Laurence M. Deutsch and Steven E. North
It has long been accepted that at "teaching hospitals" (where doctors are trained through hands-on practice) at least some portions of surgeries can be safely performed by doctors-in-training (residents) if they are properly trained and supervised by senior physicians (attendings).
But like any good idea, training new doctors by allowing them hands-on experience can be pushed beyond its reasonable limits. Recently, the practice of surgeons delegating too much surgery or sometimes even entire surgeries to inexperienced residents been brought into the spotlight.
The Boston Globe published a series of articles in 2015 outlining a rampant practice of concurrent or simultaneous surgery occurring at Mass General Hospital, one of the premier hospitals in the Northeast. The term concurrent or simultaneous surgery comes from the practice of a surgeon booking multiple operating rooms at the same time for surgeries he or she is supposed to performing. Investigators concluded that since a surgeon could not perform surgery simultaneously in two operating rooms, the surgeon could not be performing both surgeries in their entirety, and was (at best) shuttling between two different surgeries.
Investigations also showed that significant parts of complex procedures and sometimes entire procedures were being delegated to residents who were performing the surgeries without the knowledge of the patient and in many cases without sufficient training.
Now, the issue of concurrent surgery and improper “double booking” of operating rooms is gathering publicity in New York, in the case of David Samadi, M.D. Dr. Samadi has been something of a “celebrity” surgeon, appearing on TV shows to promote awareness of his field (and, some say, simply to promote himself). Legitimately, Dr. Samadi is a renowned leader in the field of robotic-assisted urology surgery, which allows robots to conduct fine-tuned surgeries in very small spaces under the computer direction of a physician.
While Dr. Samadi is an acknowledged leader in his field, he has recently come under investigation for his common practice of concurrent surgery. Some say he has habitually allowed inexperienced residents to perform surgeries he was supposed to perform. It has been reported in the press that the student physicians themselves started complaining to the New York State Office of Professional Medical Conduct (OPMC) that they were put in the position of performing surgeries on the orders of Dr. Samadi that they felt unqualified to perform. Dr. Samadi has denied any wrongdoing, though by press accounts he is presently under investigation by the OPMC. We question whether Dr. Samadi’s practices will ultimately bear scrutiny.
Dr. Samadi has promised in advertisements that he performs "the entirety of robotic surgeries" at Lenox Hill. However, investigators at The Boston Globe report that Dr. Samadi has double booked surgeries during the time he was supposed to be performing these same robotic surgeries. The implication is that Dr. Samadi could not possibly have performed "the entirety" of the robotic surgeries, as he has represented to his patients. Or, if he was in fact doing so, it would appear that the other surgeries performed under his name at the same time were done by entirely unsupervised residents.
For many years, patients have had to balance the benefits of being treated at a "teaching hospital" against the benefit of being treated exclusively by a more experienced physician. Teaching hospitals have some of the best and brightest physicians, in both experience and training. As typically large, well-funded academic centers, teaching hospitals also have some of the most advanced and cutting-edge technology. However, at these same hospitals, there is the inherent possibility that some procedures may be performed by a doctor with relatively little hands-on experience. Depending on the nature of procedure, or surgery, this can place the patient at much greater risk than if operated on by more experienced hands.
The investigations of Mass General and Lenox Hill and in particular of Dr. Samadi are making patients aware of a situation they may never have known – or thought to ask – about. As in many things, it is our opinion that poor practice tends to occur most where there is the least amount of scrutiny. Given some doctors’ apparent willingness to push the envelope in delegating surgeries (for volume, and ultimately greater profit), there may emerge from these examples a more robust and clear set of regulations, limiting the degree of such delegation.
In the meanwhile we think that patients can take some actions to help minimize exposure to such practice for themselves and their loved ones. We recommend that before undergoing any surgery, the patient have a frank and clear discussion with his or her surgeon as to what portions of the surgery the surgeon will personally perform.
It is typical for doctors and surgeons to speak of "their team" and "we" in reference to anything done to the patient. But given the recent exposés of excessive double booking practices, we suggest that simply accepting that "my team" will do the procedure is not good enough. We recommend that the patient get a clear commitment from his or her surgeon that the surgeon will do all the direct surgery or the most critical and complex part of the surgery. You won’t get this type of commitment in writing, but we think a clear discussion is still very useful. While some surgeons might push the envelope to delegate excessively for an unaware patient, we think that fewer are willing to effectively lie to a patient’s face, and not do something other than what has been promised to the patient.
If your surgeon is not comfortable even having this discussion, or takes a “none of your business who-does-what” approach, we can only suggest that the patient look elsewhere for their surgical care.
Source: The Boston Globe (3/12/17); CBS New York (http://newyork.cbslocal.com/)
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