Overlapping Surgery in Plastic Surgery

An Analysis of Patient Safety and Clinical Outcomes

Rajiv P. Parikh, M.D., M.P.H.S.; Ketan Sharma, M.D., M.P.H.; Melissa Thornton, B.S.; Gabriella Brown, B.S.; Terence M. Myckatyn, M.D.


Plast Reconstr Surg. 2019;143(6):1787-1796. 

In This Article


This study examines the effect of overlapping surgery on clinical outcomes and patient safety in plastic surgery. We found no significant differences in the rate of postoperative complications, unplanned reoperations, unplanned readmissions, or emergency room visits when comparing patients undergoing overlapping surgery cases to patients undergoing nonoverlapping surgery cases. Similarly, there were no differences in adverse patient safety events between overlapping and nonoverlapping cases. There was, however, an increase in operative time and anesthesia duration for patients undergoing overlapping surgery. This study is valuable, as it provides preliminary data to guide patients, surgeons, hospital administrators, and policymakers in making evidence-based decisions on an important and controversial issue in contemporary surgical care for which existing research is sparse. This is the first study to exclusively evaluate the safety profile and complications of overlapping surgery for plastic surgery operations and is one of only a few existing studies on overlapping surgery that evaluates outcomes beyond 30 days postoperatively.[9,12] Accordingly, it builds on and expands the small but growing evidence base on the safety of overlapping surgery.

Overlapping surgery was considered routine, until recently, at many academic medical centers. In 2015, however, the practice of overlapping and concurrent surgery gained notoriety after a prominent media report spotlighted instances of complications and patient harm that were partially attributed to surgeons being responsible for two procedures occurring simultaneously.[3] This report catalyzed a media firestorm that subsequently led to widespread public alarm and interest in these practices, ultimately resulting in a U.S. Senate inquiry, calls for regulatory mandates by government officials, revised or new policy statements from the American College of Surgeons and the American Society of Plastic Surgeons, and restrictions on the practice of overlapping surgery by hospital administrators at some major academic centers and hospital systems.[4–6,13–16] Unfortunately, although an overwhelming majority agree that concurrent surgery should be restricted to rare emergencies, there is considerable dispute regarding the practice of overlapping surgery. Critics have focused predominantly on the potential for compromised clinical outcomes and patient safety when cases are overlapped, citing anecdotal reports of patient harm, and ethical concerns (specifically, a lack of transparency in the informed consent process).[7,9,17] In response, advocates of overlapping surgery, including many prominent surgeons in national leadership positions, have referenced the potential benefits to include improved workflow efficiency, improved access to specialty surgical care, and improved surgical training with graduated responsibility and operative skills development.[2,18–20] These assertions all merit discussion.

Foremost, it is essential to evaluate the safety of overlapping surgery through the prism of evidence-based medicine, a core tenet of modern health care that is crucial to ensuring optimal quality of care and patient outcomes.[21] Although anecdotal reports of patient harm have received considerable media attention, the threat of compromised patient safety associated with overlapping surgery has not been substantiated by the available data. In this study, we did not find an increased risk of adverse safety events or complications with overlapping surgery. These findings support the work of prior efforts on the topic. Although only a few studies evaluating outcomes for overlapping surgery versus nonoverlapping surgery exist, they have consistently found no significant differences in outcomes between the two groups. In 2016, Zhang et al. conducted a retrospective review at their institution of ambulatory orthopedic procedures and found equivalent 30-day complication rates for overlapping and nonoverlapping cases.[22] Similarly, Howard et al. recently reported results from a single-institution cohort study of neurosurgery procedures over 2 years demonstrating no difference in complication rates, including mortality, between overlapping and nonoverlapping cases.[12] Additional studies, including in the spine, general, microvascular, and pediatric surgery literature, have reiterated these findings.[23–27] Based on the evidence to date, and supported by the findings of this study, overlapping surgery can be safely performed without compromising clinical outcomes.

Establishing the safety of overlapping surgery is an important first step; however, it is insufficient in the absence of informed consent. To restore public trust, it is essential to have complete transparency regarding scheduling practices and the roles and responsibilities of team members.[2,9] Full disclosure empowers patients to make informed decisions regarding their care and respects the principle of patient autonomy, a core element of ethical health care.[28] To date, it is unclear how effectively surgeons have made patients aware of overlapping surgery. A prior study, using online crowdsourcing, found that only 4 percent of the general public was knowledgeable of the practice of overlapping surgery. However, this online survey of the general public does not necessarily reflect the views of actual surgical patients. As a teaching hospital, our practice is to disclose the roles and responsibilities of team members participating in surgical care. Prior studies have demonstrated that patients are comfortable with trainee participation, provided that it is disclosed in the informed consent process.[29,30] Additional studies are warranted to evaluate whether patients are similarly comfortable with the attending surgeon indirectly supervising a resident performing noncritical portions of an operation in the setting of overlapping surgery.

Optimizing workflow efficiency, health care delivery, and access to care are among the primary purported benefits of overlapping surgery. Overlapping surgery creates the opportunity for an attending surgeon to perform more operations in less time or in the same amount of time.[24] As Beasley et al. argue, the operating room is the highest cost domain in health care and therefore incremental gains in operating room efficiency lead to significant improvements in providing cost-effective care.[18] This is especially true at tertiary academic centers and safety-net hospitals, where financial stability is highly variable and compromised productivity threatens the delivery of quality care to at-risk populations, including low-income and underinsured patients.[31] Similarly, overlapping surgery may improve access to care, especially for subspecialty procedures and in areas where there are prominent geographic disparities, such as breast reconstruction.[32,33] There are minimal data on this topic; however, based on our experience, albeit anecdotal, we believe this concept has merit. For cancer treatment, our institution (Siteman Cancer Center at Washington University School of Medicine) is the only National Cancer Institute–Designated Comprehensive Cancer Center in the state of Missouri (population of approximately 6 million) and the only National Comprehensive Cancer Network member hospital within a 240-mile radius. For many operations, there are limited options for patients in this catchment area, making it critical that we are able to provide timely care. In our experience, allowing attending surgeons to perform overlapping surgery increases the delivery of surgical care to a wider population of patients and minimizes potential delays in treatment. An additional potential benefit of overlapping surgery is that it promotes graduated autonomy for surgical trainees. Enabling trainees to perform noncritical portions of operative cases can be a valuable step in developing surgeons with the confidence to independently operate immediately after training.

There are important facets of overlapping surgery that require further deliberation. Foremost, there is continued debate on what constitutes the critical portions of an operation and who gets to define these steps. Currently, the American College of Surgeons, the American Society of Plastic Surgeons, and the Centers for Medicare and Medicaid Services have all supported policies allowing the attending surgeon to determine the critical portions.[1,2,5,6] Some have argued this is a flawed approach because of potential conflicts of interest, and have called for multidisciplinary hospital committees to define the critical portions of surgical cases.[9] We agree with the American College of Surgeons, the American Society of Plastic Surgeons, and the Centers for Medicare and Medicaid Services perspective that places the trust and responsibility in the hands of the operating surgeon. Ultimately, the attending surgeon understands the operation being performed best and is responsible for the clinical outcome. However, there may be value in developing expert consensus for common operations (e.g., breast reconstruction, appendectomy) as to what parts of the case should be considered critical versus noncritical. This may serve to reduce variability nationwide and provide a more standardized approach to overlapping surgery that patients can comprehend across institutions. An additional consideration is the impact on cost. In this study, overlapping procedures had a significantly longer (by 22 minutes) median operative time. Longer operative times have cost implications. There are many considerations in determining the cost of operating room time, but prior studies have estimated hospitals charge an average of $62 per minute of operating room time.[34] Additional investigation into the flow of the operating room with and without an attending physician present and what factors contribute to longer operative time in overlapping cases is warranted to control cost.

It is important to acknowledge the limitations of this study. For one, this study is a retrospective, nonrandomized, cohort study design. In any retrospective study design, the presence of unknown confounders may impact the results. However, the retrospective nature of this study also mitigates the potential for bias from a Hawthorne effect. In addition, this study was restricted to the experience of a single provider at a single institution and therefore may not necessarily be generalizable to all centers or providers. Acknowledging this, we included a wide variety of operations in our study to represent the broad scope of plastic surgery procedures and performed an a priori power analysis to improve the validity of our results. Furthermore, we focused on the experience of an individual surgeon to control for operative skill as a confounding variable, given that prior criticism of studies on overlapping surgery have asserted an inability to account for individual surgeon performance.[35] Although appropriately powered to compare complications of nonoverlapping and overlapping surgery overall, we acknowledge that the study is underpowered to compare complications for specific procedures. Analyses of operations from a variety of practice models and centers is imperative to building a comprehensive evidence base on the safety of overlapping surgery. In addition, research aiming to understand the patient perspective on overlapping surgery in plastic surgery is warranted to ensure patient-centered care.