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Concurrent surgeries come under new scrutiny

Beth Israel Deaconess Medical Center has told surgeons that “plans for overlapping surgery should be disclosed to the patient prior to the surgery.”

Jonathan Wiggs/Globe Staff

Beth Israel Deaconess Medical Center has told surgeons that “plans for overlapping surgery should be disclosed to the patient prior to the surgery.”

In Minnesota, heart surgeons occasionally performed overlapping operations at hospitals roughly eight miles apart, leaving the second patient waiting under anesthesia for the doctor to arrive.

In Wisconsin, a medical school paid $840,000 this year to settle a lawsuit alleging that neurosurgeons illegally billed Medicare for simultaneous spine surgeries that were largely done by unsupervised medical residents.

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And here in Boston, a patient at Beth Israel Deaconess Medical Center confronted her doctor in 2011 after learning that he had rushed her into surgery — necessitating a more powerful anesthetic than she wanted — because he was juggling two operating rooms.

Disputes over surgeons running more than one operating room have erupted at hospitals across the country in recent years, some of them long before double-booked surgeries became a divisive issue inside Massachusetts General Hospital — divisions that burst into public view after a Spotlight Team report this fall. The conflicts were, at the time, treated as local and separate events, and simultaneous surgery remained unknown to much of the public even though it is widely practiced.

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Now, in the wake of the Mass. General controversy — which led to the dismissal of the hospital’s leading critic of double-booking and ongoing federal and state investigations — the world’s largest surgeons’ organization is considering new guidelines for overlapping surgery, and numerous hospitals are examining their own policies.

The American College of Surgeons plans for a roughly 10-member committee — which includes both critics and supporters of concurrent surgeries — to craft a consistent approach to keeping patients safe and informed when doctors run two operating rooms, according to Dr. David Hoyt, executive director of the organization.

“We are going to move as quickly as we can on this,” Hoyt said. “This is a priority.”

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A Globe survey of 47 hospitals nationwide found that it is common for surgeons to start a second operation before the first is complete, often after the surgeries were deliberately scheduled to overlap briefly. However, some surgeons have operations that run simultaneously for longer periods. And few hospitals call on doctors to explicitly tell patients when their operations are double-booked.

At least one member of the College of Surgeons committee said he is deeply troubled by simultaneous surgery, especially when operations overlap for extended periods.

“Two cases at the same time with one surgeon — you’re talking about a formula for disaster,” said Dr. L.D. Britt, chairman of the department of surgery at Eastern Virginia Medical School and a past president of the American College of Surgeons. “Two patients with one surgeon trying to go from room to room with complex cases — that’s unacceptable. It should be abolished.”

Another committee member, Dr. Keith Lillemoe, chief of surgery at MGH, has publicly defended the practice of simultaneous surgery. He declined to speak to the Globe, but he led Mass. General’s recent effort to devise rules restricting concurrent surgery, writing to another surgeon, “Double booking is fine, if done properly.”

Beyond the College of Surgeons initiative, there has been considerable rethinking of the practice since the Globe report. At least nine institutions, including Duke University Health System, University of Michigan Health System, and Dartmouth–Hitchcock Medical Center, have taken a fresh look at how to manage overlapping surgeries, created comprehensive policies for the first time, added new restrictions, or considered more disclosure to patients.

Dr. Allan Kirk, head of surgery at Duke, said officials there decided to create one uniform policy at its three hospitals and to consider whether physicians should explicitly tell patients that their operation could overlap with another by the same surgeon.

“Your story has . . . spurred more open discussion about the practice of overlap and concurrency with our faculty and surgical trainees,’’ Kirk wrote in a recent e-mail.

‘We are going to move as quickly as we can on this. This is a priority.’

Dr. David Hoyt, American College of Surgeons executive director 
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Other major hospitals either have no written concurrent surgery policy or declined to discuss the topic altogether. More than a dozen institutions, including Stanford Health Care, New York-Presbyterian Hospital, and the University of Pittsburgh Medical Center, refused to answer any questions.

Their silence comes as no surprise to some double-booking critics.

“This is the surgical establishment. There is a lot invested here in keeping the status quo,” said Dr. Stanley Shapshay, a surgeon at Albany Medical Center who said he was rebuffed in the spring of 2014 when he approached the American College of Surgeons with concerns over concurrent surgery.

Double-booking is also coming under the scrutiny of a prominent member of Congress. Senator Charles Grassley of Iowa, known for taking on health care fraud, sent a letter this month to the federal Centers for Medicare & Medicaid Services questioning whether concurrent surgery rules are strict enough. The Medicare program requires surgeons to be present for “critical or key portions” of each surgery, but leaves it up to the physicians to decide what is critical and does not require them to tell patients when their cases will overlap with the care of other patients.

Grassley, in an interview, said he had never previously heard of overlapping surgery and that it defies his “Midwestern common sense” for surgeons not to “stay until everything is sewed up.”

If doctors are going to run two rooms, the Republican senator said, “it’s got to be pretty well-defined, and it’s got to be policed by [Medicare regulators], and you’ve got to make sure that patients are well-informed about it.”

Little consensus on routine practice

Hospital leaders at many institutions embrace concurrent surgery as a way to efficiently deploy their most popular surgeons and cut down on wasted operating room time. Senior doctors, the thinking goes, can focus on the tasks that demand their unique skills while surgical trainees do more routine parts, like making incisions and stitching up patients, so surgeons can move from one operating room to the next.

In fact, overlapping cases is fairly routine, according to the Globe survey. Patients are sharing their surgeon for some part of the case 15 percent of the time at MGH and Cleveland Clinic, less than 10 percent at the University of California San Francisco, and roughly 4 percent at Tufts Medical Center, according to numbers provided by those institutions.

MGH is the only hospital that provided data on a less common but more controversial type of overlap, when at least one of the two patients has an open incision. Three percent of MGH surgeries, about 1,000 operations a year, fall into that category.

But there is little consensus or scientific research on what surgical procedures are appropriate for double-booking, the allowable degree of overlap, and the proper role for surgical trainees. Hospitals can’t even agree on what to call the practice — double-booking, staggering, concurrent, simultaneous, and sequential are among the terms used — though all say they follow Medicare rules.

At Mass. General, the Globe found, a small group of medical staffers complained about at least 44 alleged problems involving concurrent surgeries in the last decade. They included cases where surgeons allegedly didn’t respond when an urgent need arose or didn’t show up, leaving the surgery to a resident or fellow; cases of patient complications, including the deaths of two elderly patients; cases where patients waited under anesthesia for the surgeon to arrive or return; and cases where operating room staff were confused about who would do the operation.

MGH officials disputed the importance or validity of almost every allegation and said internal studies found no significant difference in complication rates between overlapping and non-overlapping cases. A University of Virginia study also found no increase in complications in operations that overlapped by up to 45 minutes under closely monitored conditions.

Several institutions tried to distance themselves from the controversy at Mass. General. Officials at New England Baptist Hospital and NYU Langone Medical Center made public statements that they do not perform concurrent surgery at all. But both hospitals later acknowledged allowing some overlap so that doctors can start a second case before the first patient leaves the operating room.

“This is a practice which is pretty much universal in teaching hospitals in this country. It’s also not a fire that people want to run into very eagerly,” Dr. David Torchiana, chief executive of MGH’s parent company, Partners HealthCare, said this month at a meeting of the Greater Boston Chamber of Commerce. “So if you call up a chief of surgery who’s not at Mass. General and say, ‘So what do you guys do with overlapping cases?’ you’re going to get a carefully worded answer that tries to kind of keep them out of the discussion themselves.”

What appears to be less common than staggered surgeries is scheduling two complicated procedures at the same time with hours of overlap such as the 2012 operation the Globe reported on involving Tony Meng, an MGH spine patient who was left paralyzed. There is no evidence in the medical records that the overlap of about seven hours played a role in Meng’s sudden paralysis, a known risk of the surgery, but concerns over the case prompted a prominent orthopedic surgeon at MGH, Dr. Dennis Burke, to alert state regulators after he learned of it. Meng filed a lawsuit against his surgeon, Dr. Kirkham Wood.

The state Board of Registration in Medicine is continuing to investigate cases of double-booking at the hospital, as are attorneys for US Attorney Carmen Ortiz and state Attorney General Maura Healey.

MGH, in the wake of concerns raised by Burke and anesthesiologists, developed a more comprehensive concurrent surgery policy that, among other things, stopped allowing surgeons to double-book certain complex spine surgeries in late 2012.

The Globe survey showed that Mass. General’s policy is stricter than some institutions’ — requiring reviews of surgeon compliance four times a year, for instance — and, unlike most hospitals contacted, Mass. General was willing to publicly share its policy. But policies at some other hospitals appear to be more restrictive.

For example, University of Michigan Health System requires surgeons to finish all key parts of one case before starting another — and prohibits them from scrubbing back into the first case once they begin a second. Michigan also mandates that the attending surgeon be present for the surgical team huddle before the first incision is made. The MGH policy has no limit on going back and forth between surgeries and allows surgeons to participate in the huddle by phone.

Hospitals are fairly consistent on one thing: not requiring surgeons to explicitly tell patients when they will be caring for a second patient at the same time. Several hospital policies require some disclosure, such as consent forms at the University of Cincinnati Medical Center and MGH that say some parts of the procedure may be performed by residents, or the requirement at Tufts that if surgeons will not be present for “any portion(s) of the surgical procedure, the patient must be informed and provided with complete disclosure.”

A policy revision adopted last month at Beth Israel Deaconess comes close to mandating disclosure, telling surgeons that “plans for overlapping surgery should be disclosed to the patient prior to the surgery.”

Patients often find it unsettling to learn by chance that they have shared their surgeon with another patient. Linda Garnitz of Sharon said that on the morning of her father’s surgery with Dr. David Sugarbaker, Brigham and Women’s former chief of thoracic surgery, she ran into relatives of two other patients who had been scheduled with Sugarbaker for the same time as her father, who was also a surgeon, according to Garnitz and two other family members who were present.

“My father never would have given his consent,” said Garnitz, though he suffered no complications from the surgery about a decade ago.

Sugarbaker, now at Baylor College of Medicine in Texas, said in an e-mail that he did not recall details of the case: “I have no knowledge of any conversations regarding the surgical scheduling of that case, and I have no knowledge of the source or accuracy of the information reportedly discussed.”

More generally, however, Sugarbaker explained that some surgeries are conducive to overlapping because they include significant amounts of time when other members of the surgical team are getting the patient ready for the surgery.

Surgeons nationwide have conflicting views on the benefits and risks of concurrent surgery. Some are overwhelmed by the demands of managing two patients at the same time, while others say it allows them to make best use of their specialized skills.

Dr. Robert Pedowitz, the former chair of orthopedics at UCLA Medical Center, said he occasionally ran two rooms more than a decade ago but stopped after a few years.

“Over time I decided it was really not a very good practice for the sake of patients and I stopped doing it,” Pedowitz said. “It was too stressful for me because I wasn’t able to be there for the whole surgery” and he feared there would be mistakes that he would not be present to prevent.

The challenges also became clear to Dr. Ralph “Chip” Bolman when he was working in Minnesota and operated at two hospitals about eight miles away from each other.

Sometimes, Bolman was late getting to the next surgery, leading to complaints that patients were waiting needlessly under anesthesia with open incisions made by trainees, according to Dr. Robert Gauthier, who was an anesthesiologist at Regions Hospital in St. Paul.

“I was aware that there were concerns about these rare occurrences that were raised at the time,” Bolman wrote to the Globe. “High quality patient care is my highest priority, so I responded to these concerns by involving additional staff surgeons at Regions Hospital over time, as the administration would allow.”

Bolman, who came to Brigham and Women’s Hospital as chief of cardiac surgery in 2005, said during his tenure in Boston, he tried to restrict overlapping surgeries by other doctors and ensure patients knew when another surgeon would be involved in their care. Bolman left this year for the University of Vermont Medical Center.

Rush University Medical Center settled a federal whistle-blower suit filed in 2004 alleging that orthopedic surgeons, including Dr. Brian J. Cole, billed Medicare for overlapping surgeries that were done by residents.

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Rush orthopedic group in Chicago settled a federal whistle-blower suit filed in 2004 alleging that orthopedic surgeons, including Dr. Brian J. Cole, billed Medicare for overlapping surgeries that were done by residents.

But other surgeons, particularly in orthopedics, see real value in starting a second case before the first one finishes because the operations typically unfold in a predictable way, sometimes over many hours.

Dr. Robert Booth Jr., an orthopedic joint specialist who worked for years at Pennsylvania Hospital in Philadelphia, said his use of surgical trainees to handle more routine aspects of surgeries helped him reduce turnover time and run operations more efficiently.

But federal prosecutors accused him of routinely scheduling his patients in four operating rooms each day from 1995 to 1997 and leaving three of the surgeries to residents and fellows. He allegedly billed for all four. Medicare began barring surgeons in 1996 from billing as the attending physician for more than two simultaneous surgeries. Booth denied the charges, but agreed to reimburse the federal government $1.89 million in 2001.

Booth responded by replacing his residents and fellows with surgical physician assistants, who are licensed to perform some tasks by themselves, such as closing and dressing surgical incisions, and ended up becoming even more productive. Booth, who now works at Aria 3B Orthopaedic Institute, performs 10 knee operations a day in two rooms with the help of two seasoned physician assistants, he said.

“They close the skin better than I do,” he said.

A slew of legal scrutiny

Federal laws leave considerable discretion to individual surgeons to decide how to manage cases, making the rules difficult to enforce. As a result, disputes over double-booking sometimes came to a head only when individual doctors, nurses, or medical billing workers were willing to risk their careers to call attention to what they consider a hazard to patients.

Ganesh Elangovan said he was fired when he was a fourth-year resident in neurosurgery in 2010 after complaining that teaching physicians at hospitals affiliated with the Medical College of Wisconsin were scheduling multiple simultaneous spine surgeries, leaving him and other residents to perform some operations unsupervised.

So Elangovan went to federal prosecutors.

In January, the US attorney’s office announced that the Milwaukee-based medical school had paid the government $840,000 to resolve allegations it defrauded federal health care programs by billing for procedures at hospitals affiliated with the college that involved improperly supervised residents.

“I filed this lawsuit for one simple reason,” Elangovan, who has since left medicine, wrote the Globe in an e-mail. “I believe that leaving residents entirely unsupervised during a surgery is dangerous, and because of that, I simply could not keep silent.’’

A spokeswoman for Medical College of Wisconsin said the case focused on compliance with Medicare regulations, not patient safety, and that the institution has enacted changes to ensure compliance.

Similarly, in Chicago, a surgeon and an executive at Rush University Medical Center filed a federal whistle-blower suit in 2004 alleging that orthopedic surgeons there billed Medicare for overlapping surgeries that were done by residents. The Rush orthopedics group settled the case for $2.1 million on behalf of the six doctors, including Dr. Brian J. Cole, a team physician for the Chicago Bulls, according to the Illinois attorney general’s office. Rush and Cole declined to comment.

More recently, in Tennessee, three anesthesiologists charged that surgeons at Vanderbilt University Medical Center ran multiple operating rooms simultaneously, leaving residents to do critical parts of operations. Vanderbilt has denied the allegations, contained in a 2011 federal lawsuit that is still pending.

Finally, in New York, Dr. James Holsapple, a neurosurgeon formerly at SUNY Upstate Medical University in Syracuse, sued the hospital in 2011 for allegedly retaliating against him when he objected to the double-booking of complex spine operations. Holsapple, now chief of neurosurgery at Boston Medical Center, alleged that a patient suffered a serious spinal fluid leak after two surgeons not qualified for such procedures had to fill in because the attending got stuck handling another simultaneous case.

At MGH, Dr. Dennis Burke, frustrated by the response to his complaints, drew the ire of hospital administrators after he shared his longstanding concerns about double-booking with the Spotlight Team. Burke was ultimately dismissed in August for allegedly violating patient privacy by providing the Globe with redacted copies of his own surgical case records.

“Concurrent surgery is like the elephant in the room. Everyone knew about it [at MGH], but no one would talk about it,” Burke told the Globe recently. “What could be a higher safety issue than whether the surgeon is present in the room?’’

Dina Rudick/Globe Staff

Dr. Dennis Burke.

Dr. Peter Slavin, Mass. General’s president, has previously said that the hospital took Burke’s concerns seriously, and studied the practice, examining two years of orthopedic cases. “We haven’t found a single case where the concurrency has caused harm, so I don’t think patients should be alarmed about it,” Slavin said in an interview earlier this year.

Responses from patients and medical staff to a Globe survey accompanying the October Spotlight report revealed double-booking stirred conflicts at many hospitals, including in Boston, though less publicly than at Mass. General.

Moments before Jo-Ann Rosen’s surgery at Beth Israel Deaconess Medical Center in 2011, she said she overheard a nurse discussing that her hand surgeon, Dr. Charles Day, was in a rush and running two rooms.

Rosen said that there was no time to wait for the nerve block she had requested so she could stay awake during her wrist surgery.

“You have to report this,” a nurse told Rosen before the milky white anesthetic injection knocked her out.

Rosen woke up in pain and furious at her doctor. During a follow-up appointment several days later, she said she confronted Day and he apologized.

“I think I had a right to know he was running two rooms,” said Rosen, who suffered no long-term harm from the surgery. She filled out the Globe survey but never filed a formal complaint.

Day, through a hospital spokeswoman, declined to comment. But concerns about his management of surgeries continued until June 2015, when the hospital suspended him for among other things, failure to follow rules on “supervision of nurse or other employee,” according to the state Board of Registration in Medicine website.

The hospital declined to detail the action against Day, and whether double-booking was a factor. But spokeswoman Jennifer Kritz issued a statement: “Whenever we hear concerns about patient care, we work hard to understand and address them. In this case, as our public filing makes clear, we became aware of concerns related to Dr. Day, initiated a thorough review and took disciplinary action, which resulted in his surrendering his hospital privileges.”

Some surgeons hope that new efforts to create national guidelines for concurrent surgery will resolve the ongoing battles. As Dr. Kirk of Duke said, “There are ways to run two rooms properly — Medicare recognizes that — and there are ways not to do it, and most of the angst usually stems from people doing it poorly.”

Jenn Abelson can be reached at jenn.abelson@globe.com. Follow her on Twitter @jennabelson. Jonathan Saltzman can be reached at jonathan.saltzman@globe.com. Liz Kowalczyk can be reached at lizbeth.kowalczyk@globe.com. Follow the Spotlight Team on Twitter @GlobeSpotlight.
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