Safety in Spine Surgery: Transforming Patient Care and Optimizing Outcomes by Vitale Michael; & Rajiv Sethi MD & Kevin Wang MHA

Author:Vitale, Michael; & Rajiv Sethi, MD & Kevin Wang, MHA [Michael Vitale & Rajiv Sethi & Kevin Wang]
Language: eng
Format: epub
Publisher: Wolters Kluwer
Published: 2019-06-23T00:00:00+00:00

Unresolved Problems with the Two-Surgeon Approach and Potential Solutions

As demonstrated by Scheer et al., two major problems with a two-attending surgeon strategy are co-surgeon availability and co-surgeon reimbursement. 36 Currently, two attending surgeons trained in the same specialty can work together on the same case, but the second surgeon can only bill as an assistant, which carries a significantly decreased work relative value unit (WRVU). Two surgeons from different specialties (ie, neurosurgery and orthopedic surgery) can work together as co-surgeons for a modest increase in the total WRVUs. Although neurosurgeons are increasingly collaborating with orthopedic surgeons in adult spinal deformity cases, the large majority of pediatric deformity cases are still done by orthopedic surgeons alone. Pediatric deformity surgeons therefore have a negative financial incentive to adopt a two-surgeon approach, as a co-orthopedic surgeon can only bill as an assistant. The Seattle Spine Team has solved some of these financial disincentives in their own institution by negotiating contracts with large private payers based on a “center of excellence” agreement in which avoidable readmission are not paid for. The orthopedic surgeons and neurosurgeons in this scenario have negotiated an agreement with the private payers not to penalize the second surgeon from a WRVU standpoint such that equal payment is given to both surgeons for their efforts in any given case.

An important goal of surgery in academic centers is to educate future spine surgeons in the performance of these complex and dangerous cases. Some opponents of the dual attending approach point out the potentially negative effect that dual attending procedures will have on surgical education, as assigned residents or fellows will inevitably gain less experience at the hands of a second attending surgeon. A plausible solution to this potential problem lies within a well-run surgical education system of performance-based advancement and progressive operative responsibility. Residents interested in a spinal deformity career will begin training on routine cases that do not require two attending surgeons. Once they have demonstrated proficiency in the independent performance of basic surgical skills such as laminectomies, posterior column osteotomies, and pedicle screw placement, they can be advanced to more complex procedures. These senior or skilled residents will then have the opportunity to participate in complex procedures that do require two attending surgeons. In these cases, the skilled resident or fellow can still learn a tremendous amount by acting as a coattending in the routine portions of the case (exposure, pedicle screw placement, posterior column osteotomies), and then observe the complex portions of a case (complex osteotomies, curve correction, rod placement) as completed by two attending surgeons. Operative responsibility must always be granted based on the demonstrated skill and proficiency of the resident, the complexity of the case, and the health of the patient; but this is no different than in any other case performed by a single attending surgeon and resident or fellow assistant.

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