The ethics column seeks to introduce readers of AUANews to the authors’ perspectives on a wide range of contemporary ethical issues faced by practicing urologists.

Case

Dr. Jones is the urologist on call this week at her University teaching hospital. She has scheduled a robotic radical cystectomy with neobladder for Mr. A and has a cystoscopy and stent placement for Ms. B, a patient who was admitted overnight for an obstructing ureteral stone. She will be assisted by a chief resident for the cystectomy and a junior resident for the stent placement.

She greets each patient in the preoperative area and answers last minute questions about surgery and the consent. She then walks to Mr. A’s operating room to be present for the time out. She tells the chief resident that she will just be next door performing the stent procedure and then return. She then walks to Ms. B’s room and performs the time out and the ureteral stent placement.

She returns to Mr. A’s room and finds that the chief resident has placed ports and taken down some colonic adhesions. She joins the resident and they complete the cystectomy. The next morning she is called by the chief resident who notes Mr. A has a rigid abdomen and is concerned that Mr. A has intraperitoneal sepsis. On abdominal exploration, they find a missed colonic injury requiring abdominal washout and proximal diversion.

Discussion

A patient’s informed consent prior to surgery, as an acknowledgement of the patient’s autonomy, is a well-established standard of surgical care. Despite the ubiquity of informed consent discussions, there are several common surgical scenarios in which informed consent is not straightforward. In this article, we will discuss one of these scenarios: a surgeon participating in concurrent or overlapping procedures.

Concurrent surgery occurs when 1 primary attending surgeon is responsible for more than 1 surgical procedure with the key or critical portions occurring all, or in part, at the same time.¹ Overlapping surgery describes a similar scenario, but without any key or critical portions occurring simultaneously (see figure). High profile media investigations into concurrent and overlapping surgery have cast this practice as an unacceptable risk to patient safety and a potential source of improper billing. A 2016 report of the U.S. Senate Finance Committee recommended that hospitals prohibit concurrent surgery and regulate overlapping surgery.² Specifically, they encouraged hospitals to ensure that informed consent discussions adequately include a discussion of overlapping procedures. As a result, many individual institutions have developed policies addressing overlapping surgeries, striving to clearly define the parameters, ensure surgeon accountability and better inform patients regarding the practice.

A clear and transparent conversation about overlapping surgery and the role of other surgeons (including residents or assistants) is essential to adequate informed consent. However, this may be a challenging discussion for several reasons. First, patients may be unaware of the number of people involved in a routine surgical procedure. Indeed, the language regarding students and surgical trainees on consent documents is vague and this topic is often brushed over by surgeons for fear of undermining a patient’s trust.³ Second, patients may expect that the attending surgeon will be present for all parts of the surgical procedure (“from skin to skin”). Patients may perceive that all parts of a surgical procedure are tense and high-risk, unaware of the “low-intensity” work and preparation that is part of most surgical procedures. Further, there is no universal definition of the “critical portion” of a surgical procedure, and this may vary based on patient factors. The American College of Surgeons defines the critical portions of an operation as “those stages when essential technical expertise and surgical judgment are necessary to achieve an optimal patient outcome.”¹ The meaning of “optimal patient outcome” leaves much room for interpretation. Additionally, they state that the critical portions of an operation are determined by the primary attending surgeon.¹ Finally, patients may be hesitant to allow trainees to participate in their operation. While the need for training surgeons is agreeable in the abstract, some patients may be less open to that idea in their own surgical care.

Informed consent, according to the AUA Code of Ethics,⁴ requires the disclosure of “reasonable expectations” of surgery as well as the “identification of other medical personnel who will be participating directly in the care delivery.” The presence of the attending surgeon during surgery is a reasonable expectation of patients. Therefore, it is essential for the urologist to disclose trainee/assistant participation and the portions of the procedure during which the attending may not be present.

Figure. Schematic example of concurrent and overlapping surgeries.

In the case example, Dr. Jones did not discuss her absence during part of the procedure with the patient. Allowing the chief resident to start the surgical procedure prior to her presence may be appropriate, despite the fact that a complication occurred at some point during the surgery. However, transparency regarding the surgeon’s presence and the presence of assistants/surgical trainees is essential to maintaining trust in the patient-physician relationship.

A recent meta-analysis of retrospective studies found no association between overlapping surgery and short-term mortality or morbidity.⁵ Another large retrospective analysis found no difference in mortality or morbidity on average, but did note a higher mortality and complication rate for a subgroup of patients at high preoperative predicted risk undergoing overlapping surgery.⁶ Both noted a longer operative time associated with overlapping surgery. Two recent retrospective studies of overlapping urological surgery at academic centers similarly found no difference in short term morbidity or mortality.^7,8 In addition to the data regarding outcomes, it is important to note that surgery is itself a scarce resource. Surgeon and operating room time is in limited supply and increasing access for patients through increased efficiency is a benefit of overlapping surgery.

In spite of the data suggesting equivalent outcomes of overlapping surgery, patient perception is mixed. Two recent surveys of patients regarding overlapping surgery found that patients were uncomfortable with concurrent surgery and neutral or mixed regarding the acceptability of overlapping noncritical portions of surgery.^9,10 These data, along with the relative lack of patient understanding about concurrent or overlapping surgery, establish the need for a transparent conversation regarding these practices during the informed consent process well prior to the day of surgery.