By Stacey Kusterbeck
Overlapping surgery can allow surgeons to get more patients into surgery faster and expedite treatment. The practice also plays a role in trainee autonomy and developing safer surgeons. “But it is a topic that many providers and patients are understandably hesitant to discuss,” says Margaret Mitchell, MD, MS-HPEd, lead author of a recent study examining informed consent and overlapping surgery.1
Overlapping surgery is the practice of one attending surgeon operating in two different operating rooms (ORs) on two different patients. Critical portions are staggered so the attending is present during the critical portions of the surgeries in each OR. “This is a practice that is allowed as long as it follows appropriate guidelines. What is not allowed is termed ‘concurrent’ surgery, where there are two ORs going and the critical portions are occurring at the same time,” explains Mitchell.
Overlapping surgery was spotlighted in the media a decade ago.2 “This led to many different groups weighing in, from the Senate Finance Committee to physician-led organizations,” says Mitchell.3,4 Mitchell and colleagues wanted to see what effect all these statements and new policies had within individual hospitals. “There can be a disconnect between what is happening at a policy level and what patients are experiencing on an individual level. We wanted to understand what language was being used with patients in these discussions on an everyday basis,” Mitchell explains.
The researchers analyzed informed consent documents at 104 institutions.4 Some key findings:
- Less than one-third (29%) of the informed consent forms included verbiage on overlapping surgery and/or the absence of the attending surgeon during a surgical case. “This is worrisome that this discussion may not be happening, which is a threat to patient autonomy,” says Mitchell. However, it is possible that surgeons still may be discussing this practice with patients. “The important part here is that this conversation is occurring and that patients are aware of and engaged in their care,” says Mitchell. The advantage of having this verbiage in the informed consent document is that it acts as a checkbox to ensure the topic has been discussed. “But many institutions may instead choose to have these providers have the discussion verbally with patients. If it is not in the forms, we do worry it may not be happening. But it is hard to know the practices at different institutions,” says Mitchell. Surgeons may be in the habit of verbally explaining who will be doing the surgery, what parts of the case that person will be doing, and what kind of training that person has. Surgeons are not necessarily documenting all of that in the informed consent forms. “Often, different members of the care team meet patients before surgery, and this discussion comes about organically as well. How each surgeon approaches this topic may vary. And how much patients may want to know likely varies as well,” says Mitchell.
- Just three forms stated explicitly that portions of the procedure may be performed without the attending surgeon present.
- Six forms specified who may perform the procedure in the absence of the attending surgeon.
- Three forms had patients sign or initial this section of the consent form.
- Just two of the forms met all the criteria set forth by the Senate Finance Committee (which states that the informed consent process should include an explanation to patients that their surgery may be overlapping and what this means).
“The reason to include this information on the consent form is as a prompt to the patient and surgeon that overlapping surgery is an important topic to discuss and meaningful to informed consent. While surgeons might be discussing this topic even when it’s not on the consent form, historically, this was not always happening. It is thus reasonable and ethically appropriate for hospitals to ensure that every effort is made to inform the patient about this practice,” says Alexander Langerman, MD, SM, FACS, another of the study authors and professor of otolaryngology and faculty at the Vanderbilt Center for Biomedical Ethics and Society.
Such discussions can become time-consuming. Surgeons may find it difficult to succinctly describe the difference in training between trainees of different levels, such as medical student, resident, or fellow — and the role of each in a particular surgical case. “Surgeons may worry that patients may cancel their surgery or find another provider or even be more likely to pursue litigation if there is a poor outcome,” adds Mitchell.
The surgical informed consent process should focus on the fact that the surgeon will perform the critical component of the case, according to Amit Jain, MD, MBA, associate professor of orthopaedics and neurosurgery and chief of minimally invasive spine surgery at Johns Hopkins University. “Surgeons are ethically obligated to disclose to the patients that the surgeon will perform the critical portion of the procedure, and that other team members, who are capable and proficient, will be performing non-critical portions of the procedure,” says Jain.
Most of the time, overlapping surgeries do not actually involve the critical portion of the case, says Jain. “There are a number of things that happen during the surgical episode that don’t directly have to do with the critical portion,” says Jain. For example, prior to a hip replacement, a patient may require a Foley catheter to empty their bladder. The placement of the catheter is not a critical portion of the case, and, therefore, easily can be performed by someone else while the surgeon is doing something else — perhaps even another case. Similarly, some surgeons have a practice where they have another team member position the patient or do the final closure. “Assuming those are not considered critical portions of the case, the surgeon may not think much about it. If critical portions of the case are performed without the attending surgeon, that is ethically inappropriate,” says Jain.
Claire Hoppenot, MD, assistant professor of gynecologic oncology at Baylor College of Medicine, encourages surgeons to discuss medical education and the role of trainees such as fellows and residents, or even medical students, in surgeries and postoperative care. “It would also help clarify the amount of oversight provided during these procedures to reassure patients they are being treated by standard of care — or better!” says Hoppenot.
Patients often appreciate hearing that a resident or fellow will be involved with the case, that they may participate a little or a lot based on their level of training, and that they always will have supervision and oversight in the OR and in the postoperative care.
“Many patients have no concerns about trainee involvement and understand that their surgeon’s good results in the operating room occur within this system of trainee involvement,” says Hoppenot. Patients who do have questions are concerned about the involvement of someone with less experience and the potential for increase in complications. For this reason, surgeons stress that trainee involvement is based on their level of training. Some trainees will do very little in a procedure, while others may participate in major portions. “A discussion like this can help patients understand and trust the system and their surgeon and have any questions answered,” says Hoppenot.
Although informed consent documents are a marker of the discussion, the forms are less important than the actual discussion itself, adds Hoppenot. Consent forms can serve as a reminder of certain aspects of the surgical process that need to be discussed. “There are so many things to address,” says Hoppenot. Baylor’s surgical consent forms outline the involvement of medical students and that the surgeon will be present and participating in key and critical portions of the procedure, for example. This reminds surgeons and nurses helping with the consent process to include this information in the preoperative discussions.
If the surgeries are staggered and not done simultaneously, then no informed consent is required about the timing of the surgeries, says Joseph Bosco, MD, vice chairman for clinical affairs of the NYU Langone Department of Orthopedic Surgery, and professor of orthopedic surgery at the NYU Grossman School of Medicine. At NYU, when surgeons are allotted two ORs, in the time one OR is being cleaned and the patient is being prepared for surgery (prepping, draping, and anesthesia administration), the surgeon can perform the other case in the other OR. The cases are staggered, with the surgeon present for the initial incision and closure of the surgical procedures in both rooms. The surgeries are not overlapped or performed simultaneously. “Total joint replacements are the ideal surgical procedures for staggered surgeries. Their timing is predictable and fits perfectly with the time it takes to prepare an OR and patient for surgery,” says Bosco.
Occasionally, a patient asks Bosco if he will be doing the surgery or if an assistant will. “I tell them I am the surgeon in charge, and I have assistants who help with the case and may close the wounds under my supervision,” says Bosco.
Each patient should understand the risks and benefits of the surgery for them to give informed consent. “Reasonable people agree that detailing the hundreds of steps in a surgery and who performs them is not helpful to the patient and only detracts from the message,” says Bosco.
Stacey Kusterbeck is an award-winning contributing author for Relias. She has more than 20 years of medical journalism experience and greatly enjoys keeping on top of constant changes in the healthcare field.
References
1. Mitchell MB, Lin G, Prasad K, et al. Overlapping surgery verbiage in informed consent documents. Ann Surg. 2025;282(2):254-257.
2. Abelson J, Saltzman J, Kowalczyk L, Allen S. Clash in the name of care. The Boston Globe. Published Oct. 25, 2015. http://apps.bostonglobe.com/spotlight/clash-in-the-name-of-care/story/
3. United States Senate Finance Committee. Concurrent and overlapping surgeries: Additional measures warranted, Published Dec. 6, 2016. https://www.finance.senate.gov/download/finance-concurrent-surgeries-report
4. American College of Surgeons. Statements on principles. Published April 12, 2016. https://www.facs.org/about-acs/statements/statements-on-principles/#anchor172771
