The Wrongness of Being in Two Places at Once

In medicine, there is often uncertainty about right and wrong practice.

Not in this case.

Last weekend, a group of investigative reporters from the Boston Globe exposed the practice of overlapping surgeries at Massachusetts General Hospital (MGH).^[1] Surgeons intentionally scheduled cases so that they could work on two patients at the same time.

If you care about medicine done right, this story deserves your attention. We learn most from our mistakes.

The Globe Spotlight Team reported that patients were not informed when surgeons scheduled simultaneous cases. MGH sanctioned the practice, but other physicians had internally voiced concerns about the policy for years.

Nothing material changed. Then came malpractice cases in which plaintiff's attorneys cited overlapping cases as a factor in bad outcomes. Finally, an eminent MGH surgeon broke with tradition and took his concerns to the press.

It's important to set out that the accusations in this case involve far more than a trainee or delegate closing skin at the end of an operation. These were complicated and mostly elective cases that were intentionally double-booked (for hours) under the guise of improved productivity and increasing access to sought-after surgeons.

In its lengthy report, the Globe tells of double-booked cases in which complications occurred, trainees were left without coverage at key moments, and patients wallowed under general anesthesia awaiting arrival of the attending surgeon.

The most chilling part of the story was that Dr Dennis Burke, an eminent surgeon who stood against this practice, a man who was given a distinguished clinician award in 2009 and who had worked at MGH most of his life, was fired for being a disruptive physician.

Four aspects of this story stand out.

The first is hubris. Excessive pride and self-confidence is one of the physician's greatest enemies. Whether you are a spine surgeon, procedural cardiologist, or primary-care doctor, it is nonsense to think you can deliver your best care when taking care of two patients at the same time. We can agree that multitasking will always be part of a caregiver's day, but each patient deserves our attention in the moment we are with them. You need not be a Harvard physician to know right from wrong. These were elective cases.

The second aspect is greed. In my first week of private practice, the senior physician of my group took me aside after a meeting and said, "John, whenever they say it's not about the money, it's always about the money." The argument that double-booking surgeries allows better access to star surgeons is not convincing in Boston, a hub for medical excellence. In the US healthcare system, the more you do, the more you make. Double-booking elective cases, therefore, can only be about making more money. When an institution sanctions such a practice, its priorities are clear.

The third aspect of this story is transparency and patient consent. Wrong is the only way to describe the fact that secretaries, nurses, anesthesiologists, residents, and fellows knew but the patient did not. If you defend double-booking, tell the patient. Sometimes I wonder why doctors don't see themselves as patients. To us, the experienced professional, medical, and surgical practice is rote. It's hardly so to the person being wheeled onto a narrow table on which they will be cut open. Would any surgeon-patient consent to this practice?

Another note on transparency. In the interconnected digital world, medicine will harbor no more of these great secrets. Smartphones record conversations, take pictures, and make movies. Files can be (and are) shared to the world in seconds.^[2,3] The new reality of transparency is a good thing. Good because it's never been a better time for those who do what is right as a default.

The fourth aspect of this story is the near impossibility of questioning authority in mainstream medicine. The doctors who fought against this policy were first ignored and then vilified. "You will never be forgiven," was what one emeritus professor said to his colleague. If a man with the credentials of Dr Dennis Burke cannot raise questions about faulty practices, how could any member of the medical team?

This iron wall of medicine is nothing to be proud of. And surgeons aren't alone in crushing dissent. It happens in all areas of medicine. Doctoring is a humbling job, so critique of colleagues is no small thing. Those who review must be careful, just, and ever mindful that hindsight is sharp. But peer review and self-policing must happen. If it does not, others will do it for us—witness the Department of Justice investigation of internal defibrillator implants.^[4]

The problem with activism in medicine is that the activist gets marginalized. He or she who breaks with tradition loses standing in the guild. That should not happen when the cause of the activism is simply doing the right thing.

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