The Other 20% of the Time: Surgeons Going AWOL

The preoperative holding area is a stressful place for patients. They have a million things going through their minds. Figuring out whether their surgeon will be in the operating room or not shouldn't be one of them.

Woody Allen famously quipped that “80% of success is showing up.” He didn't say for how long. When it comes to surgeons in the OR, this has become an issue.

Ever since the Boston Globe ran its series on concurrent surgery, much attention has been focused on the question, “Where in the world is your surgeon?” Sometimes the answer is: Leaving one operating room before the procedure is completely finished to perform another operation in a different room.

Now, the American College of Surgeons has chimed in with guidelines that state “As part of the preoperative discussion, patients should be informed of the different types of qualified medical providers that will participate in their surgery (assistant attending surgeon, fellows, residents and interns, physician assistants, nurse practitioners, etc.) and their respective role explained. If an urgent or emergent situation arises that require the surgeon to leave the operating room unexpectedly, the patient should be subsequently informed.”

Surgery, when done properly, is a well-choreographed endeavor involving many highly skilled people working on behalf of the patient. The production usually happens in three acts: preoperative activity, the operation itself, and postoperative activity.

Every part of that three-act play is changing to improve outcomes and patient safety. Those changes are designed to address some nagging problems:

1. Perioperative patient homes are designed to better coordinate and communicate care between teams and minimize hand-off errors.

2. Hospitals are creating better ways to start the first case on time and minimize turnover times.

3. Better perioperative information systems alert team members to potential problems before, during, and after the procedure.

4. Informed consent platforms provide patients with better, more complete and easier to understand information sufficiently ahead of their procedure so that they understand the risks and benefits and can consent when they are not under duress in the pre-operative holding area.

5. The expanding cast of characters and dramatis personae cause confusion in the mind of the patient and their families, so hospitals and professional societies are emphasizing the need to improve communications with them.

6. Exactly when it is safe for the attending surgeon to leave the OR is up for debate. Some think it is when the “critical” part of the procedure is done. Others think that the surgeon should stay in the room until the patient is awakened from anesthesia and safely transported to the recovery room, particularly if the surgery involves a part of the upper aerodigestive system that could compromise the airway.

7. Check lists and safeguards are designed to eliminate “never happen” events, like wrong patient, wrong site surgery. Unfortunately, it continues to happen all too often.

8. Postoperative communications between the attending surgeon and the family in the reception area are deteriorating.

9. Audits, chart reviews, and billing guidelines are constantly emerging to insure that there is compliance with the rules for submitting bills e.g. attending oversight of surgery performed by trainees, like residents, and fellows.

10. Resident supervision and how to insure trainee competency in a certain specialty at the time of graduation is undergoing continued scrutiny.

The preoperative holding area is a stressful place for patients. They have a million things going through their minds. Figuring out whether their surgeon will be in the OR or not shouldn't be one of them.