'Overlapping surgeries to face US Senate inquiry'

[W19]

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http://www.bostonglobe.com/metro/20...ass-general/wxEsbg5r2poqtk88LkcHQI/story.html

These surgeons are trying to milk the system as much as they can...

 

[Pacna]

Perverse incentives --> perverse outcomes

 

[mcloaf]

http://www.bostonglobe.com/metro/20...ass-general/wxEsbg5r2poqtk88LkcHQI/story.html

These surgeons are trying to milk the system as much as they can...

Strong #hottake here. I don't think it's unreasonable to run multiple rooms depending on the situation and who's involved. Without knowing the details of each particular case it's stupid to assign wrongdoing, not that that's going to stop congress, the public, or apparently you.

 

[akwho]

Attending surgeons that are running two rooms generally have large surgical teams that they are managing. They make it sound in the article like one Doctor is operating on two patients simultaneously when in reality its usually 2-3 surgeons for a patient at various stages in their training. There is a lot of dead time in cases where an attending level surgeon isn't needed and it make economic and efficiency related sense to have two concurrent cases.

Room 1: Fellow, Junior Resident
Room 2: Senior Resident, Junior Resident, Med Student
Attending in each room for specific milestones in the case.

 

[Brahnold]

If they bar the practice of concurrent surgeries, this will reduce the effective supply of surgeons and allow surgeons to jack up prices. Supply and demand.

If they don't ban it, then enterprising surgeons can continue to make more money via double booking their time.

So I guess at the end of the day, it's hard to say which outcome is going to be better or worse for surgeons. Maybe a win-win situation? lol

On the other hand, if concurrency remains an option I could see the situation devolving into the debacle that has become of anesthesiology, where you have 1 anesthesiologist responsible for 4 ORs where most of the work is done by midlevels.

 

[TooMuchResearch]

Medicine isn't a strict supply and demand structure. Surgeons jacking up prices doesn't increase reimbursement unless the surgeons refuse elective cases from patients with insurance that doesn't reimburse what they want.

In before a libertarian jumps in with the "it should be supply and demand" argument, which is less pertinent in the context of this thread.

 

[Donald Juan]

Considering most of these surgeons doing concurrent surgeries are academic attendings who are on salary, I don't think they just have financial gains in mind.

If we take away the ability to run two rooms, it means less autonomy for residents in training. Then when we complete training and don't feel competent enough to do simple cases on our own, all the old physicians can sit around and say, "see, it's those work hour restrictions!"

 

[Brahnold]

Medicine isn't a strict supply and demand structure. Surgeons jacking up prices doesn't increase reimbursement unless the surgeons refuse elective cases from patients with insurance that doesn't reimburse what they want.

In before a libertarian jumps in with the "it should be supply and demand" argument, which is less pertinent in the context of this thread.

Well, the United States isn't a single payer system just yet, thank god, so supply and demand still plays a role in determining the prices of medical services. Less surgeon "supply" means private practice groups have more leverage when negotiating contracts with insurance companies. It also makes it easier for surgeons to survive without partaking of medicare/aid patients, which reduces the government's ability to gut those programs'
reimbursement rates without leaving their beneficiaries without access to surgeons.

 

[Gambler 101]

I've also seen the NP and PA finish cases while the surgeon left to start the next one (this was an academic hospital with surgery residency program). I'm not sure if there's a financial incentive for that? Maybe you book more cases per day so you could negotiate a higher salary?

 

[mimelim]

I've also seen the NP and PA finish cases while the surgeon left to start the next one (this was an academic hospital with surgery residency program). I'm not sure if there's a financial incentive for that? Maybe you book more cases per day so you could negotiate a higher salary?

I am currently at SCVS and have been in the fellows program that focused on academic positions. Their take home was that most academic surgeons are salaried and their income is not directly tied to their RVUs (eat what you kill model). However, they do get bonuses based on meeting certain RVU goals and your employment may be contingent upon meeting other goals.

Concurrent surgeries happen all over the place at most of the largest academic institutions in the country. I certainly can not speak for orthopedics as they are far more elective than general surgery or vascular surgery, but when we double book, it is because if we don't, we will not get through the cases that day. It is unnecessary to have an attending physician scrubbed for the majority of most of our cases. There is zero data to support that their absence in certain parts of the case lead to poorer outcomes or increased complications.

For example, on a typical day in our outpatient ORs, we will do between 8 and 15 cases in one day. We run two rooms with one attending. There will be a resident or fellow and maybe a PA student or medical student as well working with them. Depending on the training level of those in the OR, the attending will give them a certain level of autonomy. For instance, a senior resident or fellow will do 95% of most cases with the attending scrubbed in for 70% of the case. With an intern, they will do 50% of the case with the attending scrubbed for 90% of the case. With a student, the attending will stay scrubbed for the entire case.

 

[Gastrapathy]

Do you consent for that?

 

[Slack3r]

Do you consent for that?

Consent at a teaching hospital for having residents and fellows involved in your care? Ya, pretty sure that's covered.

 

[Gastrapathy]

No, consent for the specific fact that the person you are paying to do your surgery will be dividing his attention between two patients and that if the **** hits the fan unexpectedly, he won't necessarily be there or be able to get there. If we really didn't think this was a little questionable, those patients who had concurrent surgery would have been told. I'd be very curious how the billing works in these situations too.

 

[NickNaylor]

No, consent for the specific fact that the person you are paying to do your surgery will be dividing his attention between two patients and that if the **** hits the fan unexpectedly, he won't necessarily be there or be able to get there. If we really didn't think this was a little questionable, those patients who had concurrent surgery would have been told. I'd be very curious how the billing works in these situations too.

At least when I was on my surgery/anesthesia rotations, it was made clear to patients that trainees would be involved in the case and doing portions of the case with "attending supervision." What exactly "supervision" meant was rarely, if ever, discussed specifically.

 

[neusu]

Two questions.

1) If the surgeon is supervising fellows in two rooms, they presumably should be finished with a residency and board eligible. What is the concern?

2) Anesthesiologists routinely supervise multiple CRNAs and residents. While I wouldn't advocate leaving a PA/NP to do terribly much independently, why the double standard? For neurosurgery, the dissection and closure for many cases is pretty straightforward. I see no issue with someone with the appropriate level of training doing this unsupervised.

 

[Gambler 101]

Two questions.

1) If the surgeon is supervising fellows in two rooms, they presumably should be finished with a residency and board eligible. What is the concern?

2) Anesthesiologists routinely supervise multiple CRNAs and residents. While I wouldn't advocate leaving a PA/NP to do terribly much independently, why the double standard? For neurosurgery, the dissection and closure for many cases is pretty straightforward. I see no issue with someone with the appropriate level of training doing this unsupervised.

I don't understand the point in having the PA or NP left alone. They aren't training to be surgeons like the residents.

 

[Gastrapathy]

The concern is the marketing that led to people flying to Boston for this one guy to do the surgery only to discover after the fact that he spend the majority of the case in another room after they woke up injured. If the fellow didn't need more training, he would be an attending. I doubt the fellow has privileges to perform that surgery independently and, if he did, he still would have to have been the name on the consent. Board certification has absolutely nothing to do with it.

Look, I bet the reason they didn't want to tell patients, was because they knew it would be a problem and they didn't want to have to explain it. Look at all the email discussion about it on the Boston Globe's website that the reporter shared. There is a huge difference between being two places at once and recognizing that a particular part of a surgery is easy enough that it can be safely done with the attending on a smoke break. You can't predict when a trainee will get in trouble (god, if only) and there were some complications that occurred at mysterious points in the surgeries. If the trainees know that their attending is busy in another room at the critical juncture of another case, you can imagine that would change the "get help" threshold. I've done some simultaneous supervision of low risk procedures (outpatient endoscopy) and we specifically consented for that fact. That's really all I think is required here.

 

[FutureInternist]

At least when I was on my surgery/anesthesia rotations, it was made clear to patients that trainees would be involved in the case and doing portions of the case with "attending supervision." What exactly "supervision" meant was rarely, if ever, discussed specifically.

Obviously not as involved as a full on surgery, but during Residency my program director described "supervision" for lines, tubes etc as being "within shouting distance"

 

[mistafab]

There is a full chapter in the book Complications, by the surgeon Atul Gawande, that speaks on this and related topics. He discusses the two competing interests of any academic hospital: (a) the need to train future physicians and (b) the need to protect the health and well-being of patients. If you are interested in having a more in-depth look at this topic, it may be helpful to look at this book. It is, overall, a good read.

 

[neusu]

I don't understand the point in having the PA or NP left alone. They aren't training to be surgeons like the residents.

Neither is a CRNA, yet there is no issue leaving them alone.