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'Overlapping' Surgeries Safe For Most Patients, But Not All: Shots



The common practice of double-booking a lead surgeon's time and letting junior physicians supervise and complete some parts of the surgery is safe for most patients, a study of more than 60,000 operation finds. But there may be a small added risk for a subset of patients.
                
                
                    
                    Ian Lishman / Ian Lishman / Getty Images
                    
                

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Ian Lishman / Ian Lishman / Getty Images
        
    

The common practice of double-booking a lead surgeon's time and letting junior physicians supervise and complete some parts of the surgery is safe for most patients, a study of more than 60,000 operational finds.

Ian Lishman / Ian Lishman / Getty Images
            
        

Surgeons are known for their busy schedules – so busy that they do not just book surgeries back to back. Sometimes they'll double-book, so one operation overlaps the next. A lead surgeon will perform the key elements, then move to the next room – leaving other, often junior surgeons to open the procedure and finish it up.

A large study published Tuesday in JAMA suggests that This practice of overlapping surgeries is safe for most patients, with those undergoing overlapping surgeries fairing the same as those who are the sole object of their chiron's attention.

However, the study also identified a subset of vulnerable patients who might be bad candidates; The practice of double-booking the lead surgeon's time seemed to put these patients at significantly increased risk of post-op complications, such as infections, pneumonia, heart attack or death.

Researchers say a second-level study by a multidisciplinary research team from several Universities is the most comprehensive analysis of the practice of the time, focusing on the outcomes of more than 60,000 knee, hip, stomach, brain or heart surgery among patients aged 18 to 90 at eight medical centers. The study compared the outcomes of procedures done in isolation with those scheduled to overlap by an hour or more.

Dr. Anupam Jena, a physician and health economist at the faculty of the Harvard Medical School and senior author of the study, says his research team found overlapping surgeries to be "generally safe." Overlapping surgeries were not significantly associated with the difference in rates of death or post-op complications.

These findings, says Jena, are in line with all but one of several such studies conducted since 2015, when a investigating team at Boston Globe first turned searing attention at Harvard's Massachusetts General Hospital. There, at one of the nation's premier teaching hospitals, reporters highlighted the practice that at that point was little-studied and not widely discussed outside hospitals. In the extreme cases, the surgeries were essentially concurrent, with the multi-tasking lead surgeon moving back and forth between ORs.

Within a year, the Senate Finance Committee jumped in with a report detailing legislators' safety concerns about little-learned practice. . And the American College of Surgeons updated its guidelines, adding that the "critical" parts of the surgery were "inappropriate."

However, the less extreme practice of the beginning and end of surgeries overlap is still viewed by hospitals as an effective means of deploying the skillful hands of their top surgeons. Mass General, which has continued the practice, is in the company of teaching hospitals nationwide. Overlapping surgeries in this way "offers more and more timely access to certain surgical specialties," Mass General says in a FAQ on the topic, "many of them high-demand, high-volume elective procedures."

Jena says this is The first study to show that some types of patients may be particularly at risk.

"This is the only [study]which breaks out and finds certain high-risk groups, we might have worse outcomes" – namely, older Patients with pre-existing medical conditions, and those undergoing coronary artery bypass graft surgery, where blood flow is restored to the heart.

When researchers attended these high-risk patients, they found a slightly higher mortality among the patients who had undergone overlapping surgeries and were older or had underlying medical conditions – 5.8 percent compared with 4.7 percent for patients who had lead chirurg's full attention.

The scientists found similar disparity in com plication rates – 29.2 percent of high-risk patients experienced post-surgical complications when undergoing overlapping surgery, compared to 27 percent of patients whose procedure was done in isolation. (The "complications" recorded in the study ranged from minor infections at the surgical site to heart attack or stroke.)

This discrepancy, says Jena, "may occur because a surgeon separates their mental effort between two cases or [from] literally being [in] two places at once.These kinds of problems would have a measurable effect on high-risk patients. "

The study also found that surgeries booked on overlapping lasted half an hour longer than average those done in isolation.

Dr. Robert Harbaugh, former president of the American Association of Neurological Surgeons and current chair of the department of neurosurgery at Penn State's Milton S. Hershey Medical Center, was not involved in the study, but says he was not surprised to see the findings show a " modest but real "risk posed to high-risk patients.

" In my practice, if I know someone is a very high-risk patient, you're much less likely to (schedule) that patient for a overlapping surgery, " says Harbaugh Surgical patients who have multiple underlying conditions, such as diabetes or hypertension, he says, require his full attention.

This study, he says, supports his sense that there is "a specific group of patients that should be moderated more closely. "

However, Harbaugh says, overlapping surgeries are critical" to make the operating room run more efficiently. " Surgeons are fully booked two or three months in advance at his department in Penn State, he says. Allowing four surgeries a day allows patients to be treated much earlier – as well as providing a "much-needed training time" for the next generation of surgeons.

The leading surgeon is always scrubbed-in for the "dangerous part of the surgery, "

" If you're finishing an operation and you tell your resident, "you can go ahead and close the incision," Harbouh notes, and only leaves the patient with people who are "competent to open or close a case." , "they're more than competent enough to do that," he says. "Then you leave, go to another room where a [surgical] fellow has started a case. That's an effective use of time." Harbaugh estimates that 15 percent of the surgeries done by doctors in his department overlap

Harbough also notes that his surgical department at Penn State requires surgeons to explain to patients when they sign a consent form that they will step out for parts of the surgery. But he doubts that the policy of transparency is universal, he says.

Jena says there is "little information about what patients know" when it comes to the practice of overlapping surgeries. A 2017 study found few people ever heard of the practice.

He says he and the study lead author, Dr. Eric Sun, an anesthesiologist and assistant professor at Stanford University, "both would agree that doctors should be telling patients about this practice." Jena says, "At any point, the patient could say," I do not want to do this. "If they do not like the answer, Jena says," At any point, the patient could say, "I do not want care provided to me. "

Diana Zuckerman, a policy analyst and president of the National Center for Health Research, is doubtful of many such conversations likely to occur." Most patients would not know to ask, "she says. 19659008] "The good news is, for a particular patient, they should not worry," Zuckerman says, pointing to the fact that the study found no significant increase in post-op problems or deaths overall.

However, she says the questions linger over whether patients should be informed about a surgeon's other commitments, even if the risks of complications are low.

"I think it safe to say if patients were told that nobody would like it," Zuckerman says. Nobody wants to feel like the doctor is going to and out of their surgery.


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