Opinion

PETER L. SLAVIN AND THOMAS J. LYNCH

Our view of overlapping surgery

The main facade of Massachusetts General Hospital.

Pat Greenhouse/Globe Staff

The main facade of Massachusetts General Hospital.

WHEN PATIENTS WALK through the doors of Massachusetts General Hospital, they place their trust in our institution to help them with their most precious of all assets — their health and well-being. And every day, thousands of dedicated MGH staff members take that trust to heart and do everything they can to deliver the safest, highest quality, most compassionate care. Providing exceptional care is more than a mission for us, it is a covenant we make with patients and their families — and one we are profoundly committed to uphold.

The Globe has published a number of stories questioning a practice known as overlapping surgery. Overlapping surgery involves the close coordination of procedures for a surgical team so that preparation for one patient — draping, positioning, anesthesia — begins in one operating room as the care of another patient finishes in another room. At MGH, any type of overlap occurs in 15 percent of surgical cases, but in only a minority of these (3 percent) is there overlap of the surgery itself. Under all circumstances, the patient’s surgeon remains responsible for the care. The practice, managed thoughtfully and carefully, benefits patients, families, and staff.

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Overlapping surgery occurs at MGH and hospitals throughout the country for a variety of reasons. Overlapping surgery saves lives in certain clinical situations, such as after the Boston Marathon bombings and the Rhode Island Station nightclub fire, when multiple critically ill patients need rapid access to surgical care. Overlapping surgery enhances access to care, helping meet the high demand for certain specialties and specialists. Staggering appropriate cases also enables more procedures to occur during daytime hours, when the hospital is fully staffed and services such as laboratories and radiology are readily available. Overlapping surgery allows patients to be cared for in a manner that reduces wait times between cases and enhances the efficient use of expensive operating rooms. Overlapping is also the standard when multiple surgeons are involved, for example when a breast surgeon performs a mastectomy and then a plastic surgeon performs the reconstruction.

Various regulatory agencies responsible for patient safety have reviewed overlapping surgery at the MGH and deemed it safe, affirming that our hospital practices according to accepted standards. The Joint Commission, which accredits hospitals, received an anonymous complaint, looked into our practice, and recently informed us it has closed its review with no action required. Similarly, the Massachusetts Department of Public Health, also responding to an anonymous complaint, assessed our practice and policies and issued a report calling the allegations “invalid.” Beyond these investigations, the American College of Surgeons called Mass. General’s overlapping surgery policies “best practice” and noted they “exceeded standards.”

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Every time concerns have been raised, we have taken a critical look at our practices. In 2011, we engaged former US attorney Donald Stern to review allegations made by a senior MGH surgeon. The review was conducted under attorney-client privilege to ensure that those interviewed would respond freely and fully, and Stern reassured us that the allegations were not supported by his findings. At that time, the hospital was in the midst of a multiyear process to define and strengthen our surgical policies, an effort that led to a more robust overlapping surgery policy and consenting process adopted in 2012.

We have also compiled and analyzed data and found the complication rate for overlapping surgery to be the same as for non-overlapping surgery. In addition, we examined 25 overlapping procedures where complications had occurred and in every case determined that the complication was unrelated to the overlapping. Even the Globe indicated it could find no evidence that overlapping leads to patient harm, citing a study from the University of Virginia with similar findings.

In addition, the Globe questioned our consent process and information patients are given prior to their procedures. At MGH, consent for surgery often involves multiple conversations with the care team. During these conversations, the attending surgeon describes the team approach and makes sure patients understand that residents and fellows may be involved in the care. Attending surgeons also explain what will happen during the procedure, including the role of team members. The MGH policy, in fact, explicitly states that “prior to the procedure, the involvement of the attending surgeon will be discussed with each patient and/or family.”

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In the past five years, we have thoroughly examined the practice of overlapping surgery at MGH. Each anecdote and allegation has been carefully analyzed and assessed. If there is a better, safer, more effective way to take care of patients, then we will embrace it. Indeed, medicine advances when questions are raised, studied, analyzed, published, and shared. Overlapping surgery is certainly a reasonable topic to examine. The Globe’s stories and columns, in our view, have mischaracterized our hospital, our surgeons, our care, and our commitment to quality and safety.

Our best response is to continue to take exceptional care of those who count on us. To date, we are not aware of any patients who have canceled or postponed surgery because of this issue, and we appreciate this confidence in the care we provide. Our staff has been heartened by the messages, calls, and encouragement from the patients, families, and communities we serve — those who have experienced firsthand our unwavering commitment to their health and well-being.

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: katie.kingsbury@globe.com and marjorie.pritchard@globe.com.

Dr. Peter L. Slavin is president of Massachusetts General Hospital. Dr. Thomas J. Lynch is the CEO and chairman of the Massachusetts General Physicians Organization.
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