photo by Artur Bergman
There is a really simple test for whether behavior is ethical. If it is, you should perfectly comfortable talking openly about it.
If there is nothing wrong with a surgeon supervising two surgeries at once, the fact – or even the possibility – that this could happen should be disclosed to patients as early as possible, while they still have a choice about it. Patients cannot give informed consent when hospitals present a form to sign right before applying anesthesia. They cannot give informed consent when they have already scheduled surgery, arranged their affairs and checked into the hospital. They can only give informed consent when they still have practical options to say no and go elsewhere.
This is true whether the person seeking consent in a lawyer, a financial planner, an insurance salesman or a doctor. If you are working with a builder and he wants to make a major change to the plans, he will speak to you first – or, if he doesn’t, you will be rightfully angry when you find out later that he failed to do so.
Yet “running two rooms,” as double-booking surgeries is sometimes called, remains a decision largely left up to hospitals, not patients. The Boston Globe brought the practice into the national conversation with its detailed investigation of Massachusetts General Hospital in 2015. That story led to new guidelines from the American College of Surgeons and a report from the Senate Finance Committee raising concerns about double-booking. A neurosurgeon at a New York hospital who alleged that he was forced out of his job after objecting to double-booked surgical procedures recently won a lawsuit against the hospital that formerly employed him.
All of this hasn’t stopped the practice outright, however, according to an article that recently ran in The Washington Post via Kaiser Health News. Kaiser Health News, a program run by the health care-focused nonprofit the Kaiser Foundation, regularly places stories with the Post, NPR and USA Today, with a focus on “in-depth coverage of health care policy and politics.” In this instance, Kaiser brought to light an issue that is clearly more widespread than a major hospital in Massachusetts and a few other outliers, though exactly how common it remains is unclear.
The debate over double-booking surgeries has caused many hospitals, including the one attached to the University of Virginia, to heavily restrict the practice since The Boston Globe story in 2015. Yet those who defend double-booking argue that it remains an essential tool for teaching residents and fellows under the supervision of a more experienced surgeon while not simultaneously slowing patient care to a crawl.
If this is the case, however, being forthright about the prevalence of double-booking should not make the practice less useful. Meanwhile, critics claim that double-booking introduces unnecessary risk and, not without reason, suggest that it erodes patient trust. Orthopedic surgeon James Rickert told Kaiser Health News, “The only reason it has continued is that patients are asleep.” Rickert vocally opposes double-booking procedures and heads the Society for Patient-Centered Orthopedics, a consumer group.
Medical professionals disagree about whether overlapping surgeries are inherently unsafe. Robert Cima, a colorectal surgeon and medical director of surgical outcomes research at the Mayo Clinic, pointed out that his institution has employed the practice for over 100 years. Cima also co-authored a study that found overlapping operations did not result in a higher patient death rate than nonoverlapping procedures.
If this is true, it is information that should be made available to patients – along with the probability that their own procedure will be double-booked. If surgeons feel they can make the case that patients will still receive excellent care under these conditions, let them make that case to the people who will be on the operating table. Rickert and other opponents have suggested that surgeons would generally be less eager to greenlight such procedures for themselves or their loved ones than for strangers.
All surgeries involve some level of risk, but patients and families are rightfully appalled when they discover that their surgeon wasn’t even present when something went seriously wrong. Malpractice lawsuits related to overlapping surgeries are not uncommon, and will likely continue unless practices change.
It is unethical not to record when an attending physician leaves an operating room during a procedure, including pre-closing. (After all, people have been closed with equipment still inside them, among other complications.) It is certainly not ethical to conceal, actively or by omission, that the attending physician was not in the room when problems arose. If it is too much of a burden to keep track of all these comings and goings, install a webcam in the operating room and record the proceedings – and make sure the file ends up in patients’ hands.
Engaging any professional is an act of trust. No matter how much research we do or how many references we check, ultimately we place our faith in the experts we choose, believing that they will apply their expertise on our behalf to the best of their abilities and in our best interests. A professional who conceals her behavior or one who fails to fully disclose how he plans to proceed gives us reason to doubt whether such trust is well-placed.
I am willing to leave the question of whether double-booking a surgeon is ever appropriate to the medical experts. But I am not willing to delegate the ethical standards involved.