The Surgeon's Schedule: Cutting on More Than One Patient at the Same Time: It's Done but Is It Ethical? (AMA Report 8)
I thought I would move on to an informational report in this series of reports by the the Council on Ethical and Judicial Affairs (CEJA) of the American Medical Association.(See the last 4 threads.) It is Report #8-Surgeon’s Attendance During Surgery
It seems that it is common surgical practice for surgeons, especially in teaching institutions, to schedule more than one surgery under their name and all at the same time but to participate not fully in any of them. The Report states:
At its 2007 Annual Meeting, the American Medical Association (AMA) House of Delegates adopted Resolution 16, “Surgeons’ Attendance During Surgery.” This resolution asks that the AMA design policy that requires operating surgeons to “post their surgical cases so that they are actually physically present in the operating room performing or supervising their surgical cases during the majority of the case and during all crucial or essential phases of the surgical procedure.” After discussion with the sponsors of the resolution (the District of Columbia Delegation) and for reasons set forth below, the Council on Ethical and Judicial Affairs (CEJA) has decided that its current policy addresses the issues raised by the resolution.
The resolution is primarily concerned with the effect on the patient-physician relationship when a physician has 2 or more cases posted at the same time. Clearly, the physician cannot be present for the entirety of both cases. The absence of the surgeon from portions or all of a procedure without a patient’s knowledge and consent may have a negative impact on patient trust as well as safety.
However, current CEJA Opinion E-8.16, “Substitution of Surgeon without Patient’s Knowledge or Consent,” addresses these concerns. This policy states that “a surgeon who allows a substitute to operate on his or her patient without the patient’s knowledge and consent is deceitful.” In general, a physician should provide participatory supervision if aspects of the procedure are delegated to residents or other physicians. If a resident or other physician performs the procedure under non-participatory supervision, the patient should be fully informed of this fact.
It is unethical for physicians to post 2 or more cases (ie, not fully participate in any of the cases) without the informed consent of the patient. The Council believes that this Opinion fully answers the directive of the resolution and sees no need for additional ethics policy on this matter.
Well, are all my visitors, all being potential surgical patients, satisfied with the Council’s conclusion? ..Maurice.
posted by Maurice Bernstein, M.D. @ 2:02:00 PM
5 comments
5 Comments:
I am not satisfied by this opinion at all -- I think that unless it is explicitly spelled out to the patient that residents/interns/whatever are going to be doing some of the surgery (and "the patient is in a teaching hospital, they need to expect this" does not equate to informed consent, in my opinion) then the surgeon should do the entire surgery, from first incision to final suture. Given that (generally) during surgery a patient is not awake, they need to know what will happen to them while they are anaesthetised ahead of time (and in teaching hospitals, I believe that this should include telling patients about the gallery -- and asking whether it is okay for people to watch). Back to the original question, though, no, I do not think their opinion is good enough and nor does it represent true informed consent.
--PG
PG, I agree that there is much more involved in the truely "informed consent" but for this thread, let's keep the focus on the issue of the surgeon's full participation in the surgery of a patient.
I would agree that there are elements involved in the surgeon's participation in this "simultaneous multiple surgery" that is not covered simply by announcing to the patient regarding the presence of a substitute surgeon. Since the named scheduled surgeon is still the "captain of his/her ship", if my understanding is correct, this means in the case of multiple surgeries, that surgeon still has the responsiblity for attending to whatever emergencies and conditions which might be occurring in the other operating rooms. That means the surgeon has to be aware and thinking about what is going on in both or more surgeries. Can a surgeon do this as effectively and. for the patient, ss safely as if he or she was involved only in a single surgery? I wonder.
How far can a surgeon's attention and skill be stretched? ..Maurice.
Fair call, I was all over the place in that last comment, but I think there IS an ethical element of informed consent here. Speaking to your last point, though -- in the unlikely-though-possible event of simutaneous emergencies, the surgeon cannot meet his or her ethical obligations by attending to both -- and in the event of a single emergency, the non-emergent patient may be kept anaesthetised for longer than would be strictly necessary so the surgeon can attend to the emergency before 'supervising all crucial or essential phases of their surgery', which to my mind puts that patient at additional risk and for what? The time and convenience of their surgeon, which essentially boils down in to the almighty dollar in both user pays and socialised medical care.
--PG
I was deeply shocked on reading the first paragraph. Patients build up trust in their doctors only to have this taken away when another steps in.
Leaving aside the ethics for the moment (I know, I know, off topic), I thought the CMS rules now require "skin-to-skin" physical presence of the attending surgeon for compliant billing. Multiple surgeries concomitantly would seem to preclude compliant billing for any of them. Given the heavy fines that academic centers have endured, I am surprised to hear that this is still a common practice.
Or am I missing something?
SF
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