Putting patients before speed in busy operating rooms

Last year, the Boston Globe covered an exclusive story about hospitals and surgeons practicing simultaneous surgeries.

This story highlighted a commonplace practice in surgery – especially at large academic medical centers, where residents and fellows are being trained.

Now, the U.S. Senate's finance committee has taken up the cause and is poised to introduce legislation to curtail this practice.

Though, in general, I think it is an overreach of federal power to interfere with a professional practice, the blame for this necessary intervention rests squarely on the medical establishment's broken ethical compass.

The basic idea of simultaneous surgery is that a surgeon schedules overlapping operations on different patients, and uses trainees to keep the procedures going - while the senior surgeon "bounces" between rooms for the "critical" parts of each operation.

Working this way can be done safely, but it requires that the surgeon have tight command and control of both the trainees and the operation. In my experience, it is only the best and most confident surgeons who can actually do this --and it's typically only done with assistance from more senior trainees.

I would venture to say that all surgical residents at busy academic surgery training programs have come across this practice pattern and participate in it. In fact, with most surgical residents, there is a level of bravado involved with getting the cases done efficiently – safety being an assumed, but perhaps secondary, issue.

In many cases, the surgeon judges a trainee's competenceby how far along they can move in a procedure, and how quickly, without the senior surgeon being present.

But this is a terrible training yardstick, where the primary purpose is speed – not the patient's wellbeing, or the quality of training.

Many surgeons who practice in this way may disagree with my statement, because no physician wants to admit that their top priority is not the patient.

But if and when things do go wrong in this kind of setting, how often does the blame go to the trainee?

Surgical training is mentally and physically rigorous on the trainee, as it should be. Some trainees are more adept and confident than others – and those fit the "profile" for their busy surgical mentors.It is true that not all trainees can keep up with the professors.

But what's unacceptable is when a patient's condition is made worse because of a complication that results from this "needforspeed." And these complications do happen, not infrequently, as the Globe  has reported.

Most importantly, it's precisely because surgery is a business that it has become very easy to think of surgical operations as a revenue source, where "time is money."

The busiest surgeons, with the best outcomes, make the most money – and it stands to reason that the more operations they do, and the faster they are done, the more money is made.

No matter how nearly perfect a surgeon's outcomes may be relative to their colleagues' – the only relevant question is if speedhas ever led to avoidable harm to even a single patient. And, whether a trainee was ever pushed to move faster than he/she was ready to when operating on a patient.

At a time when corporate medicine is winning over medical ethics, and when salaries and promotions depend on how many RVUs a surgeon generates, it's no surprise that our ethical compass is broken.

Patients have a right to be informed if a surgeon plans to perform simultaneous surgery – and to always meet the resident or fellow who will be the assistant.

But, even more important is for busy surgeons to honestly examine their own motivations – because simultaneous surgery almost always opens the door to avoidable complications a seasoned surgeon could eliminate.

As Boston's Dr. Dennis Burke told the Globe, "A surgeon's place during surgery is at his patient's side".

Hooman Noorchashm earned his MD and PhD degrees at the University of Pennsylvania's Perelman School of Medicine. He then went on to complete specialty training in General and Cardiothoracic Surgery in Philadelphia and Boston.

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