Nobel Prize winning economist Paul Krugman described Moral Hazard as “…any situation in which one person makes the decision about how much risk to take, while someone else bears the cost if things go badly”. The fidelity of some surgeons to their patients has been brought into question by recent press reports exposing a practice whereby one attending surgeon will be responsible for two patients undergoing surgery simultaneously. This is variously referred to as Overlapping Surgery, Concurrent Surgery, Simultaneous Surgery, Double-Booked Surgery or Ghost Surgery. This practice entails surgeons in training (residents and fellows) performing varying degrees of the patient's surgery while the attending surgeon is operating elsewhere. In general, the patient is not informed of this substitution. When informed, most would not allow it. Defenders of this practice site surgeon and hospital “efficiency”, independent operating experience by trainees, mass casualty triage and access to “in-demand” specialists. Critics feel it “is a breach of ethical behavior”, that “The most likely motive for this is profit for both the surgeon and hospital” and “Overlapping surgery… threatens our obligation as orthopaedic surgeons to respect the primacy of patient welfare…”. The American College of Surgeons, in response to public disclosures, created a policy on Overlapping Surgery. Its executive director wrote, “It is essential that the patient be informed of this practice and given enough notice so they may decide whether to seek care from another surgeon or at another institution*. The US Senate Finance Committee investigated Overlapping/Concurrent Surgery practices. It expressed concerns over − 1) lack of informed consent, 2) plausible risks to patient safety, 3) use of Medicare billing regulations to determine acceptable surgical practices and 4) surgeons self- defining the “critical part” of the operation. Studies to date do not resolve the propriety of this practice. All but one is short term. Most show longer surgical durations. Most show no increase in 30-day complication rates. The only long- term study found a 90% increase in complication rate in hip procedures at one year when surgery overlapped. None document the location of the surgeon during the procedure or report efficacy. Over 7 million living Americans are beneficiaries of either a total hip or total knee replacement. These patients are made whole, their suffering relieved, their function and lives restored. These miracles of modern medicine are not without cost. The United States spends $3.5 trillion dollars annually on health care, almost 20% of our GDP. Delivering health care is a grave responsibility and any person involved in it must understand the importance and consequences of their actions. The third leading cause of American deaths is medical errors. A recent study estimated that 4 out of 100 patients entering the hospital for surgery will die within seven days. Recognizing this, a surgeon's role as a patient's moral fiduciary, concerned primarily with protecting the interests of the patient, must be honored as a sacred trust. The financial pressure on the surgeon from stagnant surgical fees is the elephant in the room that must be addressed in relation to this matter. When fees are cut, surgeons operate more. Plato, in The Republic, recounts an allegory about a magic ring that makes its wearer invisible. He asks the question; Will the power of anonymity eliminate morality and ethics? When we as surgeons become “invisible” to our anesthetized patients during surgery, how will we answer that question?
