surgeons

Largely Ceded to GI Physicians, Surgeons Urged to Reclaim Endoscopy

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Experts Describe Advantages of Developing Endoscopic Techniques for Practice

 

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New York—What do colonoscopy, polypectomy and endobiliary stenting all have in common? They are all endoscopic techniques first described by surgeons, along with control of hemorrhage, endoscopic retrograde cholangiopancreatography, percutaneous endoscopic gastrostomy/jejunostomy and control of variceal bleeding.

“It’s an old adage that general surgeons started endoscopy and gave it up to the gastroenterologists,” said Paresh C. Shah, MD, professor of surgery at NYU Langone School of Medicine, in New York City. “Unfortunately, that’s true, but we’re changing that and we need to be aggressive about it.”

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The American Board of Surgery has acknowledged the importance of surgical endoscopy through changes in residency training requirements for board eligibility. Starting in 2018, surgical residents will have to complete a flexible endoscopy curriculum and pass the Fundamentals of Endoscopic Surgery (FES) examination assessing their cognitive and technical skills. The FES program was developed by the Society of American Gastrointestinal and Endoscopic Surgeons.

But surgical endoscopy can expand and enhance practice for surgeons at any stage in their career, Dr. Shah explained at the 2016 Controversies, Problems & Techniques in Surgery annual meeting, noting that it was general surgeons again who played a role in promoting some of the more advanced endoscopic interventions, such as EndoCinch suturing, Stretta, anastomotic plication and peroral endoscopic myotomy (POEM).

“If we think of ourselves as gastrointestinal surgeons, we’re really obligated to look at the spectrum of what GI surgery is. Advanced endoscopy, therapeutic endoscopy, is nothing more than another form of GI surgery; it’s just one that happens within the lumen rather than outside.”

In the world of diagnostic endoscopy, some of the newer tools that surgeons have include microendoscopy and narrow-band imaging. “For those of you who do diagnostic upper and lower endoscopy, these are critical to have at your disposal,” Dr. Shah said. “They’ve impacted adenoma detection rate, early cancer detection, and clearly, postsurgical anatomy.”

As Jose Martinez, MD, pointed out, nobody understands postsurgical anatomy better than the surgeon who made it. “We do a lot of replumbing in the human body, and we know the plumbing doesn’t always work. We can end up with strictures or worse—a leak, fistula or perforations,” said Dr. Martinez, associate professor of surgery and chief of laparoendoscopic surgery at the University of Miami Miller School of Medicine.

Basic tools for interventional endoscopy include balloon dilation, bleeding control and feeding tubes. More advanced interventions—to manage complications that surgeons themselves may have created—include stents, clips, fibrin glue and endoscopic suturing.

Injection is an important skill to develop. “It allows you to do a lot of things in the GI tract, whether you’re injecting saline to lift the mucosa, tattoo to mark a lesion or epinephrine to control bleeding,” Dr. Shah said.

The application of clips, which have improved dramatically in recent years, also has myriad uses. “Closing small holes, mucosal defects; I use clips after endoscopic submucosal dissection (ESD) resections and peroral endoscopic myotomy, and they’re good for bleeding control,” Dr. Shah said.

When it comes to dealing with strictures, surgeons again have a number of tools at their disposal: stents, energy sources, balloons and dilators. “Many of these things were created for one purpose, but we’re using them in different ways to figure out how to best accomplish treatment for our patient,” Dr. Martinez said.

And then there are the very advanced endoscopic interventions: POEM, gastric POEM (G-POEM), ESD and endoscopic full-thickness resection (EFTR). “G-POEM changed our practice—I don’t do pyloroplasties anymore; and ESD and EFTR are now the avant- garde of what we can do endoluminally,” Dr. Shah said.

Incorporating Endoluminal Techniques

Jeffrey Marks, MD, long a promoter of flexible endoscopy, acknowledged that while the younger generation of surgeons might be more comfortable with it—especially the residents who will have to pass the FES and complete the flexible endoscopy curriculum in 2018 before sitting for their boards—more established surgeons can be a tougher sell.

“The hardest person to impress is the person outside fellowship and residency, someone in practice already. If they’re not doing flexible endoscopy, it’s hard to get them started,” said Dr. Marks, professor of surgery and director of surgical endoscopy at Case Western/University Hospitals, Cleveland Medical Center, in Ohio.

Drs. Marks and Shah recommend surgeons start with intraoperative assessment. “For one thing, the GI doctors aren’t going to want to come in to assess every anastomosis or bariatric bypass; also, the patient being asleep makes it easier—you don’t have to worry about them being uncomfortable—so it’s a great way to gain skills.”

Dr. Shah suggests having an endoscope involved in every case. “There is no downside to you doing your own intraoperative endoscopy, whether it’s foregut or colon.”

Once a surgeon has gained some comfort, some formal training can advance his or her competence. “Both the American College of Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons have hands-on courses for surgeons who have a basic skill set in flexible endoscopy to learn how to do more advanced therapies,” Dr. Marks said.

Dr. Shah also recommends working with GI colleagues to build one’s skill set for more advanced endoscopic procedures. “Most of them have more experience than you with the more advanced procedures,” he said.

This can be difficult politically in situations where gastroenterologists sense a turf war and resist sharing what they know, but the reality, according to Dr. Shah, is that most gastroenterologists are more than willing to turn over the more challenging and relatively less remunerative advanced endoscopic procedures. “It does not pay for them to do a two-hour procedure when they can do six screening colonoscopies in the same time. The reimbursement isn’t there for them, the interest isn’t there for them, and they don’t want to be responsible for potential complications.

“If you have a therapeutic or developmental endoscopist in your area or practice, partner with them,” he said. They’ll love to have that work with you. And if you don’t have a therapeutic endoscopist, there’s a very good opportunity for you to become that person for your GI community. They’ll be happy to do your pre-ops, screenings and post-ops, and to call on you when they need one of these more advanced therapeutic endoscopic procedures.”

Surgeons and Stress

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Dealing With Burnout, Depression, Aging And Finding Work-Life Balance

Some years ago, in a survey conducted by the American College of Surgeons, 40% of the respondents reported burnout, 30% reported symptoms of depression and 28% indicated that their quality of life was suffering (Ann Surg 2009;250:463-471). Since then, it has also become clear that younger surgeons, even medical students, experience burnout and related problems.

To explore topics related to the stresses experienced by surgeons young and old, the Southeastern Surgical Congress assembled a panel of experts to discuss the ways they and their institutions guide colleagues and manage challenging situations. General Surgery News invited the panel members to review these topics in depth.

GSN: What do you do when you suspect depression, anxiety, attention deficit disorder or another disorder in a surgical resident?

Dr. Behrns: These days, residents entering a program or institution are assigned mentors who act on their behalf, who can discuss problems like depression or anxiety with them. If they have ongoing issues, we would direct them to a resident assistance program. That would be a safer discussion—residents don’t want to talk with their program director or chair about those types of problems. If the resident has escalating issues, the program director or chair would encourage him or her to seek medical assistance. That would be pretty far down the line and it doesn’t happen very often, but it can happen.

Dr. Sweeney: Generally, it’s when there are behavioral issues or when we see a drop-off in the quality of a trainee’s work. If we see problems, we bring them to the attention of our program director. He has a number of options. For instance, he can ask troubled residents to meet with a member of our resident faculty support system. In one situation, we had a resident who we were all concerned about from a performance perspective. Our program director had that trainee work with a psychiatrist who diagnosed depression that had not been previously identified. He wasn’t aware he had such severe depression. He got treatment for the problem, and commented on his exit interview how much the intervention changed his life.

Dr. Meyers: Our institution has a resource, developed by one of the psychiatrists, to try and address some of these problems. If someone comes to us on his or her own, or if his or her performance is not what I expect it to be, we have a conversation to figure out possible underlying issues. If there are problems like substance abuse, which is usually not a primary problem but a coping mechanism, we make appropriate referrals for that. But most of the time, it’s just dealing with a stressful profession that requires a significant amount of time at work.

Dr. Smith: The first thing I do is have a frank discussion with them and try to decide for sure if there is an issue. In general, I’ve found that people will open up. If we identify that there is a problem, I reassure them that it doesn’t mean their job is in jeopardy. It’s important they understand that they are in an environment where they will get the help they need. Then I point them toward our employee assistance program, which is very good at getting employees counseling or other assistance. What I don’t do is try to be their clinician. I’m the program director and it’s really important not to try to be their doctor.

GSN: How do you identify residents at risk for burnout or failure before they reach PGY-3?

Dr. Behrns: A decrement in their performance would be one indication. If the performance of a resident who did well when he or she first started starts to decline, that’s a sign. Also, in a lot of residency programs, the residents are close; they’re a tight-knit group. If you see a resident becoming isolated who previously was not isolated, that’s another sign that there may be a problem. And then anytime you get information that there are issues outside of the hospital, those are further indications that residents are having issues, and you should try to address these as early as possible.

Dr. Sweeney: This is a tough one. Concerning those at risk for failure, part of making sure those who transition into practice are successful is identifying residents who shouldn’t be surgeons in the first place and assist them with moving in a different career direction. We do have a fairly rigorous evaluation process, and we’ve just started implementing some competency-based training, having people demonstrate competence in a skill before they are allowed to perform it in the clinical setting. So we’re using a lot of tools to identify residents who are not progressing appropriately or may not be ready to perform procedures. But as far as managing those at risk for burnout, I really don’t know. We are focused on adhering to the 80-hour workweek to give people time off; we’re cognizant of the fact that everyone needs to decompress.

Dr. Meyers: That really is challenging. We try to have a culture where people are comfortable self-identifying if they’re having a problem, but I think that does not happen as often as it should. Our department and our residency program have formed a wellness group with a primary goal of destigmatizing that concept, to make it OK for people to talk about the fact that they’re struggling. Another primary goal is to develop strategies to promote wellness within the residency program. In fact, our residents are meeting as a group to discuss what sort of changes in structure would be meaningful to them.

Dr. Smith: We don’t have a specific general surgery resident screening tool. But the hospital does have an annual health assessment they conduct on every employee, and part of the health assessment survey are questions that have to do with depression and anxiety. As a program director, I would not get the results of that survey, but the screening could potentially spot a resident that was having some issues. More practically, what really happens is that residents have performance issues. That is more how we identify people having problems, and I can ask them to come in and talk to me about it.

GSN: How do you intervene if a resident’s behavior is creating a hostile work environment?

Dr. Behrns: If they really have a disruptive behavior, that would go directly to the program director or chair, and we would discuss professional expectations in the department or hospital and their interactions with other colleagues. That would be a direct conversation, and if that’s the end of it, that’s fine—things can happen. If it happens a second time, we would send them a letter indicating that their disruptive behavior is not part of our code and we expect it to change. Again, we would offer them an opportunity to seek counseling with the resident assistance program and other folks. If they really can’t control their disruptive behavior, they would get another letter of reprimand; and if that failed, they would probably be dismissed. It’s very hard. But I would say, in 20 years I’ve seen only one of these situations. It’s not a common scenario.

Dr. Sweeney: Five or six years ago, Emory created a pledge, a series of statements about how we’re going to treat each other: We will not create a hostile work environment; we will not demean; we will not use sarcasm. Non–pledge-like behavior is investigated. First, we have a “cup of coffee” conversation. If that doesn’t work, individuals will be asked to meet with our director of care transformation, who helps them recognize things they might not realize about how their actions are perceived. He also helps them develop strategies for example, if you know these are triggers for you in this environment, here are some strategies to deal more effectively and potentially avoid those triggers. When those two interventions don’t work, we’ll have them work with a leadership coach to develop the skills necessary to avoid such problems going forward. If they don’t get better, there needs to be a conversation about how their persistent behaviors are not consistent with the values we hold at Emory and perhaps a different work environment would better suit them.

Dr. Meyers: If I learn of something identified by peers or nurses or faculty, the first step is an informal conversation. I see them in the hall and say, “Do you have a second?” If things persist, we have a more formal, structured conversation, but in an informal setting. Both of those steps I think of more as coaching—being a listener but also communicating that we’ve identified some challenges and trying to identify any underlying issues we can address. The third step is more formal: an intervention conversation in my office at a defined time where I say, “This needs to change, these are things that have to happen, and here are some things I need you to accomplish.” The final step is punitive, but that really is the final step and is very uncommon.

Dr. Smith: I’m proud to say this is not something that comes up much. “Hostile work environment” is a pretty significant charge. I think it’s more common to have a resident that just offended someone and wasn’t aware of it, got mad and mouthed off to someone in an unprofessional way. I did have one situation a few years ago, where a resident really was creating a kind of a hostile environment. I brought him in and said, “Here’s the problem, here are some ways we’re going to measure you fixing the problem; if you can’t fix the problem, then we’ve got a real issue here.” Most of the time I’ve found that once confronted, people are generally happy to tell their side of the story, but also to acknowledge that this is something they need to work on.

GSN: Over the past decade or so, have you noticed a cultural shift and greater sensitivity toward or acceptance of surgeons striving for a work–life balance?

Dr. Behrns: Absolutely. There’s no doubt that people are looking for a better balance between their surgical career and life outside the hospital. For years, some people identified this as a lack of commitment, but I don’t think so. I think they’re incredibly committed, but they’re also committed to their families and activities outside the hospital. They’re looking for a better balance. Nobody takes care of every patient every hour of every day. As long as people work as a team, have the patients’ best interests in mind and perform well while they’re there, they deserve time away. My attitude may not be completely common, but I think more senior surgeons are moving toward that position.

Dr. Sweeney: Very much so. I think it starts at the top. I practice what I preach. I have seven children. I do two things: I come to work and do my job, and then I spend time with my family. As a department and as a school, I think we’ve made the shift to recognizing the need for balance. When younger folks exhibit behaviors—such as working too many hours—that will lead to burnout in the end or that can create what we call at-risk situations, whether it’s around patient care or administrative or research issues, something that could put them at risk for liability down the road, we tell them to slow down. We tell them it’s OK to have balance, and we encourage people to do that.

Dr. Meyers: Generally yes. It is not the entirety of the profession, that’s for sure. Using myself as an example, I recognize it, but do not set a very good example. That’s part of the problem. We can talk about work–life balance and support people wanting to have that balance, but we don’t always model those behaviors. I think the profession as a whole recognizes the importance and necessity of this issue, and has grown to accept that. But the modeling of behaviors has not always mirrored the conversation.

Dr. Smith: There has definitely been a shift. The medical students that come into residency know they’re going to have an 80-hour workweek and no more. Their expectation is that they will be able to carry on all the normal extracurricular activities. When they finish and go into practice, that’s the work environment they expect to join. They want to work with a group; they want coverage; and when they’re off, they want to be off. I do think this correlates somewhat with the change in duty hours in 2003. There are probably people who have gone into surgery since then who would not have gone into surgery before. Now I think people just completely expect that they will have reasonable work hours and that if they’re up all night, they won’t have to work the next day.

GSN: Conversely, do you sense resentment from mid-career and senior colleagues toward younger surgeons assuming such flexibility as a given?

Dr. Behrns: I think the resentment started to fade a few years ago. I’d say now there’s an improved understanding for the need for work–life balance. A fair number of senior surgeons want to retire early because their work is not enjoyable, or they have issues with drugs or alcohol, or their family life is not good. So I think people increasingly appreciate the need for balance and understand that an all-work mentality isn’t good for anybody.

Dr. Sweeney: Potentially. There are still some people here who think the more you do, the more powerful you are. In my experience, the busiest guy also tends to be the most unhappy guy and the most difficult guy to be around. We encourage balance. There may be people who look down their nose at that, but they’re in the minority here. All the same, we’re still pretty productive. We focus as much on productivity in this organization as in any other, but having a sense of balance is really important. When people are happy, I think they tend to be more productive as well.

Dr. Meyers: What I sense is that people are not resentful of the concept, but they are less understanding of the actual execution of it, particularly if it results in some people having to shoulder a disproportionate share of undesirable work. In some camps, especially the more senior camps, there are still vestiges of “Well, I did it, why can’t everybody else do it?” That is a challenge for people to get past.

Dr. Smith: Honestly, most of what I hear is a bit of joking about it, a broader acknowledgment that probably the young people have it right and that we were the idiots who gave away our lives. I think most of the people in my age range—I finished my residency in 1989 and have been a program director for the last 10 years—think we were crazy and that the direction things are headed in now make a lot more sense. So I don’t hear a lot of genuine resentment. I think we all agree that this approach is better.

GSN: Why is retirement so hard on surgeons, and what can colleagues do to help ease senior surgeons into retirement?

Dr. Behrns: We work hard to achieve a certain place and status in our profession, and planning for retirement is just not in the lexicon of surgeons. I think phased retirements are a good idea, where people reduce their workload and slowly move into a less prominent role. Also, we don’t educate surgeons very well about the transition into retirement. We could do a better job of that, holding seminars about how to prepare for life after being the busiest surgeon in the place. That’s one part of faculty development that should get more attention. We expect people to do it on their own, but I think we need more programs to address it.

Dr. Sweeney: I’ve started thinking about this for myself. The thing I do most is spend time with my family. At some point, my kids will grow up and move off and have families of their own. So I’m starting to realize there might be a gap for me. The problem with being a doctor is that it’s all oriented around the individual achieving his or her goal, with no orientation around being part of a team or thinking past that singular goal. We need to start thinking early, way before retirement, about what makes us feel fulfilled outside the operating room. We also need to take care of ourselves so that we can enjoy being active after retirement.

Dr. Meyers: I’m not sure I have a whole lot of insight with the latter part of that question. But the first part is that so many surgeons in particular, and physicians in general, dedicate their lives to what they do professionally. It was all they did, all they knew, how they identified themselves. It’s hard to find something to fill that void. I think the biggest thing the profession can do to help is figure out opportunities for people to stay engaged without practicing, and I think we’ve underutilized surgeons who are no longer practicing. Certainly there are educational opportunities; I think a lot of institutions that train residents would be happy to have retired surgeons’ help.

Dr. Smith: I have trouble with this question because a number of my senior partners have passed through retirement age and they’ve all been pretty successful. One, who was counting down the days, retired the minute he was eligible to get money out of his retirement funds and never looked back. Another retired partner, one of the hardest-working surgeons I’ve ever known, said he can’t believe how much better he feels without the pressure and tension. Those two have reveled in the freedom from responsibility that comes with retirement, doing all the things they want to do. Personally, I have a lot of hobbies that are very time-consuming, and grandkids I love to spend time with. When I get to the point of retirement, I won’t have any trouble finding things to do. Maybe that’s the key to answering the question: Encourage people to pick up hobbies and other things to do.

Surgeons rarely apologize for horrific mistakes made during surgical procedures

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Medical error

Western medicine certainly has its benefits when it comes to emergency care, as advancements in technology are generally effective when it comes to saving one’s life in the event of traumatic injury. Preventative care, on the other hand, is essentially nonexistent in most Western nations. Simple, every day treatments aren’t all that safe, either.

Treatments such as pharmaceutical drug prescriptions, routine dental checkups and non-life threatening surgeries often turn out to be just that: life threatening. Harm caused by medical error is a lot more common than you might think.

In fact, an estimated 1.6 million Americans have died as a result of medical errors over the last decade and a half. In fact, death via medical error is so common, that it’s now considered the third leading cause of death in the U.S., below heart disease and cancer.

Hospital mistakes third leading cause of death

Hospital deaths purported to be accidental show no immediate signs of decline, either, because as it turns out, doctors aren’t too concerned about it.

The rise in these particular types of deaths prompted researchers from the department of Veterans Affairs at Boston University to take a closer look, and what they found may disturb you.

Only 55 percent of surgeons actually apologize for botching up a surgery, while the remaining 45 percent never give it a second thought, according to reporting by the Daily Mail.

Yes, you read that correctly. Nearly half of doctors don’t apologize for doing a bad job. Why you might ask? Well, because they are just too damn proud.

Doctors too proud to admit they screwed up

Making mistakes is too “difficult for the physician to admit to the patient,” said study author Dr. Thomas Gallagher.

“For a long time in the field, people thought the primary reason physicians have trouble reporting adverse events is they were worried about being sued, but there are other barriers that are more important.”

The 21-question survey administered to 67 specialist surgeons from three medical centers, revealed that 13 percent of doctors do not feel any regret for the mistakes made during surgery.

Unsurprisingly, a large majority do not discuss how to avoid repeating those same mistakes, either. Slightly more than half of doctors said they discuss whether or not the medical error could have been prevented.

The research, published in the journal JAMA Surgery, sought to understand “how embarrassing and upsetting these events are for clinicians,” failing to mention what patients and their families must be going through.

Doctors who don’t reflect on mistakes suffer emotionally

But, according to the survey, doctors who do not reflect on their mistakes are ultimately impacted emotionally.

“Surgeons with more negative attitudes about disclosure were more anxious about patients’ surgical outcomes or events following an operation.”

U.S. law requires doctors to fully disclose the occurrence of “adverse events or unanticipated outcomes” to patients, as well as to their family members. The survey found that the majority of them followed five of the eight recommended disclosure techniques, including:

• Explaining why it happened – 92 percent
• Expressing regret for what happened – 87 percent
• Expressing concern for the patient’s welfare – 95 percent
• Disclosing the adverse event within 24 hours – 97 percent
• Discussing steps taken to treat any subsequent problems – 98 percent

“The other three were: apologising to patients (55 per cent), discussing whether the error was preventable (55 per cent) and discussing how it could be stopped from ever happening again (32 per cent).”

 

A Patient-Centered Solution To Simultaneous Surgery

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The practice of concurrent, or simultaneous, surgery has largely been hidden from public knowledge until recently, and current guidelines regulating the practice fall short in protecting and serving patients in crucial ways. Simultaneous surgery occurs when one surgeon, with the help of assistants, performs two surgeries on two different patients in different operating rooms at the same time. A series of articlespublished last year in The Boston Globe propelled the practice into public consciousness. In response to the ensuing outcry the American College of Surgeons revised their guidelines with respect to simultaneous surgeries.

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The medical community hopes this will put the controversial matter to rest. The revised guidelines stress both informed patient consent and the necessity of ensuring that surgeons are present during “critical elements” of any surgery. Importantly, these guidelines leave the decision regarding what exactly constitutes “critical elements” completely in the hands of the operating surgeon. While I applaud the emphasis on informing patients, these guidelines are not nearly enough, and fall short in two crucial ways.

Truly Informed Consent

Informed consent has been the standard of care for American physicians for decades. Unfortunately, we continue to be surprisingly bad at it.

Recent research shows that only a small minority of patients—just 9 percent in one study—receive adequate information from their medical team to make truly informed decisions. I suspect that explaining to patients that their surgeon will be operating on other patients while the patient is undergoing his or her surgery will be even more difficult and less successful. Euphemisms, incomplete information, and oblique discussions will be the norm. This is an issue that deeply concerns patients: in one study, when patients were given a realistic scenario in which a resident would act as the operative surgeon without direct staff supervision, only 18 percent said they would give consent.

Additionally, the recommended timing of this discussion is completely absent from these guidelines. Telling patients on the day of their surgery—which is often when consent is obtained—that their surgeon will be absent from the operating room and busy working on different patients for parts of their procedure is terribly unfair. At that point, patients are emotionally prepared to proceed with surgery, work arrangements have been made, and family members are all assembled. This is not the time to present potentially disconcerting new information and ask patients to accept it.

When surgery is first discussed, surgeons should tell patients if they practice simultaneous surgery, and explain what this will mean in the operating room. Elective surgery schedules are typically developed weeks or months in advance of the surgery date, so forewarning patients promptly would give them adequate time to consider the idea and ask questions. It would also give them time to find another surgeon if they are uncomfortable with the practice of simultaneous surgery.

Defining Critical Elements

According to the American College of Surgeons guidelines, each surgeon should decide, acting in their sole discretion, which components of each surgery are “critical elements” worthy of their attendance in the operating room. Such a standard is subject to all sorts of confounding variables. A physician’s mood, the demands of the daily surgery schedule, or even the insurance status of a patient may affect how a surgeon views the critical parts of any one surgery. The fear this standard engenders is that what a surgeon considers to be “critical” in a procedure performed on his partner’s mother may be different from what is considered “critical” for the average patient operated on at the end of a long day.

Asking surgeons, by themselves, to define “critical” components of any patient’s surgery is completely upside down. Patients take all the risk and bear all the expense of a surgical procedure; therefore, they—through their payors or representatives—should define the standard for a surgeon’s participation in any patient’s surgery.

To use current parlance, the standard should be patient-centered, easily understood and discussed, and agreeable to the patients undergoing surgery. This type of standard would be identical to what we expect from other professionals. Lawyers, for instance, adhere to federal and state legal standards about how they practice and financial advisors adhere to fiduciary standards imposed upon them by regulators. These standards are easily understood, not just by professionals, but by everyone participating in the process — they are transparent and build trust between members of the public and the professionals who serve them. Because of such standards, Americans know exactly what they can expect in their dealings with these professionals.

Currently Medicare and other insurers fully reimburse for simultaneous surgery when the surgeon is present for only those parts of the procedure that that surgeon deems critically important. In order to reduce the influence of such subjective variables as time of day, the patient’s insurance status, or other demands upon members of the operative team, this decision should not be left to the surgeon. Instead, payers or other patient representatives should be the ones defining which elements of a surgery are critical, and patients should know exactly what to expect while unconscious in the operating room.

For example, CMS might expect a surgeon to be in the operating room from the time she moves beyond the subcutaneous tissues until only these tissues are left to close. Everyone in the operating room would understand such a standard and know what to expect, including the surgeon, assistants, the anesthesiologist, operating room nurses, and, most importantly, the patient who places his life in the care of others.

Justice Benjamin Cardozo said it well in 1914 in the case that made informed consent the law of the land: “Every human being of adult years and sound mind has a right to determine what shall be done with his own body,” and this extends to the right to make judgments over who shall perform surgery and under what conditions. A patient-centered, transparent standard for simultaneous surgery is surely the way forward. It will increase patient trust in their operating team and keep the team on the same page; it will simplify informed consent discussions for patients; and it will ensure that all patients know exactly what to expect when they are unconscious and vulnerable. Payers and regulators, working with the medical community, should adopt such standards expeditiously.