by David B. Hoyt, MD, FACS
Over the last several months, the issue of concur- rent and overlapping operations has received considerable attention in the lay and professional press. The American College of Surgeons (ACS)
Statements on Principles have long included a section
on the surgeon’s responsibility to be present for key
parts of the preoperative, intraoperative, and postoperative phases of care. In light of the media play that
this topic is now receiving, however, the ACS leadership recently determined that the time was ripe to
clarify the College’s position on this matter.
Overlapping and concurrent operations:
The issue of concurrent and overlapping surgery
came to the public’s attention last fall, when the
Boston Globe’s Spotlight team reported on alleged
double-bookings of surgical procedures at a nationally recognized area hospital.*
As most surgeons know, overlapping operations are
performed routinely and safely at many health care
centers, particularly teaching hospitals and trauma
centers. Overlapping operations occur in two general
circumstances. The most common scenario is when
the key or critical elements of the first operation have
been completed, and it is unlikely that the primary
attending surgeon will need to return to that procedure.
In this circumstance, the surgeon may supervise the
start of another operation while a qualified health care
professional, such as a resident or a surgical assistant,
performs the final, rudimentary components of the first
operation, such as closing the incision. Less commonly,
the primary surgeon will have completed the critical
elements of the first operation and begun performing
key portions of a second procedure in another room.
Concurrent operations, on the other hand, are
procedures in which a surgeon is involved in two
operations—both of which are in the critical stages
Proponents of overlapping and concurrent operations maintain that the practice allows hospitals to
reduce wait times and frees up their most in-demand
surgeons to do more procedures. Furthermore, teaching hospitals often condone the practice as a means of
allowing trainees to develop graduated autonomy in the
completion of common procedures, and trauma centers
sometimes rely on overlapping operations when faced
with clusters of emergency and urgent cases.
Opponents have t wo primary concerns: that sometimes the attending surgeon may be away from a case
for an extended period of time, during which complications may arise; and that some surgeons may provide
their patients with insufficient information about the
practice before receiving consent.†
The College’s stance
As an organization dedicated to surgical education and
training, the College recognizes the benefits of allowing
interns, residents, and fellows to participate in certain
aspects of operations with varying levels of autonomy
based on experience, technical skill, and cognitive ability. To ensure patient safety, though, the College also
maintains that the attending surgeon should remain
in the operating room or immediate vicinity for the
entire procedure, ready to intervene should a complication arise. Furthermore, the ACS has advocated that
patients be fully informed of their primary surgeon’s
direct and indirect involvement in their care before
they consent to an operation.
The College’s Statements on Principles have long
reflected these positions. However, the ACS has avoided
being overly prescriptive and has viewed surgical scheduling as a responsibility best handled at the institution’s
The revelations in the Boston Globe’s exposé and
subsequent articles‡ brought to light the considerable
*Abelson J, Saltzman J, Kowalczyk L, Allen S. Clash in the name of care.
Boston Globe. October 25, 2015. Available at: https://apps.bostonglobe.com/
spotlight/clash-in-the-name-of-care/story/. Accessed March 28, 2016.
†Mello MM, Livingston EH. Managing the risks of concurrent surgeries.
JAMA. 2016;315( 15):1563-1564. Available at: http://jama.jamanetwork.com/
article.aspx?articleid=2505160&resultClick= 3. Accessed April 25, 2016.
‡Abelson J, Saltzman J, Kowalczyk L. Concurrent surgeries come under
new scrutiny. Boston Globe. December 20, 2015. Available at: www.bos-
story.html. Accessed April 25, 2016