EXECUTIVE SUMMARY

Only a small minority of patients had knowledge of the common practice of overlapping surgery, but almost all believed it should be part of informed consent. Respondents believed surgeons should:

• inform patients in advance;

• define the critical components of the operation;

• document for what portion of the surgery the surgeon was present.


Overlapping surgery — operations performed by the same surgeon with the start of one surgery overlapping with the end of another — has been common for many years. Yet only 3.9% of the general public had any knowledge of the practice, found a recent study.1

More than 90% of the 1,454 respondents believed that the attending surgeon should inform patients in advance of overlapping surgery, define what the critical components of the operation are, and document what portion of the surgery he or she was present for.

“Surgeons should not practice in a fashion that they do not feel comfortable explaining to patients,” says Peter Angelos, MD, PhD, FACS, Linda Kohler Anderson professor of surgery and surgical ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

If surgeons believe overlapping surgery is ethical, they should feel comfortable disclosing it to patients. “Going forward, there will be increasing expectations of transparency that should improve the informed consent process,” adds Angelos, co-author of a recent paper on this topic.2

One reason overlapping surgeries aren’t routinely addressed in the informed consent process is that it’s been common practice for decades. “It was done so commonly, particularly in academic centers, that it didn’t rise to the level of something that was necessarily discussed specifically,” says Michael Kent, MD, FACS, director of minimally invasive thoracic surgery at Beth Israel Deaconess Medical Center in Boston.

A significant number of respondents were willing to support overlapping surgeries under certain circumstances. “I was very impressed by the insight that lay respondents had,” says Kent. Written comments acknowledged that portions of an operation were critical while others were not, and that the practice allows experienced surgeons to provide care for more people. “But one consistent message was, ‘I want to know about it. I want to hear you describe it to me, and I want to provide informed consent if I agree, or disagree and not provide informed consent,’” says Kent.

Overlapping surgeries already are becoming part of the informed consent conversation at large medical centers. “If overlapping surgeries are done safely and with the appropriate informed consent, there are advantages not only to the surgeon and hospital, but the patient as well,” notes Kent.

Surgeons can provide care to more patients in a given unit of time. It might be possible for a given patient to undergo surgery in a week instead of a month, for instance.

Another recent study surveyed 200 patients and family members at an academic medical center to quantify patients’ feelings and knowledge of overlapping and concurrent surgery.3

“It was a topic that had gathered a lot of attention in national news. We sought to understand how that impacted patients’ perceptions,” says Jonathan Edgington, MD, the study’s lead author, of the Department of Orthopaedic Surgery and Rehabilitation Medicine at the University of Chicago. On average, respondents were neutral with surgical procedures involving overlap of two noncritical portions, but were not comfortable with overlap involving a critical portion of one or both surgical procedures.

One finding that stood out: strong feelings that hospitals are performing overlapping or concurrent surgery to increase revenue. “This was an important detail to glean, as it helps guide the discussion with patients with regard to the practice,” says Edgington.

Diane Payne, MD, MPT, co-author of a recent paper on overlapping and concurrent surgery,4 says nondisclosure of these practices is ethically problematic. “Disclosure is an institutional and provider issue,” says Payne, an assistant professor of orthopaedic surgery at Emory University School of Medicine in Atlanta.

Some institutions include language that covers overlapping surgeries in formal written consent forms. “But whether that language is specifically reviewed is up to the provider obtaining consent,” says Payne. For ethicists, Payne sees “a huge role in educating providers as well as administrators — assuming that the ethicists are aware it happens.” 

REFERENCES

1. Kent M, Whyte R, Fleishman A, et al. Public perceptions of overlapping surgery. J Am Coll Surg 2017; 224(5):771-778.

2. Hoyt DB, Angelos P. Concurrent surgery: What is appropriate? Advances in Surgery 2017: 51(1):113-124.

3. Edgington JP, Petravick ME, Idowu OA, et al. Preferably not my surgery: A survey of patient and family member comfort with concurrent and overlapping surgeries. J Bone Joint Surg Am 2017; 99(22):1883-1887.

4. Levin PE, Moon D, Payne DE. Overlapping and concurrent surgery: A professional and ethical analysis. J Bone Joint Surg Am 2017; 6;99(23):2045-2050.

SOURCES

• Peter Angelos, MD, PhD, FACS, Linda Kohler Anderson Professor of Surgery and Surgical Ethics/Associate Director, MacLean Center for Clinical Medical Ethics, the University of Chicago. Email: pangelos@surgery.bsd.uchicago.edu.

• Jonathan Edgington, MD, Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago. Email: jonathan.edgington@uchospitals.edu.

• Michael Kent, MD, Director, Minimally Invasive Thoracic Surgery in the Division of Thoracic Surgery and Interventional Pulmonology at Beth Israel Deaconess Medical Center, Boston. Phone: (617) 632-8252. Email: mkent@bidmc.harvard.edu.

• Diane Payne, MD, MPT, Assistant Professor of Orthopaedic Surgery, Emory University School of Medicine, Atlanta. Phone: (404) 778-1550. Email: diane.payne@emory.edu.