Some of Swedish Health’s top neurosurgeons have routinely run multiple operating rooms at the same time while keeping patients in the dark about the practice, The Seattle Times has found. Swedish touts its patient outcomes and is clarifying its consent forms.

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Since her surgery, Phyllis Johnson’s neck has been so askew that she can no longer look toward the sky. After his surgery, Duane Pearson found his hands frequently stinging with pain. Orna Berkowitz’s surgery was supposed to be routine, but she ended up in the hospital for 41 days.

The three patients had placed their trust in the same doctor, Rod Oskouian, a top neurosurgeon at Swedish Health.

But there was something they didn’t know: Oskouian’s attention was split during each of their procedures, with internal data showing he was running two operating rooms at the same time.

Johnson, Pearson and Berkowitz recently learned about the double-booked cases from a reporter. Each said they likely wouldn’t have consented to the surgery if they’d known that was happening.

Those cases, along with many others at Swedish, illustrate the wide gulf between the expectations of Swedish patients and the reality of what’s happening in the operating room once they are under anesthesia for perilous procedures. In recent years, some of Swedish’s top brain and spine surgeons routinely ran multiple operating rooms at the same time while keeping patients in the dark about the practice, according to internal surgery data obtained by The Seattle Times as well as interviews with patients and medical staffers.

Four surgeons at the Swedish Neuroscience Institute — Oskouian, David Newell, Johnny Delashaw and Jens Chapman — ran multiple operating rooms during more than half their cases over the past three years, according to the data. Oskouian did it 70 percent of the time. To manage two rooms, surgeons generally leave less-experienced doctors receiving specialized training to handle parts of the surgery.

 

Swedish’s interim CEO, Dr. Guy Hudson, previously said the best way to describe cases involving multiple operating rooms was the word “overlapping,” suggesting that a second surgery may start as a first one is coming to a close. As evidence, he said Swedish’s internal system won’t let surgeons schedule cases to start at the same time.

But the data obtained by The Times show a conflicting reality: Between 2014 and 2016, there were more than 200 instances when surgeons began two cases at the same time or within five minutes of each other. When doctors ran multiple operating rooms, they typically overlapped their cases for more than an hour, according to the data. More than 700 of the surgeries were entirely eclipsed by other cases the attending surgeon was handling.

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Recent research on overlapping surgeries has drawn inconsistent conclusions about whether it can lead to worse outcomes for patients, and Swedish officials pointed to some of those studies in responding to this story.

Hudson said last week that Swedish is still exploring the outcomes of its own overlapping versus non-overlapping cases, but he cited metrics showing that the institution and its Cherry Hill facility have consistently had better overall outcomes than industry norms. And he said that with rising demand and a training program for fellows, running multiple operating rooms allowed surgeons to treat more patients.

But Hudson said Swedish is working to be more transparent about the issue. Earlier this month, neurosurgeons at Swedish’s Cherry Hill facility began testing a new consent form that explicitly mentions the prospect of overlapping surgery.

“As a surgeon, I believe trust is the most important attribute between a patient and their doctor,” Hudson said. He also said he has learned that his past statement that surgeries could not be scheduled to start at the same time was incorrect.

Oskouian and Newell declined to comment. Chapman did not respond to messages seeking comment. An attorney for Delashaw said he “was routinely and appropriately present in each operating room during overlapping surgeries, and he always sought to achieve the best outcome for his patients.”

The Times previously reported on a range of internal concerns about patient care at Swedish’s neurosurgery unit, where surgical volumes had been surging and contracts incentivized doctors to do large numbers of procedures. The articles examined particular concerns about Delashaw, the institute’s top surgeon.

After the initial Times articles, Swedish CEO Tony Armada resigned, as did Delashaw. The state Department of Health and the U.S. Attorney’s Office have also launched investigations, without publicly specifying their focus.

 

Patients weren’t aware of other surgeries

The dozen or so surgeons at the Swedish Neuroscience Institute have taken varying approaches to managing their workloads.

Some of the doctors ran simultaneous cases on just a handful of occasions over the past few years. Oskouian, however, had 1,355 overlapping surgeries between 2014 and 2016, and in nearly three-quarters of those cases, the time the patient spent in surgery was mostly eclipsed by another case, according to internal data.

Some doctors typically had only brief overlaps with their other cases. When Chapman, however, had two operating rooms running at the same time, the average overlap was for 2 hours, 59 minutes.

The Times obtained internal surgery data showing when each surgical procedure began and finished. The records do not include patient names or other identifying information.

The Times has interviewed dozens of Swedish patients in recent months. Of the patients who provided detailed records showing the dates and times of their surgeries, 13 show up in the data as having surgeries that overlapped another case. Most said they had never heard or considered that their surgeon might not be doing the entire procedure and that they likely wouldn’t have consented if they’d known that.

All 13 patients said they had expected their surgeon to be in the operating room throughout the procedure, and none recalled anyone ever suggesting that would not be the case.

Phyllis Johnson of Bellevue, who has struggled to hold her head up since her 2014 surgery, says she wouldn’t have agreed to the operation if she had known it was double-booked. Records show that for about half her surgery, her doctor was running a second operating room. (Steve Ringman/The Seattle Times)
Phyllis Johnson of Bellevue, who has struggled to hold her head up since her 2014 surgery, says she wouldn’t have agreed to the operation if she had known it was double-booked. Records show that for about half her surgery, her doctor was running a second operating room. (Steve Ringman/The Seattle Times)

“I would have never let it happen like that,” said Johnson, who has had troubles lifting her head since a spine procedure with Oskouian. She has difficulty walking and gets help from her daughters to prop her up with pillows at bedtime because she can’t sleep lying flat. Her records and the data indicate her 1 hour, 27 minute procedure overlapped with another Oskouian surgery for 43 minutes.

Pearson, whose hands now go through periods of extreme pain in addition to constant numbness and tingling, had complications after his spine surgery that sent him back to the hospital for four weeks and forced him to temporarily use a feeding tube in his abdomen. He said he had chosen and vetted Oskouian as his surgeon and never considered the possibility that his doctor might not be in the operating room the whole time. His entire surgery ran parallel to another Oskouian case.

In consent forms signed before surgery, patients give their surgeon the OK to do the procedure. A recent version of the form said the surgeon “will be assisted by a care team” that includes doctors in training.

That form didn’t mention the prospect that those doctors in training could be doing parts of surgery without the attending doctor’s supervision.

Katherine Powell, a retired nurse who helped prep patients for the operating room at the Cherry Hill campus, recalled surgeons in the past few years not wanting their patients to know that the doctors were running multiple operating rooms and in some cases asked that their patients be kept separated from each other while they waited for surgery.

Karen Sprague, a nurse who retired at the end of 2015 and prepped patients for surgeries at Swedish’s Issaquah facility, said some Oskouian patients began asking questions after noticing other patients arriving or waiting for surgery. Some would wonder who was doing the procedure after a surgical fellow would come in to prep them.

Sprague said she raised the issue with managers, asking what she was supposed to tell patients when multiple surgeries were scheduled to run at the same time. Sprague said she was told to tell the patients that Oskouian was doing the surgery. She didn’t feel like that was an honest answer.

“How could a man be in two places at the same time?” Sprague said.

I don’t think patients pay close enough attention to consents and probably don’t ask enough questions.” - Dr. Christopher Smythies

Hudson said he couldn’t speak to the experiences of individual staff members but said Swedish is working to improve transparency for patients.

More than a dozen current and former staff members have expressed concerns in interviews about how little time some surgeons were spending in the operating room. The Times previously reported how fellows at times had to take breaks during surgery to wait for the primary surgeon to return and that surgeons were off seeing patients in the clinic while running two operating rooms. Sometimes the surgeons would miss part of the procedure even if they had just one case going, staffers said.

But the medical records each patient shared with The Times show little indication of the practice. Some of the records track detailed aspects of the surgery — such as the time the patient arrived in the OR, the time anesthesia began, and even the times some nurses took breaks during the surgery — but they generally don’t describe when the surgeon was in the room or what parts of the procedure were performed by the primary surgeon.

Notes filed by the surgeons are often vague when describing how each part of the surgery was performed. Some use the passive voice or “we” to describe who was doing the work. The records typically say the surgeon was “present” for the critical portions of the case — a standard of involvement required by Medicare, but one that is undefined and instead left to the judgment of the doctor.

While those patient records don’t show surgeon in and out times, some anesthesiologists concerned about the practice began tracking surgeon involvement in their notes, according to four people who spoke on condition of anonymity.

Hudson said Swedish is now working to improve how the organization tracks the time surgeons spend in the operating room.

 

 

Overlapping surgeries, complications

Berkowitz, the woman who spent 41 days in the hospital, first heard of Oskouian from a Swedish doctor who recommended him.

Berkowitz did some vetting. Oskouian had some excellent reviews online. He was leading classes on spine surgeries and doing research. He seemed like the ideal doctor for the job, and Oskouian seemed to agree, telling Berkowitz the planned procedure was something he did all the time and that it would be no problem at all.

The first surgery took place in August 2014. But internal data for that day show Oskouian was running a second surgery that entirely eclipsed Berkowitz’s case. The next week, in stage two of Berkowitz’s surgery, the same thing happened, according to the data.

In the days that followed, Berkowitz developed a series of problems that forced her to undergo three more surgeries to fix a spinal-fluid leak, redo her spinal-decompression procedure and remove a fluid drain that had inadvertently been sutured to her body, according to records.

Berkowitz said she never even considered the possibility that Oskouian would be running two operating rooms on the days of her procedures. And she said she never would have consented to it if she’d known.

“It’s a very sensitive surgery,” Berkowitz said.

This X-ray from October 2014 shows the hardware in Orna Berkowitz’s lower spine from two operations that year. She didn’t know that, during those entire surgeries, her doctor also had cases in other operating rooms. In the days that followed, Berkowitz developed a series of problems that forced her to undergo three more surgeries.  (Courtesy of Orna Berkowitz)
This X-ray from October 2014 shows the hardware in Orna Berkowitz’s lower spine from two operations that year. She didn’t know that, during those entire surgeries, her doctor also had cases in other operating rooms. In the days that followed, Berkowitz developed a series of problems that forced her to undergo three more surgeries. (Courtesy of Orna Berkowitz)

Research on overlapping surgeries has shown conflicting results about whether it puts patients at risk.

Last year, the Mayo Clinic examined overlapping elective surgeries at its institution and found no difference in outcomes for those cases compared to nonoverlapping ones. But the study emphasized that its data only applied to the Mayo Clinic’s handling of overlapping cases and “may not extrapolate to other centers.”

An examination of three spine surgeons at the University of California, San Francisco found outcomes between overlapping and nonoverlapping cases were mostly similar, except overlapping cases had longer procedure times and lower rates of patients who were discharged back to their homes. Doctors at the University of Toronto, meanwhile, evaluated the outcomes of hip-fracture surgeries and found that overlapping patients faced a higher risk for complications — and increased risk the longer the overlap lasted.

Doctors have long debated how to handle busy surgery schedules and the role of fellows in the operating room.

Some doctors see running two operating rooms as inappropriate, undermining the trust of patients who believe their chosen surgeon will be the one at their bedside during the case. Other doctors say the practice is necessary so that sought-after surgeons can utilize their skills efficiently while assistants handle less-important parts of each case. Others fall somewhere in between, greenlighting the start of a second case only once their first case is near conclusion.

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Dr. Christopher Smythies, a neurosurgeon in the Seattle area for MultiCare Health who doesn’t overlap his cases, said overlapping surgeries are a common and accepted practice in academic and training medical centers. He said the practice can cross a line if the attending surgeon isn’t available for critical parts of a surgery and noted that even parts of a case that are typically simple can take an unpredictable turn and suddenly require the attention of an experienced surgeon.

Smythies suspected the consent forms that patients sign are sufficient to give notice of the practice of overlapping surgeries, although he believes many patients would be surprised to learn how those cases are handled in the operating room.

“I don’t think patients pay close enough attention to consents and probably don’t ask enough questions,” Smythies said.

After The Boston Globe published a story in 2015 that explored a controversy over surgeons handling multiple cases at Massachusetts General Hospital, the American College of Surgeons (ACS) developed guidelines stating that doctors could do “overlapping” cases, but said it was inappropriate for doctors to have key portions of two cases happening at the same time. The ACS also said patients need to be informed of the practice.

The role of fellows has also been an issue in Seattle and was recently the subject of a lawsuit against Virginia Mason in a urology case. In that case, the plaintiffs contended that they specifically requested a top doctor handle a procedure only to later learn that a fellow handled the work. The patient developed complications that required months of rebuilding his penis. The couple won an $8.5 million verdict last month.

Chapman, one of the top spine surgeons at Swedish, previously faced a lawsuit involving a double-booked surgery when he was at the University of Washington. A fellow began the 2013 case by meeting the patient, Sharon Rowe, and completing the consent process, according to court filings and partially redacted state records.

I don’t think any human being would consent to being in a mill like that.” - Tyler Firkins, attorney

The fellow later reported in a letter to the state Department of Health that it was the first time he’d seen Rowe. He said he called Chapman on the phone, and Chapman told him to make an incision to start the case, according to the fellow’s written account. The fellow described that he did the incision, left the room and went to another operating room to begin another Chapman case. Chapman then came in to work on Rowe’s case.

Rowe developed complications after surgery, including incontinence. The hospital later pointed to surgical notes saying a cauterization device had “entered the sacral part of the spine” during the incision process and told Rowe in a letter that “the primary cause of the surgical complication involved a lack of appreciation of your specific anatomy,” according to records.

The state Department of Health concluded that the case was handled within the standard of care. But records obtained by the Times after the newspaper pursued a public-records lawsuit against the UW last year show the university paid a $1.25 million settlement in the case. A UW spokeswoman said in a statement that Rowe’s outcome and lack of follow-up communication were “not acceptable nor in alignment with the standards of our organization.”

Last month, UW also introduced a new consent form that explicitly says a patient’s doctor may participate in an overlapping case. Swedish’s new form is similar, requiring patients to put their initials next to a statement that says “my surgeon may be scheduled to perform surgery in two operating rooms at the same time.”

Tyler Firkins, an attorney considering a lawsuit against Swedish on behalf of a Delashaw patient who has reported failed lower-back surgeries that had to be partially corrected by another doctor, said the issue of double-booked surgeries is one he is exploring. He said the old Swedish consent papers don’t adequately inform the patient about the practice of running multiple operating rooms at the same time.

“I don’t think any human being would consent to being in a mill like that,” Firkins said.

Firkins said he was planning to seek information from Swedish showing whether his client, Tonya Jilbert, was among those whose case overlapped with another.

Records obtained by the Times indicate her second surgery lasted 70 minutes, with 40 of those minutes overlapping with another case.

 

The back of Phyllis Johnson’s neck shows scars from her surgery. She has trouble walking, and her family props her up with pillows at bedtime because she can’t lie down flat. (Steve Ringman/The Seattle Times)
The back of Phyllis Johnson’s neck shows scars from her surgery. She has trouble walking, and her family props her up with pillows at bedtime because she can’t lie down flat. (Steve Ringman/The Seattle Times)