How ‘overlapping’ surgery helps patients

The Department of Justice has fined Baylor St. Luke’s Medical Center $15 million for allowing cardiac surgeons to perform more than one surgery at the same time. The government believes that surgeons should never have to divide their attention between two different patients, and FBI agents should be policing overlapping surgery.

In terms of public relations and emotional outrage, overlapping surgery doesn’t make sense — but that’s just not how the real world of medicine works.

The authors of this essay practice neurosurgery in two radically different environments, Alabama and San Francisco. The ability to run overlapping surgery is essential to maintain access to care for our most vulnerable patients. Even more so, our academic papers in leading neurosurgery journals demonstrate that overlapping surgery is both safe and effective.

There are critical nuances in definitions. True simultaneous surgery is not a good idea, and it is not allowed. Simultaneous surgery means that the critical parts of surgery happen at exactly the same time. The professional surgical societies speak with a unified voice; this is not to be tolerated. 

Overlapping surgery refers to portions of one surgery overlapping with another. This may not even be actual surgery. Before an incision is made, anesthesia puts the patient to sleep. The nursing team checks medications. The surgical technician counts instruments. A host of different professionals make surgery happen.

A common scenario unfolds as follows. A surgeon may come to work expecting to perform elective cases, for example, a neck fusion for nerve compression (one hour) and long-duration spinal deformity reconstruction for scoliosis (six hours). These may be booked months in advance. Yet, patients with more acute surgical needs are constantly presenting. They might have infections or tumors that risk paralysis. They may have fractures requiring fixation before they can be discharged.

Allowing overlapping surgery means the “add-on” surgery can be performed in between the other planned cases. This ensures all the patients can be treated without potentially harmful delays. 

Without overlapping surgery, should surgeons cancel an elective case, a patient who has waited months for surgery, to satisfy emotional bean counters? Should surgeons operate late into the night, risking complications from fatigue?

A study published by Dr. DiGiorgio noted that patients who were able to have surgery in an overlapping fashion had a shorter wait time for surgery and a shorter hospital stay. Overlapping surgery improves access to surgical care.

Data from the University of South Alabama, published by Dr. Menger, showed that many overlapping surgery models have actual surgery incision times that don’t even overlap. It can take hours to turn over a room and prep a patient for surgery, more than enough time to complete another case in an overlapping room. Indeed, when the Senate Finance Committee first evaluated overlapping surgery in 2016, it found that only 3 percent of surgeries had any overlap during the actual incision time. 

Overlapping surgery has been proven to be safe in multiple studies at multiple hospitals. As such, the burden of proof should be on those trying to regulate and stop overlapping surgery. Meanwhile, there is evidence that prohibiting the practice decreases access to care.

In healthcare, many policies trade efficiency for safety. Yet policymakers rarely study the tradeoffs with the same scrutiny they would give a new pharmaceutical or device. A patient who must wait longer for surgery can suffer harm, yet those harms don’t make headlines. 

This decrease in efficiency is amplified in patients who lack private insurance. We both work at safety-net hospitals where there is often nowhere else for these patients to go. It becomes a scarcity issue. If regulations seek to clamp down on this process, the rich and the influential will not be the ones waiting longer for surgery. Stopping overlapping surgery will reduce access to care for vulnerable patient populations.

Our message is simple: Allow us to treat patients.

Surgeons across the country have set up a safe models for overlapping surgery. It can be discussed with patients. The process is described in the informed consent. A back-up surgeon is available.

Let patients and physicians decide. The federal government is using billing regulations to enforce a safety rule without considering the tradeoffs. More regulation of this practice has one main scientifically proven outcome: a reduced access to care.

Dr. Richard Menger is vice chair of neurosurgery and assistant professor of political science at the University of South Alabama. Dr. Anthony DiGiorgio is an assistant professor of neurological surgery and faculty in the Philip R. Lee Institute for Health Policy Studies at UCSF.