading the blind, and poor care for everyone, present and future.

I subscribe to the Zwisch Model (http://bulletin.facs.org/2015/08/teaching-in-the-or-new-lessons-for-training-surgical-residents), but the resident's attention span is not always long enough to graduate to "dumb help" and beyond. Even though they've never done the case at hand, and have not researched the steps or listened to my words on positioning, technique, etc, they expect to do the whole thing skin to skin.....they often can't appreciate the subtle differences between patients/cases that make one a teaching case and the other a "watch and learn" case. So, even if it's the first time you've done a Lap colectomy with them, and they've never seen a medial to lateral dissection (or researched it), if you tell them to assist, they tend to pout, and give very poor assistance, and then label you in a negative way.

/end soapbox

Woof.

What are the repercussions for not getting teaching awards or pissing off residents?

 

[SLUser11]

Woof.

What are the repercussions for not getting teaching awards or pissing off residents?

If teaching residents is what you love to do, then losing them as an audience is the biggest repercussion, either because they try to avoid your cases, or they go to the cases, but are hardened/blunted by their opinion of you, and you essentially can't teach them.

For me, it's a difficult line to walk. I still piss off residents periodically, but selfishly consider myself to be a bit of a martyr in the situation...(i.e. I'm doing this for YOU).

 

[Pir8DeacDoc]

Maybe it's different in oto and I certainly mean no offense, but man your residents sound like they suck. My attendings were all fellowship trained. Damn right they did cases on occasion that I had no business being any part of. I watched, learned what I could, and helped if at all possible. Demanding autonomy and getting pissy with the attending if they don't give it to you sounds awful. At the end of the day we all want/need to be trained but that can be done without a reckless attitude that endangers patients.

 

[SLUser11]

Maybe it's different in oto and I certainly mean no offense, but man your residents sound like they suck. My attendings were all fellowship trained. Damn right they did cases on occasion that I had no business being any part of. I watched, learned what I could, and helped if at all possible. Demanding autonomy and getting pissy with the attending if they don't give it to you sounds awful. At the end of the day we all want/need to be trained but that can be done without a reckless attitude that endangers patients.

I sometimes feel like residents are overly-entitled, but I think it's a generational thing. I'm technically Gen Y (by 1 year), and I certainly have a unique snowflake mentality, but I wasn't afraid of high expectations, and I always had excellent follow-through.

The deeper we get into "millennials," the more I feel that there is a shift in blame....when the performance is bad, it obviously must be a problem with the teacher, or perhaps the test, because the student is just way too talented and special to be the real cause of the problem.

A funny SNL skit illustrating my point: http://www.nbc.com/saturday-night-live/video/millennials/2916016


On a side note, I'm also frustrated by some residents' lack of self-awareness. If you ask them, they all state clearly that they want expectations high, and they are okay with "tough love," and basically insinuate that they are nothing like the typical millennial student...but these proclamations are discordant with their actual behavior.

 

[MediCane2006]

Maybe it's different in oto and I certainly mean no offense, but man your residents sound like they suck. My attendings were all fellowship trained. Damn right they did cases on occasion that I had no business being any part of. I watched, learned what I could, and helped if at all possible. Demanding autonomy and getting pissy with the attending if they don't give it to you sounds awful. At the end of the day we all want/need to be trained but that can be done without a reckless attitude that endangers patients.

Yeah, even as a PGY-10 level fellow I definitely have stood back and watched in some of the more complex cases that my fellowship-trained attendings are doing. Without meaning to sound judgmental, your residents sound like a bunch of entitled little ****s.

(damn millenials grumble grumble)

 

[vhawk]

That's easy to say if you are a weathered attending with more business than you want or can handle, but what about when you are starting out, building a practice, and possibly in competition with some people across town? Academics is much more similar to the community than it used to be....we have to say "yes" to most things, are held to RVU targets, and have to compete for cases. If you pull the stuff mentioned above, which sounds honorable but often comes off to the patient as rude, you won't just lose that patient....you could lose a referring physician, or worse....then that patient decides to go online and trash you on 1 of thousands of unregulated doctor rating websites......

If you are a service line physician, it's easier to stand up to people...if you are a faceless attending in "trauma" or "surgery" then perhaps you can get away with it, but if you are a specialist, and the patient drove 5 hours to come see you, and you basically threaten them with no care if they want to ensure that you do the case.....who's winning? The residents never see the case, and you look like a jerk.

And then it becomes harder for patients to demand it, so they stop doing it.

Basically this is just another discussion where we realize acting your conscience and acting morally and ethically is sometimes hard and sometimes has a cost. And then you call me naive again, and you are probably right again.

 

[SLUser11]

And then it becomes harder for patients to demand it, so they stop doing it.

Basically this is just another discussion where we realize acting your conscience and acting morally and ethically is sometimes hard and sometimes has a cost. And then you call me naive again, and you are probably right again.

It's not naïve, it's righteous...I just don't have the courage or energy to fight that fight every day...the risk:reward ratio is not balanced for these small battles, so you just eat it...and it makes you feel dirty sometimes.

The fundamental issue is that the best thing for the patient does not match the best thing for the resident. As I said before, the only way to reconcile that is to be utilitarian about it, and decide that the ends justify the means, and our choices serve the greater good.

 

[Krukenberg]

Interesting article. If your loved one had to get a major operation, would you politely ask the attending that they personally perform the major steps of the case (obviously with assistance), rather than a trainee?