Careful, compassionate, concurrent surgery
CONCURRENT SURGERY, THE practice of a surgeon having two operating rooms going at the same time, has been the subject of considerable public attention after the Globe’s Spotlight team released an investigative report of this practice at Massachusetts General Hospital. This is an important topic to me, because, as a head and neck cancer surgeon, I practice concurrent surgery at times. I also, in my academic job, research the operating room and how to make surgical care safer and more efficient.
The surprised reaction that many people had about the existence of concurrent surgery makes sense to me — the general public does not know much about the day-to-day activity of the operating room beyond what is portrayed on television. When friends and relatives ask me about my job and about my sometimes all-day cases, they commonly ask questions such as, “How do you go to the bathroom?” and “How do you go all day without eating?” They presume that I’m in the OR the whole time my patient is. The truth is, sometimes I’m not — and in these instances, I believe this is for the best.
I operate in a teaching hospital, which means I nearly always have the assistance of junior doctors who are in training as residents or fellows. A lot of surgery is simple maneuvers — cutting, retracting, sewing — and the foundation of surgical training is perfecting these maneuvers. The first time my residents close an incision, I watch every stitch as well as how they grasp the surrounding tissue, the position of their hands, even the way they hold their bodies. I’m teaching not only my vision of perfect technique but also efficient technique. When residents show aptitude, I relax, and, little by little, let them do more on their own — especially when I see that they recognize on their own when a stitch is out of place and needs to be fixed.
There are two key reasons I will leave an operating room during an operation. First, and most commonly, I make it a point to take breaks, to recharge my mind and body, eat some food and go to the bathroom. Surgery is taxing both mentally and physically, and a quick break keeps me performing at my best. Second, I need to help other patients. This may be as simple as quickly checking a scan or a laboratory test that has urgent importance, or it may be that I have to examine a patient or even that I have a patient being prepared in another operating room who needs my attention. The latter (and even the former) can be surprising to patients.
Cancer doesn’t wait around, nor do many surgical problems. As a specialist, I work to help as many patients as possible in a timely manner and find ways to get more patients into my allotted operating room time. One of the ways I do this is I plan ahead — I book my cases precisely, I ensure the proper tools are there, and I keep my team on track to minimize wasted time in the operating room. When I have the opportunity, another way I do this is to line up patients in two operating rooms so that I can move from one patient to the next — focusing my efforts on what we call the “critical portions” of each patients’ surgical procedure. This is the concurrent surgery that has received so much attention.
When I handle concurrent procedures, I have to carefully design the schedule around when I can and cannot be absent from an operating room. Surgical procedures have “critical” and “noncritical” portions, and this changes on a case-by-case basis depending on the patient and his or her unique problem as well as the team I’m working with. For instance, if I’m working with a brand-new intern, then every moment, from preparation to wake-up, is critical. If I’m working with a seasoned fellow with five years of operating experience, then the critical portions are much more focused. For instance, in one of my cancer operations, cutting out the cancer is unquestionably critical, but getting down to it or closing up afterwards may or may not be.
The hard part of surgery isn’t the doing, it’s the planning. True, there are some elements of cases that I would trust to no one’s hands but my own — these are absolutely “critical portions” — but it is the judgment about how to approach a problem, and how to handle it, and how to clean up afterwards that is my most important service to my patients. By analogy, I may be an excellent builder, but I am first and foremost an architect of surgical cases, and I subcontract some of the more routine elements to my trusted assistants — assistants with whom I have trained and worked alongside many times.
This is the way I and every surgeon before me acquired surgical skills, slowly doing more and more of an operation, until I had enough skill and judgment to start handling cases on my own.
Now, as the teacher, I must balance the requirement to provide excellent surgical care with the need to give independence to my trainees. My approach is to follow the advice of one of my mentors, who told me the way she decided what parts of the procedure I would do was “only the parts that I can fix if you don’t do them perfectly.” This is what good surgeon-educators do — give their residents enough leash to get the experience they need, but do so in a way that ensures that our patients still get the best possible care.
Sometimes, this leash involves stepping out of the operating room. If I am watching my trainees, they know that if I am silent they are doing it perfectly. In experienced trainees, this can lead to an “autopilot” effect, where they use my silence as a proxy for their own judgment. When I step out of the room, they must think harder about each stitch, each maneuver. This is the first taste that trainees get for what it will be like once they graduate and must use their own judgment to provide good care.
Even though there are good reasons for me to leave the operating room, and even though this is a safe and routine part of surgical care at academic hospitals that has been approved by sanctioning bodies, I recognize the appropriate limits. I must always be available. What I don’t do is leave to go see my kid’s soccer match, or have a leisurely lunch off campus. What I also don’t do is leave when my trainee isn’t up to the necessary tasks. Sometimes this means that the second operating room is delayed and that my patients wait longer than anticipated before going back to the operating room. But this is how I ensure that the patient on the table gets the best possible care.
Of course, although I hope that this first-hand account of my practice casts light on the surgical process, I recognize it leaves an obvious unanswered question: A given case’s “critical portion” is a subjective definition by the surgeon, and that surgeon’s opinion is the only data we have to justify when it is safe to leave, when a trainee is ready for a task, or what parts of a case need special attention. While the subjective judgment of the surgeon is the best evidence we currently have, what we need to begin developing is objective data about what constitutes critical portions. We need to find natural points that all surgeons can agree upon, or at least develop better criteria for judging critical portions. We are on the cusp of a better and wide-scale understanding of surgical practice that will make such data possible.
Data collection and analysis take time, however. So what can we do tomorrow? If you’re a patient, in your first visit with a surgeon, ask about the plan for your case, the surgeon’s strategies for trainees, and the way the surgeon handles his or her surgical schedule. I encourage you to get to know any residents who may be involved in your operation; they are a highly valuable second set of eyes who have already completed college, medical school, and often years of training so their ideas, questions, and participation elevate care. I would argue you do not need to require the absence of trainees or the continuous presence of the surgeon but rather a well-thought-out plan that has your best interests in mind.
If you are a surgeon or part of a surgical team, discuss your plan with your patients. You should let them know whether a trainee will be participating in or handling a portion of the procedure, and you should let them know if you are going to be out of the room.
Also, I would ask my fellow surgeons to be open to greater study of the operating room and surgical activity, as objective data are our best path forward to improving surgical care. The reaction that stemmed from the recent Globe coverage has opened a valuable dialogue on surgical activities, giving us new insight into our patients’ understanding of the care we provide. This is a dialogue we should welcome, participate in, and learn from as part of our constant quest to improve our discipline.
DISCLOSURE: Ellen Clegg, the Globe’s Editorial Page editor, is the life partner of Ellen J. Zucker, a Boston attorney who serves as counsel to Dr. Dennis Burke, an orthopedic surgeon who has been publicly critical of policies at Massachusetts General Hospital. In keeping with the Globe’s guidelines on ethics, Clegg recused herself in August from any role overseeing editorials, opinion columns, or letters pertaining to MGH. The Globe’s opinion pages are a separate operation from the Globe’s newsroom, which is run by Editor Brian McGrory; Clegg has no role in determining news coverage. Editorials involving MGH are overseen by Deputy Managing Editor Kathleen Kingsbury; opinion columns and letters involving MGH are overseen by Deputy Managing Editor Marjorie Pritchard. Kingsbury and Pritchard can be reached by e-mail at: firstname.lastname@example.org and email@example.com.