The ethics of running multiple operating rooms simultaneously: Is this Ghost surgery?

“This fellowship program will provide me with great experience—the program director often runs 3 operating rooms.” This was the resident’s response to a query about her recent fellowship interview. The attending physician of record would be operating with the neurosurgeon on a combined skull base operation, and the other two rooms were just standard endoscopic sinus cases with a postgraduate year 2 resident and a fellow, respectively. We have always found this very common practice of running multiple operating rooms simultaneously very troubling. The first response was to question the resident if the golden rule was applicable to her in this scenario: “Would you want to be the patient in one of these operating rooms?” The response was predictably “no.” Our advice to the resident was not to consider a fellowship program that permits such a practice of running multiple simultaneous operating rooms. We then pondered the ethical considerations of such a common practice in the United States. More recently however this practice of concurrent surgery was a subject of a major investigation by the Spotlight reporting team at the Boston Globe. A major focus of this investigation documented several orthopedic cases at the Massachusetts General Hospital was a lack of full disclosure to the patient. The American College of Surgeons (ACS) guidelines for their fellows clearly state the responsibility of the surgeon: “The patient’s surgeon should be in the operating suite or the immediate vicinity for the entire surgical procedure.” “The surgeon may delegate part of the operation to associates or residents under his or her personal direction, because modern surgery is often a team effort.” The guidelines go on to say “It is proper to delegate the performance of part of a given operation to assistants, provided the surgeon is an active participant throughout the key components of the operation. The overriding goal is the assurance of patient safety.” There is no mention of the surgeon running multiple simultaneous operating rooms. There is also no mention of what determines the “key component.” It should be remembered that the ACS was founded in 1912 on the principles surrounding the surgeon’s responsibility to the patient. In the operating room policies manual issued by the University of New Mexico Hospital (UNMH), the key portion of a procedure is defined as all periods of more than minimal risk (“the determination of which will depend on the particular patient and the skills/experience of the resident being supervised” ). Is making an incision or dissecting a major artery considered a minimal risk that could be done without supervision? The vagueness of both the ACS and UNMH guidelines allows for considerable latitude in interpretation. One of the most difficult parts of our practice over the past many years has been the dual responsibility and obligations of an academic teaching surgeon. Our first responsibility and arguably our highest duty is to give the best possible care to our patients. In addition, we have to teach our young residents how to make critical decisions and operate. Our patients are made to understand verbally and in a written consent form that residents will participate in their surgery but that the primary surgeon will be responsible for their care. We usually tell our patients that we will be in the operating room from the moment that they go to sleep until they wake up. We certainly cannot fulfill our promise to our patients if we run simultaneous surgeries. This gray area of guidelines for surgery was highlighted in an article published in The Seattle Times, titled “ ‘Ghost Surgery’: When Your Surgeon Isn’t the One You Expected” (September 29, 2012). The ACS tells its fellows that it is unethical to mislead a patient about the identity of the person performing an operation. If a first-year surgical resident is doing major portions of an operative procedure without the attending or contracted surgeon in attendance supervising, does that qualify as deception? Is the training surgeon in effect the ghost surgeon? Running multiple simultaneous operating rooms brings up several major issues: