Informed Consent Considerations if Surgeon Delegates Portion of Operation
Many patients assume their surgeon will be performing their entire operation when that may not be the case. “This should be part of the informed consent conversation,” according to Patricia L. Turner, MD, MBA, FACS, executive director of the American College of Surgeons. “Surgeons should emphasize to patients that surgery is a team approach. In academic settings, there will most certainly be multiple members of the team present to ensure teaching and training of the next generations of surgeons.”
Surgeons should be clear there will be other providers in the OR, and that some elements of the operation — not the critical portion the attending has to manage, but other elements — can be delegated to a qualified member of the surgical team. “However, the primary attending surgeon’s personal responsibility for the safety and the welfare of the patient cannot be delegated,” Turner cautions.
The terms “concurrent” and “overlapping” sometimes are used interchangeably. Turner says it is important to note these terms carry different meanings.1 Concurrent surgery suggests the key portions of the procedure (for which the attending surgeon must be present) are occurring in two different patients in two different rooms (i.e., concurrently). “That is not appropriate,” Turner explains. “Overlapping surgeries, however, are perfectly appropriate and reasonable as an attempt to get the best care to as many patients as possible.”
Overlapping operations allow hospitals to reduce wait times for surgery, and it allows in-demand surgeons to perform more procedures. The attending surgeon is present for the key portions of the case, but there are other elements (e.g., incision and closure) that might be delegated to other qualified surgical care team members. “This practice frees up the attending surgeon to perhaps do the critical portion of another operation,” Turner explains. “However, the attending surgeon should remain in the immediate vicinity.”
Turner says the determination of what constitutes “critical portions” of surgery, when the surgeon has to be present, is a decision the surgeon makes. “It varies based on the operation itself, based on the patient, and based on who the members of the team are,” Turner notes. “There’s a difference between someone in their first year of training and someone in their eighth or ninth year of training.”
A group of researchers interviewed 51 academic surgeons to find out how they decided what parts of a procedure are “critical” and necessitate their presence.2 Those surgeons said they relied on several factors to help them determine “critical” parts of procedures: portions that required the surgeon’s firsthand observation, portions that involved challenging anatomy, portions involving structures that could not be repaired if injured, and portions where severe consequences would result if an error was made.
Ellen Wright Clayton, JD, MD, and colleagues surveyed hospitals on policies for overlapping surgery and found policies varied significantly.3 Hospitals defined “critical portions” of surgery in different ways. Some facilities defined it as “those stages when technical expertise and surgical judgment are necessary to achieve an optimal patient outcome.” Others defined it as “skin incision to skin closure.”
The varying definition affected surgical efficiency and the autonomy of surgical trainees and patient experience. “Having discussions about what this means, and whether current practices adequately protect the patients, are important,” says Clayton, co-founder of the Vanderbilt Center for Biomedical Ethics and Society.
Clayton has identified two central ethical questions: Under what conditions is this a permissible practice? What do patients need to be told? “With increasing emphasis on transparency, it’s hard to argue that patients shouldn’t be told about this,” Clayton observes.
Patients should know if there will be other people involved in the operation, including residents. “Fear of upsetting patients by discussing this topic is not good enough. That sort of paternalism is no longer acceptable. The surgeon should talk to the patient about it,” Clayton asserts.
Paul E. Levin, MD, executive vice chairman in the department of orthopaedic surgery at Montefiore Medical Center in New York, says there are times overlapping surgeries “might be an appropriate, safe, and reasonable thing to do. Physicians have lots of challenging hats to wear, and one of them is supposed to be watching the cost of healthcare, which we’re not very good at.”
Keeping the OR in use constantly is cost-effective. “If you have a practice that is ethically sound that saves money and delivers good patient care, that is a good thing,” says Levin, who co-authored a paper on concurrent and overlapping surgery.4
Every institution is run somewhat differently. Some employ trainees, and others do not. There are many physician assistants at some facilities, but few at other places. “That’s why each institution should determine what is ethically acceptable,” Levin says. “A multidisciplinary group could approach the issue and answer the question: How can we do this safety and effectively?”
REFERENCES
- American College of Surgeons. Statements on principles. The operation — Intraoperative responsibility of the primary surgeon. Updated April 12, 2016.
- Langerman A, Brelsford K, Hammack-Aviran C. Working definitions of “critical portions”: Results from qualitative interviews with 51 academic surgeons. Ann Surg 2022; Feb 17. doi: 10.1097/SLA.0000000000005419. [Online ahead of print].
- Mitchell MB, Hammack-Aviran CM, Clayton EW, Langerman A. A survey of overlapping surgery policies at U.S. hospitals. J Law Med Ethics 2021;49:64-73.
- Levin PE, Moon D, Payne DE. Overlapping and concurrent surgery: A professional and ethical analysis. J Bone Joint Surg Am 2017;99:2045-2050.
Surgeons should be clear there will be other providers in the OR, and that some elements of the operation — not the critical portion the attending has to manage, but other elements — can be delegated to a qualified member of the surgical team. However, the primary attending surgeon’s personal responsibility for the safety and the welfare of the patient cannot be delegated.
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