Double booked surgeries

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anbuitachi

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MGH surgeons left patients waiting under anesthesia while they did second surgeries, whistle blower charges - The Boston Globe

or

MGH surgeons left patients waiting under anesthesia while they did second surgeries, whistle blower charges - The Boston Globe

Pretty brave of this anesthesiologist to fight against her hospital/surgeons. We all know ortho docs are one of the richest specialties, and I actually think this is a common practice in many major institutions.

While I do not know if complication rates actually go up, the patients should know about it, and there is limited data about long term effect of giving GA longer than neccessary
 
Lots of medical specialities do similar billing practices. It's acceptable

If the lawyer can start billin me from the time they "leave" their office to meet me at the court house (even though they may take a dump first but they are on the "clock")

This is a stupid whistle blower case

All that will come out of this will be revised consent forms saying surgeon may be working on another case at same time
 
Why is it acceptable to have the patient under GA waiting for the surgeon to come? I've had this issue a # of times in double booked surgeries. Sometimes it's cause the surgeon is having issues in the other room, and now this patient whos already under GA is there waiting for a hr for nothing. Just cause it's common practice doesn't make it not bad for the patient..


aneftp said:
Lots of medical specialities do similar billing practices. It's acceptable

If the lawyer can start billin me from the time they "leave" their office to meet me at the court house (even though they may take a dump first but they are on the "clock")

This is a stupid whistle blower case

All that will come out of this will be revised consent forms saying surgeon may be working on another case at same time
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anbuitachi said:
MGH surgeons left patients waiting under anesthesia while they did second surgeries, whistle blower charges - The Boston Globe

or

MGH surgeons left patients waiting under anesthesia while they did second surgeries, whistle blower charges - The Boston Globe

Pretty brave of this anesthesiologist to fight against her hospital/surgeons. We all know ortho docs are one of the richest specialties, and I actually think this is a common practice in many major institutions.

While I do not know if complication rates actually go up, the patients should know about it, and there is limited data about long term effect of giving GA longer than neccessary
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I honestly do not think this is bad practice. With a good communication system and PAs the times could be minimized. I just think she could not roll with the flow.
 
From the article: "Wollman said the patient suffered a serious and sudden constriction of the airways while Surgeon B was not present, though a senior trainee was. The lawsuit said that Wollman complained to the operating room director about Surgeon B’s absence, writing, “Isn’t he obligated to be there?”
So this attending anesthesiologist needs the ortho guy in the room to treat bronchospasm ??!!!. What a joke. This anesthesiolgist sounds like a real pain in the a$$ and incompetent to boot.
 
This practice is ok if done correctly. It is not ok to leave a patient anesthetized for an hour with nothing happening for whatever reason to suit the surgeon's schedule or desire to bill more RVUs.
 
Don't know anything about the case. Did the patient go into bronchospasm cause the anesthesiologist had to cut down the anesthetic cause the patient's pressures were in the toilet for an hour just sitting on the table under GA and the patient got light and spasmed? Not saying that the anesthesiologist can't treat bronchospasm or hypotension, but usually something is going on while the surgeon is away in another room (prepping, exposure, closing, etc.) It happens all he time, and usually isn't an issue, but the few times issues do arise is the time for internal reviews.
 
anbuitachi said:
Why is it acceptable to have the patient under GA waiting for the surgeon to come? I've had this issue a # of times in double booked surgeries. Sometimes it's cause the surgeon is having issues in the other room, and now this patient whos already under GA is there waiting for a hr for nothing. Just cause it's common practice doesn't make it not bad for the patient..
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Why run 4 rooms medical direction?

Legally by the books "present for critical aspects" means u gotta to be in all room 4 for induction and extubation plus other aspects of the case? Correct?
 
Big difference between waiting 15 minutes and 1.5 hours. The later is complete BS and shows poor comunication between all teams (surgery, anesthesia and nursing).

We have many spine surgeons and orthopedic surgeons that do this. Works out great with proper communication and planning. I have no problem with it so long as you don't have a room full of staff sitting around playing suduko for hours before incision.
 
sevoflurane said:
Big difference between waiting 15 minutes and 1.5 hours. The later is complete BS and shows poor comunication between all teams (surgery, anesthesia and nursing).

We have many spine surgeons and orthopedic surgeons that do this. Works out great with proper communication and planning. I have no problem with it so long as you don't have a room full of staff sitting around playing suduko for hours before incision.
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Agreed, nothing wrong with 15 minutes, maybe longer if issue arise, but usually something should be done. But you can see where complications may arise when you got a patient with having a shoulder repair under GA in beach chair position with nothing going on for an hour and a half. Definitely a communications issue.
 
sevoflurane said:
Big difference between waiting 15 minutes and 1.5 hours. The later is complete BS and shows poor comunication between all teams (surgery, anesthesia and nursing).

We have many spine surgeons and orthopedic surgeons that do this. Works out great with proper communication and planning. I have no problem with it so long as you don't have a room full of staff sitting around playing suduko for hours before incision.
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I agree 15 min is not a big deal, but you often have 2 surgeries w same surgeon booked to start 30 min apart (like robotic prostates from a recent article). Now the surgeon assumes all will be well, and by the time he's done w 1st case, the 2nd case is under GA, his assistants already docked the robots and did basic stuff and he just needs to come in and do the critical parts. But plenty of surgeries end up being more complicated than expected and take significantly longer. In those cases it's not poor communication, the issue is in the booking/expectations
 
I understand the production pressure and wanting to facilitate work flow, I get it. But, why is it acceptable to expose the patient to unnecessary GA and it's associated (albeit minimal) risk? Like the bronchospasm mentioned, I don't think the issue was needing the surgeon to treat it, I think the issue was this was a patient that should not have been under GA at the time and was exposed to the unnecessary risk and had an event as the result of this.

I know I'm probably being a bit idealistic but this should not happen, and certainly not regularly. I applaud the anesthesiologist for speaking up against the machine of production.


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Crabbygas said:
So the patient is under anesthesia for an hour or so waiting for the surgeon. I'll bet that would happen a whole lot less if the surgeon got the bill for the extra time instead of the patient.
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Yes I feel uneasy about patients getting billed for anesthesia time that is of zero benefit and possibly harmful to them, but is of benefit to OR efficiency and surgeon convenience. I'm glad this lawsuit will shed more light on this rampant practice.
 
I've often wondered what Medicare or other payers would have to say if a concerned person told them that they'd been billed for an unnecessary hour of OR time and anesthesia ...

... because the surgeon was unavailable ...

... because he was doing another case they were also getting billed for.


Really long delays (an hour+) are totally predictable in this model. If you live on the edge trying to squeeze some extra efficiency out of overlapping cases, it's inevitable that eventually a couple of outlier cases will line up just wrong, and instead an acceptable 5 or 10 minute wait you get an hour.

It's like airlines overbooking flights. On average it works out OK. Occasionally it doesn't and passengers get screwed.

Hospitals are guilty of this too. How many of us have sat in the OR with a patient on PACU hold for 15 minutes or an hour because the hospital is playing shell games by running the PACU lean?
 
pgg said:
I've often wondered what Medicare or other payers would have to say if a concerned person told them that they'd been billed for an unnecessary hour of OR time and anesthesia ...

... because the surgeon was unavailable ...

... because he was doing another case they were also getting billed for.


Really long delays (an hour+) are totally predictable in this model. If you live on the edge trying to squeeze some extra efficiency out of overlapping cases, it's inevitable that eventually a couple of outlier cases will line up just wrong, and instead an acceptable 5 or 10 minute wait you get an hour.

It's like airlines overbooking flights. On average it works out OK. Occasionally it doesn't and passengers get screwed.

Hospitals are guilty of this too. How many of us have sat in the OR with a patient on PACU hold for 15 minutes or an hour because the hospital is playing shell games by running the PACU lean?
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Pacu hold is the worst but is a lot harder to manage than double surgeries. For one patient care is improved since you stay in the or under care of anesthesiologist. It's hard to control admissions from the ED
 
Let me present another scenario. Would you rather wait 1 hour under anesthesia to have world famous xyz surgeon at mgh do you complex onc/cardiac case. Versus going to local regional hospital where the surgeon has not seen a complex xyz but he is single booked. Give me the extra hour under anesthesia. These surgeons are rock stars their is a reason people travel to these flagship institutions.
 
narcusprince said:
Let me present another scenario. Would you rather wait 1 hour under anesthesia to have world famous xyz surgeon at mgh do you complex onc/cardiac case. Versus going to local regional hospital where the surgeon has not seen a complex xyz but he is single booked. Give me the extra hour under anesthesia. These surgeons are rock stars their is a reason people travel to these flagship institutions.
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Would you rather have rockstar surgeon do your procedure after a few cocktails, a little buzzed, but not drunk; or community surgeon who hasn't done this procedure in 20 years? That question is just as relevant. Just because one scenario is better than an alternative doesn't make it ideal. Why not have rockstar surgeon do your procedure sober and without an extra hour under anesthesia? Wouldn't that be the best choice?
 
narcusprince said:
Let me present another scenario. Would you rather wait 1 hour under anesthesia to have world famous xyz surgeon at mgh do you complex onc/cardiac case. Versus going to local regional hospital where the surgeon has not seen a complex xyz but he is single booked. Give me the extra hour under anesthesia. These surgeons are rock stars their is a reason people travel to these flagship institutions.
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In my experience the community guys are often better than the professors with the rockstar reputations.
 
SaltyDog said:
Yup. I can think of only 2 surgeons from my residency program that I would let touch me. Compare that to PP where I would be OK seeing 90% of them.
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It's true up to a certain point in true private practice.

The guys at real academic tertiary center get all the dump offs/high risk patients.

Money is obviously a motivating factor since most surgeons max earning potential are from ages 35-55 years old.
 
I mean a lot of surgeons are 'rockstars' BC they have lots of research not necc because they do amazing shoulder replacements.
 
It's easy to run 2 rooms with the right surgeon and team. If the surgeon isn't able to efficiently get through his cases during the day, he is NOT given 2 rooms. Really that simple. Furthermore, our high volume surgeons are booked up 3 months out and sometimes way longer depending on time of year. So kncking out 10 cases a day is what we need to do to keep the clinics/cases free flowing.
Currently doing 10 cases today flipping rooms. We are all in communication with ea. other. Once hardware is in and we start to close the knee I text my anesthesia buddy to take the next patient to the OR. That patient gets induced and we proceed to positioning and prep. Surgeon scrubs out of the previous case once he is notified that we are ready for him (meaning we are scrubbing). NP closes while he goes to the next total joint to get things started with the scrub tech. NP finishes in the previous room and then comes into the next case-- rinse and repeat all day long. Anterior THA takes about 60 min. skin to skin or 75 min. WIWO. TKA usually 45 min. skin to skin and 1 hr. WIWO. Revisions are saved for the end of the day and we don't flip once we get into those cases.

Ultimately, the the patient isn't "sitting around" for a surgeon to show up at any time. We aren't waiting around to bring the next case to the OR either. It's not rocket science, but the right system needs to be in place.
 
We all have a mutual understanding. Realistically, we aren't waiting around for a surgeon.
15 minutes of wait time would be an eternity for me and rarely if ever happens. We all keep mental notes of efficiency and if a surgeon doesn't fit the bill, he doesn't get two rooms. All surgeons that run 2 or more rooms have metrics that are looked over in detail every quarter.

As for academics vs PP. Both have very capable surgeons. Once we dig into orhto-onc... there are some amazing ones that are in academics.
Worked with one in residency. He actually had 3 rooms at times. Also worked with some really awful slow surgeons in academics. So it's a mixed bag.

Ortho-onc superpod didn't last long in academics because he eventually understood his value and moved on to PP.
 
Given the choice i think patients would chose 10min extra anesthesia vs 2 more months of waiting for surgery...
 
aneftp said:
It's true up to a certain point in true private practice.

The guys at real academic tertiary center get all the dump offs/high risk patients.

Money is obviously a motivating factor since most surgeons max earning potential are from ages 35-55 years old.
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In academics, the real guys are doing research at a high level and clinically the residents do the cases. In private practice, they do the cases all day long at a higher level. Sign me up for PP surgeon all day long.

Now I'm obviously making generalizations, but when I entered the world of private practice surgery I was stunned at their clinical skill. I mean I worked with world famous surgeons in residency. The names on the textbooks. And they sucked in terms of surgical skill level compared to what I see on a daily basis with good private busy private practice surgeons. And oh yes, our private surgeons are still at a massive level 1 trauma center taking 500 lbers dumped from Outside Hospital.

There is a real difference with an experienced skilled surgeon that has done a case hundreds and thousands of times compared to an academic surgeon that has residents and fellows doing large portions of a case while they scrub in for the "key portion".
 
Mman said:
In academics, the real guys are doing research at a high level and clinically the residents do the cases. In private practice, they do the cases all day long at a higher level. Sign me up for PP surgeon all day long.

Now I'm obviously making generalizations, but when I entered the world of private practice surgery I was stunned at their clinical skill. I mean I worked with world famous surgeons in residency. The names on the textbooks. And they sucked in terms of surgical skill level compared to what I see on a daily basis with good private busy private practice surgeons. And oh yes, our private surgeons are still at a massive level 1 trauma center taking 500 lbers dumped from Outside Hospital.

There is a real difference with an experienced skilled surgeon that has done a case hundreds and thousands of times compared to an academic surgeon that has residents and fellows doing large portions of a case while they scrub in for the "key portion".
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It all comes down to money with any speciality. Academics or no academia.

Ortho trauma surgeon at state institution I was at got incentive bonus. So he's raking in close to 7 figures with zero overhead. Works like a dog and good at what he does. Very little research. Doesn't want anesthesia residents in his rooms cause they slow him down. Doesn't even want Surgery residents unless they are senior Surgery residents.

Give them enough money they will come. But that's the exception. Depends what the agenda is of administration
 
aneftp said:
It all comes down to money with any speciality. Academics or no academia.

Ortho trauma surgeon at state institution I was at got incentive bonus. So he's raking in close to 7 figures with zero overhead. Works like a dog and good at what he does. Very little research. Doesn't want anesthesia residents in his rooms cause they slow him down. Doesn't even want Surgery residents unless they are senior Surgery residents.

Give them enough money they will come. But that's the exception. Depends what the agenda is of administration
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He should be easily breaking 7 figures if he works a lot as ortho
 
waterbottle10 said:
He should be easily breaking 7 figures if he works a lot as ortho
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No overhead. All malpractice paid plus state pension for ortho surgeon.

People gotta look at entire package.

My plastic surgeon friend "makes 7 figures" even in year 2 out. Once u count office lease, staff, equipment, advertising. He's literally left with around 300k in net income. He's a very close friend as well.

Now in year 10 out. He really makes net over 1-1.2 million.

Most ortho docs I know make around $600-800k net. He super stars obviously net more. One owns his own plane and yatch docked in Aruba.
 
sevoflurane said:
We all have a mutual understanding. Realistically, we aren't waiting around for a surgeon.
15 minutes of wait time would be an eternity for me and rarely if ever happens. We all keep mental notes of efficiency and if a surgeon doesn't fit the bill, he doesn't get two rooms. All surgeons that run 2 or more rooms have metrics that are looked over in detail every quarter.

As for academics vs PP. Both have very capable surgeons. Once we dig into orhto-onc... there are some amazing ones that are in academics.
Worked with one in residency. He actually had 3 rooms at times. Also worked with some really awful slow surgeons in academics. So it's a mixed bag.

Ortho-onc superpod didn't last long in academics because he eventually understood his value and moved on to PP.
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That's been my experience as well. You shouldn't be under GA for an extra hour with that sort of system.

We even have a few cardiac surgeons that get two rooms.
 
Mman said:
There is a real difference with an experienced skilled surgeon that has done a case hundreds and thousands of times compared to an academic surgeon that has residents and fellows doing large portions of a case while they scrub in for the "key portion".
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Dumb question but can the same be said for anesthesia? If an anesthesia graduate goes straight into supervising residents and CRNAs, how would their efficiency and skill set compare to someone who does their own cases when compared a couple years down the road? I guess if you supervise more rooms, that's more cases seen and done and more potential to do multiple procedures. But your quote argues that's not the same as doing your own cases day in and day out.
 
MoMoGesiologist said:
Dumb question but can the same be said for anesthesia? If an anesthesia graduate goes straight into supervising residents and CRNAs, how would their efficiency and skill set compare to someone who does their own cases when compared a couple years down the road? I guess if you supervise more rooms, that's more cases seen and done and more potential to do multiple procedures. But your quote argues that's not the same as doing your own cases day in and day out.
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Yes the same can be said. But unless you are in a small hospital, attendings >> residents. There usually are way more cases than residents can cover (which often is not the case in surgery. Surgery residents may even compete for cases at some places) . So the anesthesiology attendings cover residents half the time here maybe so they still do many cases by themselves.
 
MoMoGesiologist said:
Dumb question but can the same be said for anesthesia? If an anesthesia graduate goes straight into supervising residents and CRNAs, how would their efficiency and skill set compare to someone who does their own cases when compared a couple years down the road? I guess if you supervise more rooms, that's more cases seen and done and more potential to do multiple procedures. But your quote argues that's not the same as doing your own cases day in and day out.
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I personally do a lot more procedures in ACT supervising than I would doing my own cases. A lot more epidurals, a lot more difficult intubations, a lot more central lines, a lot more arterial lines, and a lot more peripheral nerve blocks. There is no way I could be as fast and slick at those things if I was doing my own cases since I'd do fewer of them. Now I'm probably not as good at knowing when to turn the vaporizer from 1 to 0 at the end of the case, but procedurally I do way more.
 
sevoflurane said:
Currently doing 10 cases today flipping rooms.
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Man, a superpod (I like that term) that can crank out 10 total joints in a day is an anesthesia group's wet dream. A few of the more seasoned guys at my last gig were close to that pace, but didn't have the volume (or at least the desire) to burn through that many in a day. Compare that to my lineup today - 3 TKA's scheduled from 0700-1730 :bang:. The guy has good outcomes, and his patients love him but damn - speed it up dude. He recently had the audacity to ask my group if we could start doing our SAB's in preop so he could "squeeze in" a 4th case (insert jerking off emoji here), 'cuz you know - that extra 15 minutes it saves over 3 cases will make all the difference. Umm, how bout you learn to do a knee in less than 3 hours and then we'll talk mmkay.
 
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SaltyDog said:
Man, a superpod (I like that term) that can crank out 10 total joints in a day is an anesthesia group's wet dream. A few of the more seasoned guys at my last gig were close to that pace, but didn't have the volume (or at least the desire) to burn through that many in a day. Compare that to my lineup today - 3 TKA's schedule from 0700-1730 :bang:. The guy has good outcomes, and his patients love him but damn - speed it up dude. He recently had the audacity to ask my group if we could start doing our SAB's in preop so he could "squeeze in" a 4th case (insert jerking off emoji here), 'cuz you know - that extra 15 minutes it saves over 3 cases will make all the difference. Umm, how bout you learn to do a knee in less than 3 hours and then we'll talk mmkay.
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What's the difference between a pod doing 10 cases in 2 rooms 2 pods doing 5 cases each in each room
 
SaltyDog said:
Man, a superpod (I like that term) that can crank out 10 total joints in a day is an anesthesia group's wet dream. A few of the more seasoned guys at my last gig were close to that pace, but didn't have the volume (or at least the desire) to burn through that many in a day. Compare that to my lineup today - 3 TKA's schedule from 0700-1730 :bang:. The guy has good outcomes, and his patients love him but damn - speed it up dude. He recently had the audacity to ask my group if we could start doing our SAB's in preop so he could "squeeze in" a 4th case (insert jerking off emoji here), 'cuz you know - that extra 15 minutes it saves over 3 cases will make all the difference. Umm, how bout you learn to do a knee in less than 3 hours and then we'll talk mmkay.
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Even better, if you do the SAB in preop, you're losing 15+ minutes of spinal time, which a slow surgeon might need. Where I trained, our slow surgeons would run out of spinal time often enough that we started doing CSEs and/or tetracaine spinals just so we weren't converting to GA when the spinal wore off.

We did the same for some of our slower OBs doing repeat sections ... unreal.
 
waterbottle10 said:
What's the difference between a pod doing 10 cases in 2 rooms 2 pods doing 5 cases each in each room
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Nothing financially, although you can get through them quicker if you're flipping rooms with 1 surgeon and not waiting for turnover, etc.
 
waterbottle10 said:
What's the difference between a pod doing 10 cases in 2 rooms 2 pods doing 5 cases each in each room
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Time. Superpod can't crank out 10 cass with one room. Now multiply that OR time by 3x a week = 30 joints.
 
SaltyDog said:
Man, a superpod (I like that term) that can crank out 10 total joints in a day is an anesthesia group's wet dream. A few of the more seasoned guys at my last gig were close to that pace, but didn't have the volume (or at least the desire) to burn through that many in a day. Compare that to my lineup today - 3 TKA's scheduled from 0700-1730 :bang:. The guy has good outcomes, and his patients love him but damn - speed it up dude. He recently had the audacity to ask my group if we could start doing our SAB's in preop so he could "squeeze in" a 4th case (insert jerking off emoji here), 'cuz you know - that extra 15 minutes it saves over 3 cases will make all the difference. Umm, how bout you learn to do a knee in less than 3 hours and then we'll talk mmkay.
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Mmkay- haha!
Financially we do very well with these guys and only put our best anesthesiologists in those rooms. We have equally efficient and proficient spine surgeons, vascular surgeons, gastric bypass surgeons, pediatric surgeons and one hell of a thoracic surgeon.
Funny story: Was warned about how fast his wedge resections can be. My first case with him I was sweating bullets because I wanted to impress this guy with my own efficiency, but gave 50mg of Roc thinking I wanted optimal surgical conditions for the wedge resection. 15 minutes after incision... the lights were on and at the 20 min. mark we were done. I was like WTF just happened. :wideyed:
And he's not dangerous.
Just incredibly gifted.
 
SaltyDog said:
Must suck never getting to work with those guys .
:poke: 😀
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Ohhh they work but they are happy going to all the different ASC's around town. :yuck:
The pace at the ASC's is def. let's say... different.
We have enough old guys, part timers, semi-retired docs in our group that they enjoy that type of pace during the days.
Gimme a couple more years and i'll be in that boat.
 
sevoflurane said:
Ohhh they work but they are happy going to all the different ASC's around town. :yuck:
The pace at the ASC's is def. let's say... different.
We have enough old guys, part timers, semi-retired docs in our group that they enjoy that type of pace during the days.
Gimme a couple more years and i'll be in that boat.
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The guys I know at the ASC are humping it double-time.
 
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sevoflurane said:
Mmkay- haha!
Financially we do very well with these guys and only put our best anesthesiologists in those rooms. We have equally efficient and proficient spine surgeons, vascular surgeons, gastric bypass surgeons, pediatric surgeons and one hell of a thoracic surgeon.
Funny story: Was warned about how fast his wedge resections can be. My first case with him I was sweating bullets because I wanted to impress this guy with my own efficiency, but gave 50mg of Roc thinking I wanted optimal surgical conditions for the wedge resection. 15 minutes after incision... the lights were on and at the 20 min. mark we were done. I was like WTF just happened. :wideyed:
And he's not dangerous.
Just incredibly gifted.
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That's what sugammadex is for🙂
 
Arch Guillotti said:
The guys I know at the ASC are humping it double-time.
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Yeah, ASC life, especially supervising CRNAs, isn't a leisurely existence. In a lot of ways, 1:1 for a couple of heart cases is a much more relaxed day, even though the patients are far sicker.
 
narcusprince said:
Let me present another scenario. Would you rather wait 1 hour under anesthesia to have world famous xyz surgeon at mgh do you complex onc/cardiac case. Versus going to local regional hospital where the surgeon has not seen a complex xyz but he is single booked. Give me the extra hour under anesthesia. These surgeons are rock stars their is a reason people travel to these flagship institutions.
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World famous doesn't mean competent. My brother just had his 2nd lum lam revision for "complications" (3 procedures total in 4 months) done by a world-renowned TX neurosurgeon. Needless to say I'm less than impressed with this "rockstar".
 
jwk said:
World famous doesn't mean competent. My brother just had his 2nd lum lam revision for "complications" (3 procedures total in 4 months) done by a world-renowned TX neurosurgeon. Needless to say I'm less than impressed with this "rockstar".
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The best of the best should be able to handle two rooms and keep times reasonable. I would want the best surgeon available for complex surgery. Even if I am double booked.
 
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