 Langerman Alex is practicing head and neck cancer surgeon and researcher. His research is focused on the intersection of business, ethics, and data science in the operating room. And he is a graduate of Pritzker and the head and neck otolaryngology head and neck residency program here at the University of Chicago. He went off to Vanderbilt where he completed a fellowship. And then we were fortunate enough to have him back here on the faculty for a number of years where he did some really innovative work. And I had the good fortune of working with him and calling him for help in the operating room on more occasions than he would like to admit. But Alex just recently moved to Vanderbilt, where he is continuing his work in surgery as well as research in ethics. And I must say, Alex is a good friend and also someone that I've known since his early 20s, we were deciding before he went to medical school, Alex and I worked together. So it's a real pleasure for me to welcome Alex. Thanks Peter, thanks everyone. It's such a privilege to be here. This was a very hard three acts to follow. They were awesome presentations, so it's a privilege to be a part of it. I think you're hearing a theme today that when Mark asked me to give the talk, I gave this very generic title and the gentleman in the back, I'm not sure I know you, but thank you for generating some buzz about the talk. I did change the topic just two weeks ago based on some stuff recently in the news. So disclosures, I am not doing a good a job at Stacey as far as my thing. But I also started a company while I was here at the University of Chicago. I think we were very similar pathways there. And I won't be talking anything about any of the products there, but I will be sharing some data that was generated by that company because it supports some of the concepts here. Okay, so I'm a data guy, as Peter mentioned, and I study the operating room. I look for ways to collect data out of the operating room. And so we can see here is this idea of double booking surgery. So let's see if this works. Yeah, great. So basically if you have a surgeon and they're working in multiple rooms, that's called double booking concurrent overlapping cases, the different terms and larger. The thing was this did not come out of my lab, but actually out of the Boston Globe, which was pretty fascinating. This is real data that they obtained through sources that they will not reveal about what was actually happening on the actual surgical schedule. Now that name of the patient there was also published. This was a patient who had a bad outcome. And so there was a complaint against this surgeon who they're showing their picture at the little bit of bottom. It's pretty dramatic. And this was the title of the expose, the clash in the name of care, which is it's a good read and I encourage people to read it. And it's even including things like Bobby Jenks who was a pitcher I believe and credited the end of his career to this surgeon here. And that's all in that article as well. So this blew up on social media. And that's my favorite part. That's pretty cool. It created a lot of stir and a lot of writing sort of immediately about it. So what is the sort of rules around concurrent surgery? Well, if you look at the billing rules, the CMS will say that it's that, the critical or key portion and you'll notice that it's very important here that it says that the teaching physician determines. And the whole idea behind this is theoretically there's somebody in the room doing something, a resident, a trainee of some kind. And that the attending surgeon is bouncing between these rooms. But they're ensuring that they're there for the critical portions of the procedure. Whether or not they're doing it, the point is that they're participating in that. And then the American College of Surgeons sort of first of all affirms that the surgeon is personally responsible. That's unobvious. And that they can delegate parts of the procedure. That that's ethical. It's part of training. It's a longstanding tradition of making sure that everything happens for the patient but that you delegate appropriate parts to your trainees. And that it's a proper to delegate, of course, again, with this key components of the operation. So an undefined term, I think importantly an undefined term at this point, but something that that is how we've defined it is based on what the physician decides. So I put these goofy pictures up here just to start with a statement that says, I'm not really someone who subscribes the captain of the ship, surgeon is the captain of the ship of the operating room, much more it's like the A team here. So everybody participates in the care of the patient. And the reason that I think it's important to make that distinction is because I'm drawing a particular dyad in here between the patient and the surgeon. Because even though this is the A team, the only person that the patient has met before the operation is the surgeon. That's the person that they came to their clinic. That's their doctor in many circumstances. And that's also the person who's going to be taking care of that patient after the operating room event ends. Whereas the rest of the team tends to be pretty focused in the operating room, particularly talking about the anesthesiologist and the nurses who will be taking care of that patient. So in this case, the surgeon, and I show the students, show delegation. So the surgeon is delegating the care of that patient, whether explicitly or just implicitly is in if I work at the University of Chicago, I'm implicitly delegating the care of the anesthesia to my anesthetic colleagues. And similarly, the setup of the room, the padding of the patient, the other things that the nurses take care of to ensure that patient's safety and documentation. And then delegating portions of the actual technical performance of that procedure to trainees. This article came out. It's an interesting timing on this article because the events at Massachusetts General were starting to come to a bit of a fever pitch. This is before the expose was announced. And the editor and chief of the journal that this was published in is the chief of surgery, I think at Massachusetts General or an important surgeon in Massachusetts General. So there's probably some reason why that happened to come out then, but I don't know. But it was in defense of overlapping surgery. So they bring up a really good point. This idea that American college surgeon stands by this as well. This idea that it's important to train trainees. And if the first time that they're ever alone is the first time that they're on practice, that's probably a bad thing. And the reason that it's important is because if you think about it, let's say that you and I are operating together and you're performing this procedure and I'm watching you perform the procedure. If you're going along and I'm not saying anything, you know, you're doing a good job, right? Because I'll start complaining or pointing out things if something's not right. Whereas if I'm not in the room, that same silence has a much different meaning. You're stuck with your own thoughts. You're thinking through the procedure. So it's really important for trainees to get that experience, to be able to think through, have the angst of wanting, should I make this, show me they're not. You never want to put a trainee in that situation and not something where they're adequately prepared to handle that. But they're still a little bit of a stress and they need to go through that. They point out some key things, you know, attending a surgeon, disclose and provide informed consent, you know, do all the right things, supervise, and I think this is really key here, knowing their trainee skill level, they'll come up again and be immediately available. So this is what happens when you actually have a surgical case. This is everything that goes into a surgical case. I spent a lot of time surgery over a workflow. And so you can see that here's the procedure down here. Patient actually enters the room there and leaves the room there. And this is not necessarily to scale as far as the time. In fact, this probably takes up a much larger portion in many cases. But for short cases, that's not the case. And then throughout this case, there's different portions of procedure that may be critical portions and maybe sort of non-critical portions. And we'll get into those definitions a little bit. But the point is, you already see there's tons of delegation that's going on. There's tons of saying, okay, you know, this needs to happen by this person, this thing has to happen to this person. And the attending surgeon's not doing all of those things. So even though they're the person that the patient's, you know, contracting with, they're not handling all those things. And I would even argue some things I shouldn't be doing. I mean, I certainly know how to put in a fully catheter. I've done it hundreds and hundreds of times. But the last time I did it was many years ago because, you know, other parts of the team are performing that function. So should I be the one that's naturally turned to do that? Should be the most experienced member of the team for that part? Maybe. All right, so there's some forces that are acting upon hospitals and surgeons and healthcare in general. So one of them is the increasing employment by hospitals of surgeons. So moving away from the private practice model to an employed model. And so because of that, you know, surgeons want to maximize their time for profit. But, you know, as they become employees of hospitals, they're going to want to, you know, the hospitals are going to want to maximize their time. Now that, you know, as Taylor Swift says, the payer's going to pay, pay, pay, pay, pay. And, you know, so they're going to pay the hospital. But, you know, as our healthcare payment system shifts, we're going to see that it's not going to necessarily, and this is something that Stan Goldblatt and I were talking about earlier, it's not necessarily going to be on an item by item, you know, our VU-based system. You may actually have, you know, accountable care organizations, bundle payments, other things where it's even going to be beneficial to the payers and healthcare system as a whole to maximize the time of the highest paid part of healthcare, right? It's the professional fees, the professional labor is the most expensive part of healthcare. And so it's beneficial to the whole system to maximize surgeon time. Okay, so if we look at this idea of an optimized surgical scheduling, you know, this is where you can see that, you know, the surgeon's basically bouncing back and forth between the procedures. And this is that nonoperative time that I showed you in that graph earlier. And so this would be great. So basically the patients, the surgeon's got absolutely no downtime whatsoever. But there's quite a bit of downtime there, you know, for the operating room, for the other members of the team. So then we can imagine a really optimized schedule there where just the critical portions of the procedures and they're jumping through the room. So basically there's absolutely no downtime. This sounds really stressful to me as a surgeon, but, you know, it actually, you know, it doesn't leave much room for teaching or for talking to families, counseling patients. Gretchen, what you said at the end of your talk was the greatest thing I've heard all day, which is the idea of not just a technician, but really you want to take care of it. So we don't just want to do the surgery, we want to actually, you know, help our patients. So this seems stressful, but theoretically this would be the most optimal use of the time. There's probably a balance somewhere in here. And I should say this is also a bit of a manufacturer here because it's not possible under medical rules. And then here lies the biggest problem with this idea. So you can create this perfect schedule and then something can happen in this case and it runs long and suddenly you are overlapping like you didn't intend to. Now you apply that to the other, let's get this one and it's going to break down immediately. So why does this unintended overlap happen? And this is data from three surgeons here, A, B, and C, who are performing all the same procedure. Let's have a closer stack to me. And up on this axis is time, okay, and then these are each of the steps of that procedure, just numbered out. And so each bar here represents one of their iterations of that procedure. Procedure one, procedure two, procedure three for surgeon B. And I'll just draw your attention to step four. Something happened in that case. It just ran longer. And that happens sometimes. And it happens for all sorts of reasons that we don't really understand. We don't have great data on what happens in the operating room, believe it or not. And so any of these things could happen. It might be mentioned in the operative report. It might not. And these are things including missing, telling is absent, of course. But also if the trainee is like, good or not very good or they struggle. If it's something to do with the patient itself or if it's a system factor. So we need to understand these things to begin to think about how to intelligently schedule surgery to maximize surgeon's time but still ensure that they're giving good care to the patients. So what it is, it's a balance here. Between patient waiting, which we never want, anesthetic time that's unnecessary. Or unattended surgery, where someone is doing it but no one's a responsibility to pay attention. We would never want anything like that. And then, but we'd also want the surgeon waiting. And this is a wasted resource for healthcare. And also there's a work-life balance thing. I mean, you know, believe it or not, we're people too. And, you know, to maintain, to prevent burnout and to maintain a good surgeon workforce, you want to also ensure that they're not doing things that are sort of non-value-added time. So we need better data on surgical activity. And that's getting back to this critical portion of the procedure idea. The idea that, so, you know, patients anatomy is going to feed in to the definition of what the critical portion of the procedure for that patient's going to be. The case factors, which include things really specific to that case. And then the surgeon factors, which includes also the ability of the assistants and that surgeon's familiarity with their team. If you're working with your fellow that you've worked with for the past six months, doing the same exact thing over and over and over, and they're good, and you know they're technically good, and you've given them a little leash, and you can see that they're doing the good job, that's the sort of, you know, case where you know that the critical portion, the part where you absolutely need to be doing it, is going to get smaller and smaller as the fellow is able to take over more control of that. So, you know, what people have asked for is why doesn't the American College of Surgeons just define critical portion of the procedure? And that would be hitting the central thing here. But one of the problems is it doesn't take into effect the factors that might modify the critical portion of the procedure for that case. Nevertheless, I took a stab at it, some ideas of critical portions. So the objective of the procedure, the part of the procedure might have substantial risk of adverse outcomes, and a part that requires intraoperative decision making. Now what I think is interesting about, you know, Larry's presentation, his most recent one, is, you know, for his cases, some of them, the critical portion of the procedure may not have even occurred in the operating room. It's that planning staff, or it's a couple of ideas about we'll make an incision here, an incision here, an incision here. But some of the technical aspects of that really aren't that critical. Some of them are, for his cases, it's very complicated cases, but some it's much more about the planning. And so it's hard to define critical portions for a given procedure. And then there's also this last part, which I think is important. And this means two things to me. So it's, part of it is if I tell you I'm personally going to be doing it, then I'm lying if I don't do it. So that is completely wrong. And then additionally, it's what I feel like I need to personally do. And let's get back to that team factor. So this idea that if I'm operating with a bunch of novices that have never done the case before, then basically the whole case is a critical portion because I'm the only one in the room who can do it. Whereas if it's a case that's quite routine, and I'm working with a team that has done it many times before, there might be very little of it that I personally need to do. We had some research just recently. Claire Smith, I don't know if she's in the audience, but she did some research with me just recently along with Christine Guyden, really neat stuff where she interviewed surgeons about their feelings about doing surgery on awake patients. So patients who are conscious in the operating. And you guys are probably already reading the slide, and so I don't need to go through it other than to say there's a couple of key things I would just quote. So because when the patient really sees that someone else is doing it, so the resident's operating on the patient, the surgeon is sort of helping direct them, there's sometimes a little bit of upsetting that group. So it's this idea of surgeons not wanting to have their patients be anxious or uncomfortable, despite perhaps something going on that they feel is okay. You know, they trust their resident, they know that they're doing a good job, they're watching and doing a good job in this scenario, but they're worried that the patient may get so anxious about that it may cause harm that was unintended. And then this one is sort of a shocking thing. And I believe that this surgeon is probably, again, a good person acting off that same principle of trying to alleviate anxiety, despite the fact that there's a bit of subterfusion there. And so what this creates is there's this tension between ensuring patient comfort, alleviating anxiety, ensuring good outcomes, but also giving residents appropriate clinical training. And an important finding out of this study as well, which I'm showing you is that many surgeons reported they just didn't do teaching during awake procedures, that they just did it themselves for these reasons, and it was they reserved teaching for when the patient's fully asleep. Well, that makes you wonder, you know, I mean, do you feel good about teaching or do you not feel good? And should we explore that a little more? Okay, so I don't know if this is gonna play. If I, no, it's not, can you play it or can I play it? I can, I got it. Okay, so very briefly, there are two surgeons here, one's holding the blue thing, one's holding the knife. Oh, and I'm just gonna, there he goes. Okay, who's doing the procedure? They're both doing it, right? They're both doing it, but one of them's the attending surgeon, one of them's the resident. The point is, it's really hard to define who, quote, does the procedure. Now we can generate some really interesting data about who's creating more of the technical moves or something, but the point is really, you're operating with your brain. You know, the attending surgeon's there, they're helping the resident, it's a technical procedure, it's a team procedure, and so really narrowing down, like, are you doing it or is your resident doing it? You know, unless you're not in the room at all and the resident is operating completely independently, the reality, any time you're around, you are doing it as an attending surgeon. And so that, again, gets back to this idea, this is something that Peter and I were just talking about, I think it was a really good point that he made, which was, it's, you know, the surgeon's duty to ensure that the procedure goes well, that everything goes off correctly for that patient, utilizing all of the resources that are available to that surgeon. So, you know, if that includes the trainees, that includes the delegates, it includes everybody that's around that. So the surgeon's ultimately responsible for the good outcome, but doesn't necessarily have to physically do every single part of the procedure. Okay, so this was along these same lines and I think it's important, so this was a neat New England journal article, and this is talking about the silence of the switch, and you can see the beginning here. We sat in the operating room chairs, soundless in our socked feet, and this is a resident reporting that she did not feel comfortable when her attending would have them take off their shoes and then the attending had, you know, was standing over the patient as if they were gonna be doing the procedure during awake surgery, and then the attending gets up silently and lets the resident sit down and actually do it, but pretends like, you know, pretends like she's doing it. And so the two things here that they bring up as far as their critical steps, so one is the surgeon-patient relationship. This idea that if the trainee's gonna be doing it, they have to have some skin in the sort of ethical game here and actually help consent the patients, help the patient understand that the trainee's gonna be doing things in the procedure, and then there's also the subjective data, and so it's not just like what they're physically gonna be doing, but perhaps with the specific complication rates or additional risks that the patient may be taking on as a result of having that trainee participate in their surgery. So I think that transparency and truthfulness and training are absolutely ethically correct. I think they're clearly societally demanded, and, you know, one example of this is the surgeon scorecard. So if you're familiar with ProPublica, this caused a lot of stir about, I don't know, four months ago or something. But the idea was ProPublica released all this outcomes data about surgeons. So you can see here, you can look up a hospital, I looked up a random hospital, and, you know, names a hospital by name, and it says, you know, for each of these surgeons who's performing that procedure in that hospital, you know, these are their complication rates. And, you know, so this is a high complication, you know, at least one surgeon has a terrible complication rate, there's real data transparency that's happening out there. Now, this caused a big stir because actually their methodology was not great. And if you sort of go back and calculate some of the numbers which other people have done, they've shown that the likelihood of being, you know, in this group versus this group can be pretty close depending on how high of a volume you have. And so it's sort of unfairly marking some people perhaps as high complication or vice versa as low complication. And this becomes this risk of, you know, if you're as a patient and you rely on some data that's not that great and you make a decision about, you know, going to a doctor for those reasons, there's a risk that you're gonna be misled in ways that you don't intend. And so if it's not 100% accurate information, it's gonna be a problem. So we need more and better information, we need people to be doing it more. And I would say the same thing for the Boston Globe article, although I think it's brave and great that they're doing this, you know, they didn't show all the other times that this guy had his operative procedure. Maybe this is the same thing that that surgeon does every single time. This is the only complication they've ever had. Maybe we can't blame it on the overlapping surgery. Sure looks suspicious when seen in isolation. There's also maybe not enough data here. So again, we're looking at sort of the nonoperative times versus the operative times. And so what if this were the schedule that he saw? We said, well, gosh, you know, they didn't do anything. You know, the patient was being positioned and prepped and they were giving him an art line which took an extra hour and they're all these other things and finally when your operation was ready to start, that surgeon was ready to hop over and do the procedure so they never left Bobby Jank's room. You know, or conversely that they were completely overlapping or even better yet, seeing the critical portions of the procedure and how they were overlapping or not. And so I think you could have even more transparent data and then really get to the answer, do you have a physician who's maybe doing the wrong thing or do you have a physician who's actually really trying to do a good thing and just trying to maximize the amount of time that they can give the caring patients. So I think it's absolutely correct. I think it's a solidly demanded and I think it's technically possible. And this gets back to the stuff I talked about last year and I continue to work on my lab is with continuous data recording in the operating room, we can actually get at the answers to some of these questions. And we can balance the surgeon time, training experience and most important patient safety. So thanks very much. Hans is though you've answered all. Yeah, I guess I have, yeah, yeah, that's good. So, good. Excellent. Thanks very much. That's great.