Double-Booked: When Surgeons Operate On Two Patients At Once

Known as double booking, the attending surgeon lets residents or fellows perform parts of the surgery while the attending works in another room on another patient. But the occurrences of the surgeon seeing "other" patients and not being able to be located has happened. This has lead to patients being under sedation and forcing residents to do the surgery.

Known as “running two rooms” — or double-booked, simultaneous or concurrent surgery — the practice occurs in teaching hospitals where senior attending surgeons delegate trainees — usually residents or fellows — to perform parts of one surgery while the attending surgeon works on a second patient in another operating room. Sometimes senior surgeons aren’t even in the OR and are seeing patients elsewhere.

Hospitals decide whether to allow the practice and are primarily responsible for policing it. Medicare billing rules permit it as long as the attending surgeon is present during the critical portion of each operation — and that portion is defined by the surgeon. And while it occurs in many specialties, double-booking is believed to be most common in orthopedics, cardiac surgery and neurosurgery.

Critics of double booking leads to complications, unnecessary risks and enriches specialists. I wonder if there is a discount for not having the attending surgeon's expensive hands on/in the patient at all times.

Critics of the practice, who include some surgeons and patient-safety advocates, say that double-booking adds unnecessary risk, erodes trust and primarily enriches specialists. Surgery, they say, is not piecework and cannot be scheduled like trains: Unexpected complications are not uncommon.

All patients “deserve the sole and undivided attention of the surgeon, and that trumps all other considerations,” said Michael Mulholland, chair of surgery at the University of Michigan Health System, which halted ­double-booking a decade ago. Surgeons might leave the room when a patient’s incision is being closed, Mulholland said. A computerized system records the doctor’s entry and exit.

khn.org...

What? The patients were not told they would have a resident and not the attending doing the surgery?

Patients who signed standard consent forms said they were not told their surgeries were double-booked; some said they would never have agreed had they known.

I wish I were surprised......

a reply to: seasonal

I worked at a large Medical Center for 15 years. I worked in the OR for 10 years. It was common practice that the attending physician could have 2 rooms booked at the same time. They had to actually scrub into each case at some point during the surgery. Yes, residents did part of the surgery. That is how they learn. SOP was that when the attending was not in the room, there had to be a chief resident (resident in their final year of residency) in the room.


The OR I worked in was sectioned into areas based on type of surgery. Orthopedic surgery was done in a specific group of rooms located near each other. Neurosurgery rooms near each other, etc. Surgeons would literally strip off sterile attire, walk to the scrub area which was usually located between rooms, rescrub and enter the room next door.


There is usually so much involved in surgery that if the attending had to go to another room, the residents continued operating doing other aspects of the surgery that needed to be done anyway. I can not recall ever seeing a patient remaining under anesthesia while the resident stood and did nothing. They had plenty to do that really didn't require the attending and they ALWAYS had a chief resident in charge during those times.


Residents learn by doing, not by watching. Junior residents were relegated to holding retractors, closing the patients incision, and applying dressings. No junior resident was ever left in charge that I am aware of. I have seen attendings demand a third room and they were always politely turned down by the nursing staff. If the attending got irate about it, the head nurse of that department was quick to get involved and remind them that it wasn't going to happen.

While I would want my surgeon to be good at multi-tasking, I would never want him (or her) to be juggling multiple surgeries at once. Yikes. And this practice is so commonplace that it has a name. Double yikes.

I grew up in a small-sized University town and locals all knew to avoid the teaching hospital due to this very type of thing.

Young doctors need the opportunity to learn, this is true... but patients undergoing non-emergency surgery have the right to know who their surgeon will be. Patients need an opportunity to agree to be a doctor's (or resident's) patient. It seems so obvious, it is scary that this isn't a right granted to the patient.

This is a very common practice at teaching hospitals. The attending surgeon (as well as the attending anesthesiologist) will move from room to room supervising Fellows and residents (Its seldom more than 2). As a general rule however, you will not see a 1-2 year resident left alone. Fellows on the other hand by and large require less supervision.

The same is true for most part of a hospital esp in the ICU. hour to hour its the residents and fellows with input from the attending.

The nursing staff is also there too keep an eye out. I myself as night charge nurse in a busy PICU told a Fellow 'No" when he wanted to do what in my opinion was a risky and unwarranted procedure on a patient. He was adamant so I refused to allow him the nursing staff he needed until the attending arrived who agreed with my assessment.

a reply to: VegHead

I understand what you are saying but my experience is totally different. Residents were usually the first doctor to see the patient. They did rounds, interviewed the patients etc. The attending usually came in to see the patient last and got most of the patient information from the resident before ever stepping in the room. It one of the reasons I can't watch television medical fiction shows. They make it look like the attending has a gaggle of idiot junior residents following them around asking stupid questions. Reality is far different. Patients usually meet the residents first and anyone that thinks the attending will be the only surgeon in the room has watched too much television.

a reply to: Khaleesi


I understand the process, seems like with many things there are people, in this case, surgeons that may be abusing the "leaning".
Of course the surgeons need to learn, if I was at a teaching hospital, and was asked if I minded if a student did my surgery, I would only allow this if the attending was in the room 100% of the time. If not then no and I would seriously consider another hospital.

I think we pay enough money to have the attending stay in the room. The reason is complications and unforeseen issues after you are "open".

originally posted by: VegHead

I grew up in a small-sized University town and locals all knew to avoid the teaching hospital due to this very type of thing.

Most teaching hospitals have better outcomes than private. Also in a teaching facility, there is more systems in place and the staff is more empowered to say 'No" or ask that critical question 'Why" etc.

Teaching hospitals tend to be research facilities as well so they often offer more cutting edge treatment etc.

a reply to: FredT


I'm an x-ray tech. You probably wouldn't be surprised (but others would) by how much an experienced attending respects the staff around them. Young residents tend to be more arrogant. Attendings have had time to learn that the nurses and other personnel are competent in their respective fields. I actually had an attending look at a resident during surgery, point to me and say "She just saved your @ss."

originally posted by: seasonal
a reply to: Khaleesi


I understand the process, seems like with many things, there are people, in this case, surgeons that may be abusing the "leaning".
Of course the surgeons need to learn, if I was at a teaching hospital, and was asked if I minded if a student did my surgery, I would only allow this is the attending was in the room 100% of the time. If not then no.

I think we pay enough money to have the attending stay in the room. The reason is complications and unforeseen issues after you are "open".

Believe me, the attending is not going to leave an incompetent person in charge. Ultimately the attending is responsible and they know it. Residents are not medical students. They are doctors. No 'student' will be doing your surgery and the attending will be there for most of the time, especially the most critical stages of surgery. A resident will most certainly be doing part of (probably) every surgery that is done in the US. Anyone who thinks the attending is there for every second of the case, has watched too much tv. Some cases last many hours. TV wants you to think no one ever scrubs out and they all stand there for 12 hours straight. It's BS and quite frankly stupid to think that.

originally posted by: VegHead
While I would want my surgeon to be good at multi-tasking, I would never want him (or her) to be juggling multiple surgeries at once. Yikes. And this practice is so commonplace that it has a name. Double yikes.

I grew up in a small-sized University town and locals all knew to avoid the teaching hospital due to this very type of thing.

Young doctors need the opportunity to learn, this is true... but patients undergoing non-emergency surgery have the right to know who their surgeon will be. Patients need an opportunity to agree to be a doctor's (or resident's) patient. It seems so obvious, it is scary that this isn't a right granted to the patient.

They always introduce the resident to the patients. When attending a teaching hospital you actually get multiple doctors looking out for your health. That's why statically they are always the topp hospitals in the country. Care is significantly higher at these hospitals. They are all ways on the cutting edge of research and they train the future surgeons many of whom are very talented.

Well it's a good thing that the residents were not allowed in my case. Mine had to have two doctors at the same time working on both femoral arteries to insert a [pipeline device in the brain]. Man I was I bleeding profusely when I came out. I still have one more surgery and I have to be awake for that one. So I will know if an resident is working on me. Glad that is not my case, than I would definitely would have a heart attack.

originally posted by: Khaleesi
a reply to: seasonal

I worked at a large Medical Center for 15 years. I worked in the OR for 10 years. It was common practice that the attending physician could have 2 rooms booked at the same time. They had to actually scrub into each case at some point during the surgery. Yes, residents did part of the surgery. That is how they learn. SOP was that when the attending was not in the room, there had to be a chief resident (resident in their final year of residency) in the room.


The OR I worked in was sectioned into areas based on type of surgery. Orthopedic surgery was done in a specific group of rooms located near each other. Neurosurgery rooms near each other, etc. Surgeons would literally strip off sterile attire, walk to the scrub area which was usually located between rooms, rescrub and enter the room next door.


There is usually so much involved in surgery that if the attending had to go to another room, the residents continued operating doing other aspects of the surgery that needed to be done anyway. I can not recall ever seeing a patient remaining under anesthesia while the resident stood and did nothing. They had plenty to do that really didn't require the attending and they ALWAYS had a chief resident in charge during those times.


Residents learn by doing, not by watching. Junior residents were relegated to holding retractors, closing the patients incision, and applying dressings. No junior resident was ever left in charge that I am aware of. I have seen attendings demand a third room and they were always politely turned down by the nursing staff. If the attending got irate about it, the head nurse of that department was quick to get involved and remind them that it wasn't going to happen.

Your absolutely correct.
Nothing new here, move along.

And something I learned before surgery, I guess a newbie from the teaching hospital said it was okay for me to drink Gatorade and not water before the surgery. Don't do it. The doctors almost canceled my surgery because of it. Only clear liquids and a small sip at that. It can fill your lungs in surgery from what the anestiologist told me.

originally posted by: Diabolical1972
Well it's a good thing that the attendees were not allowed in my case. Mine had to have two doctors at the same time working on both femoral arteries. Man I was I bleeding profusely when I came out. I still have one more surgery and I have to be awake for that one. So I will know if an attendee is working on me. Glad that is not my case, than I would definitely would have a heart attack.

You may 'be awake' but I doubt you will remember who is in the room. Anesthesia will be involved and they like to give that nice hypnotic inducing med that makes you forget everything that happened. There is no such thing as an 'attendee'. There are attendings (the doctor in charge), fellows (doctor that is doing extra training in a specialty) residents (of varying degrees of experience) and maybe even a medical student watching.

originally posted by: Khaleesi

originally posted by: Diabolical1972
Well it's a good thing that the attendees were not allowed in my case. Mine had to have two doctors at the same time working on both femoral arteries. Man I was I bleeding profusely when I came out. I still have one more surgery and I have to be awake for that one. So I will know if an attendee is working on me. Glad that is not my case, than I would definitely would have a heart attack.

You may 'be awake' but I doubt you will remember who is in the room. Anesthesia will be involved and they like to give that nice hypnotic inducing med that makes you forget everything that happened. There is no such thing as an 'attendee'. There are attendings (the doctor in charge), fellows (doctor that is doing extra training in a specialty) residents (of varying degrees of experience) and maybe even a medical student watching.

No this last operation, there will be no anesthesia at all. They will only give me anxiety reliever [verisal]

originally posted by: Diabolical1972

originally posted by: Khaleesi

originally posted by: Diabolical1972
Well it's a good thing that the attendees were not allowed in my case. Mine had to have two doctors at the same time working on both femoral arteries. Man I was I bleeding profusely when I came out. I still have one more surgery and I have to be awake for that one. So I will know if an attendee is working on me. Glad that is not my case, than I would definitely would have a heart attack.

You may 'be awake' but I doubt you will remember who is in the room. Anesthesia will be involved and they like to give that nice hypnotic inducing med that makes you forget everything that happened. There is no such thing as an 'attendee'. There are attendings (the doctor in charge), fellows (doctor that is doing extra training in a specialty) residents (of varying degrees of experience) and maybe even a medical student watching.

No this operation there will be anesthesia at all. They only give me anxiety reliever.

Oh dear God. I hate when non medical people insist they know more than medical staff. If you had surgery you had an IV. If they stuck your femoral artery, I guarantee you got some form of anesthesia. I worked in the OR for 10 years. Anxiety relievers are a form of anesthesia. Just because they didn't 'knock you out' doesn't mean they gave you no anesthesia.

a reply to: Khaleesi

Oops.

"Sorry about that lung damage, terrible recovery or death" said the unsupervised resident.

originally posted by: seasonal
a reply to: Khaleesi

Oops.

"Sorry about that lung damage, terrible recovery or death" said the unsupervised resident.

I'd love to see that waiting line for surgery after they say attendings have to be there 100% of the time. Elective surgery would come to a stand still. And I've seen emergencies happen in the OR. Usually it involves the surgeon stopping what they are doing while the anesthesiologists deal with the situation. If every armchair doctor around here had to 'walk a mile in their shoes' you would realize how unrealistic your expectations are. Most emergencies in the OR, in my experience, involves anesthesia and has nothing to do with the attending being in or out of the room. Go peddle your hyperbole somewhere else.

a reply to: Khaleesi

Sorry, responding to Diabolical1972.

And something I learned before surgery, I guess a newbie from the teaching hospital said it was okay for me to drink Gatorade and not water before the surgery. Don't do it. The doctors almost canceled my surgery because of it. Only clear liquids and a small sip at that. It can fill your lungs in surgery from what the anestiologist told me.

a reply to: seasonal

I am a medically retired charge nurse (intensive care in the UK). From 1985-1993 I worked in a 16-bedded private cardiothoracic intensive care unit in central London. We had a cardiac surgeon who would have have 3 theatres on the go. One theatre would have several registrars (with the MRCS qualification) opening the chest and harvesting radial arteries and/or saphenous veins. The consultant surgeon would be in the second theatre with one registrar acting as 1st assistant, placing the patients on and off cardiopulmonary bypass and coronary grafting. In the third theatre there would be 1st assistants closing the chest.

I can't recall any iatrogenic problems occurring with this particular surgeon's patients in the time I worked there. I can't imagine that being allowed now.