Simultaneous RALPS - Ask Questions before signing up

yup, it happens.

Our general advice here is for folks to use surgeons that have done 1000s of surgeries. Maybe we should amend that to surgeons that have done their 1000 surgeries one at a time...

Thanks Pratoman (and the Boston Globe of course); that's a REALLY interesting story. On one hand, it does seem like Dr S is walking on the edge. On the other hand, 'new' residents do need to learn how to operate somehow. Since only on person can sit behind the robot display (I guess) how does one learn?

When one goes to a teaching hospital for a procedure, I wonder how many patients realize that residents may take part in the action.

Prat,
Thanks for that and thanks to the Boston Globe for that "expose", hate to think this is common practice. That's almost as bad as having a Surgical Assistant that is not even covered on your health plan.(Out of Network-Ouch) Oh ya, but I probably Ok'd him..while under anesthesia! Never met the Assistant or it was never brought to my attention. Just like it was never brought to the attention of these patients that the good Doctor that he would be leaving the operating area.
Seems of course the Hospital defends this process. Don't know ,but I would seem that any part of a RP would be "major" and I would not want him to leave to go to another surgery (thus boosting his stats!) at any time. Double billing my ass!..eer almost literally!
wings

Great article. Thanks for posting.

When I did my research into surgery, every thing I read stressed finding an experienced surgeon. That was key in my decision. The surgeon who diagnosed me was young, so I wondered how many robotic surgeries he had done. When I asked him, he was mildly evasive, and sort of laughed off the question. I liked him otherwise, but if he couldn't answer me seriously I wasn't turning my body over to him.

In the article about Samadi, it points out he does all robotic surgeries by himself. So if you're going in for a RALP from him, he will be at the console. I believe there are a few posters on this forum who saw him.

Do you actually think that the MD anesthesiologist(MDA) that you met before your surgery and who sent you a bill after, actually did your anesthesia? Highly unlikely. Here is the routine: at all but smaller, rural hospitals(where there are no MDAs, CRNA only) and with rare exceptions at somewhat larger hospitals, an anesthesiologist is paid by medicare and private insurance for supervising as many as 4 operating rooms, with a Certified Registered Nurse Anesthetist ( CRNA, what I retired from) in each room. The CRNA may work for either the hospital or MDA. In most- or many- states, supervision of a CRNA by an MDA is not required by law, not ever required by Medicare. But since most surgeons are averse to having any possible blame for anesthesia problems being placed on them, they highly prefer having an MDA's name on the record. Another MD they can put the blame on if something goes wrong with anesthesia. So, the norm- even though not required by law- is if MDAs are available, they will supervise the CRNAs. If this is the situation, in order for them to be paid by MC Medicare requires they be present for the most critical moments of going to sleep(induction) and waking up and in in several times during the case. But I am here to testify that this is rarely the case. The most I have seen at one place is the supervising MDA would pop in at induction and initial the chart with a time, and if not needed(the norm) leave immediately. Then they would come in in the middle and initial and again at the end. That is the best. The norm for my 36 years was to never see them outside the lounge unless I needed an extra pair of hands or help and called them. Then they were mostly pretty good about showing up, but normally you seldom saw them actually in the OR. I can guarantee you that is the norm throughout the country more often than not. And what about student CRNAs being trained? I can guarantee you that if there is a school, they are doing the anesthesia either under the supervision of a CRNA or MDA. Happens all the time.

But even though it is all a bit of a scam, it is not all bad. Just think about it. A CRNA 1st gets out of Nursing school with straight A grades , followed by a required 2 years or so of ICU/critical care experience and the highest possible reference's from various docs and nurses, and finally gets accepted to anesthesia school. Where he/she is trained in all types of anesthesia and surgeries by MDAs and CRNAs in a big surgical center/hospital. An MDA 1st graduates from medical school and gets accepted to anesthesia residency where he/she is also trained in all types of anesthesia and cases, by MDAs and yes, even CRNAs! I have personally trained MDs in epidural placement!

Then they both graduate and arrive at a hospital with no experience other than school(which is a lot of experience in both cases). One(the CRNA) immediately goes to work in the OR 8+ hours a day, the other(MDA) goes to work supervising CRNAs. Which, in some ORs, means you will only see them in the OR on occasion, if you need them and call them. So, the most critical and difficult part of anesthesia is getting the airway secured, getting the endo-tracheal tube(ET) in the right place. (or maybe getting the spinal or epidural in). Arriving out of school, both CRNA and MDA will have put in from a few hundred to 1000++ ET tubes. By the end of the 1st year out of school, the CRNA may have put in another thousand+ ET tubes. The MDA? who knows, but he can't put in very many, because he is not doing it unless he is working doing only his own cases rather than supervising. Now admittedly, if he puts a tube in, it is likely because he has been called due to difficulty getting the tube in, so he will be getting the tougher cases, although often that will be only for the inexperienced CRNA. But that doesn't happen often. So what do you think happens after 5 or 10 years of the CRNA putting in 1000+ tubes a year while the supervising MDA puts in 1 or 2 dozen a year or less? Same thing with spinals and epidurals. I used to put in 300-500 epidurals a year, while my supervising MDAs might put in 10, or zero. As the years roll on, that is one heck of a lot of difference in hands on experience. It was unheard of for a labor and delivery nurse to ask any MDA to do her epidural when she went into labor to have her baby at the large 600 bed hospital where I worked as well as other hospitals where I worked, they would always request me or some other very experienced CRNA. They knew better than to do otherwise.

So, though it is very often not the truth when an anesthesiologist tells you he is going to put you to sleep, and though he will send you his bill anyway for doing so, and instead that MDA is likely supervising at least 4 CRNAs at once(and sending a bill for each) it is not necessarily a bad thing. There certainly is no extra risk involved with the CRNA, and you might even well be better off and getting the far more experienced and possibly more skilled person doing your anesthesia. But still, there is something not right about how some(not all) MDAs tell the patient they will be doing their anesthesia. When the large majority of anesthetics every year are administered by CRNAs. (there are probably still some hospitals where this is not the case, but I never worked at any of them from 1977- 2013.) I will personally never be worried about the results of that situation. But a surgeon booking two rooms during the same hours? I think I would rather pick another surgeon.

Oh, also I asked Tewari. Specifically if he does the entire surgery. He was honest (I think) He told me he often has the residents position the arms of the robot, and also close the external punctures after surgery. And that he often has a resident sit with him behind the console. But nobody touches the controls except him, from beginning to end.

my surgeon asked my permission for "observation" by residents during my operation. I asked if he was going to perform it. He said "Yes".

I've often wondered if it were he or the resident that sewed up my bladder neck/urethra sutures. (They came loose). My surgeon had 1,200 robotic prostatectomies. I guess what I question is...."How could something such as a suture come loose if it's been done over 1,000 times by any one individual?"

a thousand of anything is alot. especially tying a suture.

I also wonder if these surgeons play fast and loose with terminology. 'I'm doing all of the operation" can be justified in a surgeon's mind if "yes...I'm doing it even if there's someone else at the controls. I"m still in charge...therefore....I'm doing the operation (In the largest sense of things).

...they know what the patient means....and they answer "honestly" ....but....not as the question is meant as asked by the patient. Know whadda I mean Vern?

If I ever find myself in a similar situation again....surgery....and the surgeon asks if it's alright if.... I believe it's in my best interest to just say "No. No teaching". And don't sign the consent form.


edit: I personally believe my sutures were never "tight". I believe they were loose when they rolled me out of the OR. I asked someone (who outta know) how sutures can "come loose". She said it's usually due to some sort of trauma. My doc accused me of doing something to cause it. I did nothing. To scared to move faster than a 90 year old blind man. No trauma. At least by me. But...that's all moot now. one of life's little unanswerable questions.

The surgeon who did my daVinci RALP typically does 3 and maybe 4 per day. Patients arrive and are staged about 2 hours apart. I know because I met the patient after me. And he met the guy after him. (I was first for the day.
Do the math. How can a surgeon do 2000 surgeries without doing multiples per day? it's big business.