"Overlapping" surgeries are safe for most patients, but not for everyone

Surgeons are renowned for their busy schedules – so busy that they do not just book consecutive surgeries. Sometimes they make a double booking, so one operation overlaps the next. A senior surgeon will do the key things and then move on to the next room – leaving other surgeons, often subordinates, to open the procedure and complete it.

A large study published Tuesday in JAMA suggests that this practice of overlapping surgeries is safe for most patients, those who undergo overlapping surgeries have the same characteristics as those who are the only object of the surgeon's attention.

But the study also identified a subgroup of vulnerable patients who could be bad candidates; The practice of double booking the time of the senior surgeon seemed to greatly increase the risk of postoperative complications, such as infections, pneumonia, heart attack or death.

According to researchers, the study conducted Tuesday by a multidisciplinary team from several universities is the most comprehensive analysis of the practice to date. It covers the results of over 60,000 knee, hip, spine, brain and heart surgeries in patients aged 18 to 90 years. centers. The study compared the results of the procedures performed in isolation with those who had to ride an hour or more.

Dr. Anupam Jena, physician and health economist at Harvard Medical School's faculty and lead author of the study, said his research team had discovered that overlapping surgeries were "generally safe" . The overlapping surgeries were not significantly associated with the difference in death rates or postoperative complications.

These results, says Jena, go in the same direction as many of the studies of this type conducted since 2015, when an investigative team from the Boston Globe first drew attention to the Massachusetts General Hospital Harvard. In one of the country's leading university hospitals, journalists pointed to a practice that was little studied and little discussed outside of hospitals. In extreme cases, the surgeries were essentially simultaneous, the main multitasking surgeon shuttling between the operating rooms.

In one year, the Senate Finance Committee came out with a report detailing security concerns of legislators regarding poorly studied practices. And the American College of Surgeons has updated its guidelines, adding that it was "inappropriate" to juggle the "critical" parts of an operation.

However, hospitals still consider the less extreme practice of overlapping the beginning and end of surgeries as an effective way to mobilize the skillful hands of their best surgeons. Mass General, who continued his practice, is in the company of university hospitals in the country. This overlap of surgeries "provides broader and faster access to certain surgical specialties," said Mass General in an FAQ on the subject, "many of which are elective procedures with high demand and high volume" .

Jena says it's the first study to show that certain types of patients might be particularly at risk.

"This is the only [study] the results could be worse ", namely in elderly patients, those with pre-existing medical conditions and those undergoing coronary artery bypass, where blood flow is restored to the heart.

When researchers turned to these high-risk patients, they found slightly higher mortality rates in patients with overlapping surgery who were older or who had underlying medical conditions – 5, 8% vs. 4.7% for patients who had all the attention of the surgeon. .

Scientists found a similar difference in complication rates: 29.2% of high-risk patients experienced post-surgical complications when undergoing surgery, compared to 27% of patients whose surgery was performed in isolation. (The "complications" recorded in the study ranged from minor surgical site infections to a heart attack or stroke.)

According to Jena, this gap "could occur when a surgeon separates his mental effort between two cases where [from] to be literally [in] two places at a time. Such problems would have a measurable effect on high-risk patients. "

The study also revealed that surgeries with overlapping overlap took an average of half an hour longer than surgeries performed in isolation.

Dr. Robert Harbaugh, former president of the American Association of Neurological Surgeons and current director of the department of neurosurgery at the Milton S. Hershey Medical Center at Penn State, did not participate in the study, but It was not surprising to see the results of this study. a "modest but real" risk for high-risk patients.

"In my office, if I know someone like a very high risk patient, you are much less likely to (plan) this patient for an overlapping surgery," Harbaugh said. Surgical patients who suffer from several underlying conditions, such as diabetes or hypertension, he says, require his full attention.

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

However, according to Harbaugh, the overlap of surgeries is crucial "for the operating room to operate more efficiently". Surgeons are full two or three months in advance in his service at Penn State, he says. By allowing four surgeries a day, patients are treated earlier – while providing the "next generation of surgeons" with a much needed training period.

The main surgeon is always cleaned for the "dangerous part of the surgery," notes Harbaugh, and leaves the patient only "competent to open or close a case" residents.

"If you complete an operation and you tell your resident," you can go ahead and close the incision, "they are more than competent enough to do it," he says. "Then you go, go to another room where a [surgical] Comrade started a business. It's an efficient use of time. Harbaugh estimates that 15% of surgeries performed by doctors in his department overlap.

Harbaugh also notes that his surgery department at Penn State requires surgeons to explain to patients, when they sign on the consent form, that they will withdraw from part of the surgery. But he doubts that the policy of transparency is universal, he says.

Jena says there is "little information on what patients know" regarding the practice of overlapping surgeries. A study conducted in 2017 revealed that few people had heard of this practice.

He states that Dr. Eric Sun, lead author of the study and anesthetist, an adjunct professor at Stanford University, and himself, "would agree that physicians should inform the patients of this practice ". Jena recommends that patients ask, before surgery, if their surgeon will share their time.

If the answer is not satisfactory, Jena answers, "At any time, the patient can say," I do not want care to be provided to me. "

Diana Zuckerman, Policy Analyst and Chair of the National Health Research Center, questions many conversations of this type. "Most patients can not ask," she says.

"The good news is that, for one patient in particular, they should not worry," said Zuckerman, pointing out that the study did not reveal any significant increase in the number of problems postoperative or death in general.

However, questions remain as to whether patients should be informed of the surgeon's other commitments, even if the risks of complications are low.

"I think it's safe to say that if patients were warned, no one would like it," Zuckerman says. "Nobody wants to feel that the doctor comes and goes in his office.