S05E80 Controversy over Ghost Surgeries and Transparency in the Operating Room
We turn a spotlight to a growing scandal in surgery as hosts Dr. Sam Jejurikar @samjejurikar, Dr. Salvatore Pacella @sandiegoplasticsurgeon, Dr. Lawrence Tong @yorkvilleplasticsurgery, and Dr. Sam Rhee @bergencosmetic scrutinize the unfortunate practice of 'ghost surgeries' at teaching hospitals.
Attending surgeons are in the hot seat for allegedly billing procedures they don't fully perform, often leaving residents at the helm of critical surgical moments. Take a behind the curtain look at medical ethics and patient safety revolutionized as we dissect recent legal confrontations that have shaken some of the nation’s esteemed hospitals. Whistleblowers' testimonies from within the medical realm are spotlighted, revealing a breach of trust that threatens the well-being of patients.
The plot thickens as we tackle a potential proposal to install cameras in operating rooms. Could this be the panacea for transparency in surgery, or might it cast a shadow of unease over surgeons' shoulders? As we debate the pros and cons, from heightened accountability to the potential psychological toll on medical professionals, the conversation veers into the realm of patient-surgeon trust dynamics.
Hear our expert panelists weigh in on the delicate balance of maintaining patient confidence while ensuring their safety, especially in the context of the recent Floridia Brazilian Butt Lift mandates. We're not just turning on the lights in the OR—we're aiming the spotlight on the intricate dance of ethics, trust, and the quest for surgical integrity.
@3plasticsurgerypodcast #podcast #plasticsurgery #cosmeticsurgery #plasticsurgeon #beauty #boardcertified #aesthetic 3plasticsurgeonsandamicrophone #bergencosmetic #bestplasticsurgeon #beforeafter #aesthetics #realpatientrealresult #boardcertifiedplasticsurgeon #njplasticsurgeon #njplasticsurgery #nyplasticsurgeon #nyplasticsurgery
S05E80 Controversy over Ghost Surgeries and Transparency in the Operating Room
TRANSCRIPT
Sam Rhee (00:01.222)
All right, welcome to another episode of three, actually, four plastic surgeons and a microphone. We are here with Dr. Sam Tajurkar from Dallas, Texas, Dr. Lawrence Tong from Toronto, Canada, and as always, Dr. Sal Pichella from San Diego, California. I am Sam Rhee, and I am from Paramus, New Jersey. Our topic today is about doctors ghosting patients where they charge for surgeries that are left to residents. And-
There have been recent articles and lawsuits where doctors at some of the largest US teaching hospitals are blowing the whistle on what they say is a money-making practice that endangers patients where they're scheduling two or even three operations at the same time and billing for work that they didn't do. But before we get started, I'll have Dr. Tong read our disclaimer.
Dr. Tong (00:53.476)
Thank you. This show is not a substitute for professional medical advice, diagnosis or treatment. This show is for informational purposes only. Treatment and results may vary based upon the circumstances, situation and medical judgment after appropriate discussion. Always seek the advice of your surgeon or other qualified health provider with any questions you may have regarding medical care. Never disregard professional medical advice or delay seeking advice because of something in this show.
Sam Rhee (01:21.842)
There was an article recently by Bloomberg Law where they talked about over a dozen lawsuits on the federal and state level where hospitals have been accused of billing for thousands of cases costing taxpayers hundreds of millions of dollars where the teaching physician left residents unattended to perform spine, brain, and other surgeries. And when they talked about this with department heads,
Especially when there were an extremely high rate of surgical injuries, the doctors dismissed this or sorry, the departments dismissed this saying, this is just part of the system, essentially. So what do you guys think about this practice of ghosting patients and leaving residents to operate?
SAL PACELLA (02:11.542)
So this has been a well-accepted common practice throughout history, okay, particularly at teaching hospitals, academic centers, et cetera. And this has been accepted by hospitals, department chairs, et cetera. And if you look at the documentation of this, at the end of the state, at the end of the doc, so for our listeners out there, every time a surgery is performed, there's a written record of the surgery that's documented.
And at the end of it, it says if there are residents or students or fellows involved with the care, the last line says, I was present for the critical portion of the procedure. Okay? And so the idea is that if a tenant surgeon has multiple rooms running, those are sort of offset a little bit. They're not starting at the same time. So perhaps a senior resident or a chief resident may be able to start the operation. Once you get to the critical portion.
then the attending surgeon would come in and that would give he or her time to start the next case. And the idea behind this is they can maximize the total throughput through the system. Academic centers are very busy. And quite honestly, that process has been a very, very good way for adept residents and fellows to gain operative experience. But now we're sort of seeing a flip in that, right? And it's, I...
I, the thoughts on this really challenge me here. I don't know, I'm curious what you guys think.
Dr. Sam Jejurikar (03:46.299)
You want to go next, Larry?
Dr. Tong (03:48.108)
Sure. Well, I think the important point of what you said is the critical portion of the procedure. And I think that the allegations here are that these staff physicians were not there for the critical parts of the operation and that patients were being harmed because of it. And there have been, you know, research that shows that, you know, running multiple rooms might have, you know,
deleterious effects or consequences for patients. So I totally agree with Dr. Pacella in that this has been an established way that academic centers run. The attending staff is not generally expected to do the whole case from start to end. And there's definitely economies of scale and efficiency when doing multiple rooms. But I think that it has to be tempered with the fact that
You know, the oath as a physician is do no harm, and it's the responsibility of the physician, the staff physician, to understand what the capabilities of the resident and the fellow are, and just to be there at important moments or people are gonna, you know, patients may suffer from this. Now, this isn't just small institutions. In the article, it mentioned, you know, Mass General, the orthopedic surgery department.
was doing this and the whistleblowers were physicians and anesthesiologists who felt that you know patients some patients were being put in harm so harm's way so I think that um you know these types of practices um should be continued to uh to continue but uh basically done in the right way.
Dr. Sam Jejurikar (05:37.17)
Yeah, I think, you know, we all trained a long time ago. And what was acceptable practice when we were residents 20, 25 years ago is not acceptable practice today. It was just different. I mean, I remember, you know, Dr. Tong taking me through cases when he was a resident and I was a resident and that was just a different era. Yes. Oh, a hundred percent, a hundred percent. Yeah.
Sam Rhee (05:58.615)
I mean, Dr. Song is an exceptional surgeon though, let's just put it that way.
Dr. Tong (06:04.3)
Too kind, too kind.
Dr. Sam Jejurikar (06:09.41)
And none of us went into academics. All of us actually went into private practice plastic surgery where the doctor patient relationship is a lot more established. And a lot of the academic medical centers residents do a lot of the actual care. I think where the problem is, is this notion that Sal and Larry talked upon being the critical portion of the case and how that's set up for abuse.
Critical portion of the case, you know, isn't closing skin in an academic medical center, it's probably not making the initial incision, but you know, where do you draw that line? And what happens in a lot of these places is instead of it just being staggered rooms where the surgeon can, you know, merely increase throughput, there's a tendency for abuse where surgeons could have three rooms simultaneously going so they can maximize their billing. And that's when the abuse actually happens. And if it's other physicians that are reporting this, not...
Clearly it's a situation that they don't think is in the best interest of patient safety. So, I mean, I don't really think this is controversial. If physicians don't think it's a safe practice and they're reporting it as whistleblowers, there's clearly a problem.
Dr. Tong (07:15.432)
Well, in the report, they mentioned simultaneous procedures happening at different facilities. So physically impossible for surgeons to be at two places.
SAL PACELLA (07:23.191)
Mm.
Dr. Sam Jejurikar (07:25.386)
possible.
SAL PACELLA (07:26.462)
Oh, you mean so like, so like, so like a surgeon running a case at the VA and then being at the main hospital, is that what you're talking about? By the way, I distinctly remember Dr. Tong taking three, me through multiple procedures, um, as an intern. Um, and I remember there was just an inseparable amount of ball busting going on. I, I can't quite remember exactly what I'm on.
Dr. Tong (07:35.57)
Yes, yes, yes.
Dr. Sam Jejurikar (07:56.674)
Exactly.
Sam Rhee (08:00.402)
I mean, let's put it this way. I think we see it from a surgeon's and a resident's perspective, and that's a different perspective than a patient's perspective. So as residents, I have very vivid memories of taking a junior resident through my first rectus harvest for a chest closure, you know, for an infected sternum. And it was...
Amazing. It was a great case. I learned so much from it. And, you know, were the critical parts of that procedure done by the attending surgeon? Honestly, no. Like, I don't think I saw the attending surgeon other than like him telling me, do you think you can handle this case? And I said, yes. And he said, okay, don't call me then. And then that was it. And so, for
me as a resident developing and learning my surgical skills, it was invaluable for me to be able to take the lead on a lot of cases. The problem is, is that, yeah.
SAL PACELLA (09:07.374)
Go ahead, sorry, let you finish.
Sam Rhee (09:09.29)
The problem is that there is the ability to be able to trust your residents who are good to the abuse of money. So in that situation, it wasn't that the surgeon was going to make more money by running to another room. He was sitting somewhere in his office drinking coffee or BSing with somebody. That's just sort of who he was.
There were other cases in Lenox Hospital. They paid $12.3 million to settle for a surgeon who was alleged to have bounced from operating room to operating room. University of Pittsburgh Medical Center settled with the Department of Justice for 8.5 million after one of their top surgeons had a similar practice where they abused the patient's trust, inflated anesthesia time, and resulted in serious harm to patients. So this can.
This is not just a small thing. This is a really, really big thing. And I do know there were cases where I sat there with the patient intubated, waiting for the surgeon because they were in another room. They had run into some difficulty. It took longer than they thought it was going to. And we're like, where's so and so? And it's like, yeah, they ran into some bleeding or this, that, or the other thing. Was that optimal for that patient and for my patient that I was sitting with? Absolutely not. And like Sam said, these are practices that are no longer appropriate.
at all. And the fact that this is done solely for money, not for patient safety, not for patients, improved results is horrible. But the problem is, is that hospitals, administrators are all looking to and surgeons are looking to maximize revenue. So I think as a patient now, when I think about going through this, what?
SAL PACELLA (10:54.195)
Well, I don't know if it's all about money. I think it's about volume. Like, you know, if you, well, no, maybe it's acuity, right? Like, if you've got multiple fractures or multiple things going on one night on a trauma call situation, you're gonna wanna get those cases done as soon as possible. You know, let's say that there's not a capacity for patients to wait, right? You know, I don't think it's solely about money. I think it's about,
Sam Rhee (10:59.91)
That's money!
SAL PACELLA (11:22.006)
convenience and it's about, you know, acuity sometimes. But, but, but let me.
Sam Rhee (11:27.034)
I think that if...
Dr. Sam Jejurikar (11:27.55)
But I think in the cases that were in this article, Sal, it was more about money. I mean, if you're talking about elective spine practices or surgeons being in different facilities, then that's about money. Like.
SAL PACELLA (11:36.658)
Yeah, yeah, right, right. Well, let's kind of take this a little bit further. So I'm gonna give you an example of two hospitals in the Los Angeles area. We'll choose LA because it's not San Diego, okay? So Cedars-Sinai is a high priced private practice.
Sam Rhee (11:40.251)
Yeah, and-
SAL PACELLA (11:58.882)
hospital in the middle of Los Angeles. And then there's of course LA County Hospital, which is affiliated with a teaching institution. It's kind of in a worst part of town. Okay, so this type of practice, do you think this happens more at a place like Cedars or a place like the county hospital?
Dr. Tong (12:18.324)
I would say the county hospital.
SAL PACELLA (12:20.214)
Right, and so because it's a teaching facility, right? And so I severely doubt any of this happens at places where patients have gold plated insurance, but it sure as heck happens at places where patients don't have insurance or patients are Medicaid or Medi-Cal, okay? And so there is absolutely something about the quality of insurance that patients have that allows the practice to go,
to go crazy at some of these county facilities.
Sam Rhee (12:54.43)
I disagree, Sal, and I will tell you the Lenox Hill example, Lenox Hill is a very posh hospital on the Upper East Side. They were doing the same thing. And MGH, Boston Hospital last year had to pay $14.6 million to settle a lawsuit that alleged overbilling by double book surgeries simultaneously overseen by the same surgeon. The three out of court settlements totaled, this was their third settlement. They paid out $32.7 million on this.
So you think this is just at your local county hospital or your teaching hospital.
SAL PACELLA (13:27.082)
No, no, I don't think it's just at that. I think it's more rampant at county hospitals.
Sam Rhee (13:32.278)
This is happening everywhere. And this was from five orthopedic surgeons who kept patients under anesthesia longer than necessary because they were juggling procedures in dual operating rooms. The whistleblower was an anesthesiologist and this is where I think we as doctors have to police ourselves. If we see something like this, there's a tremendous amount of pressure from your department, from the hospital, from other people not to say anything.
And yet this is truly not helping patients and in fact probably hurting them. And there's no doubt the anesthesiologist said their career suffered but they felt like they had to do the right thing by speaking up. So I think that we're going to probably see more cases like this, especially as financial pressures grow. And you're right, Sam. And this is one of the reasons why I think private practice is not subject to this is
Sam Rhee (14:31.718)
physician relationship. But we're not immune to it. I will say this, in Korea, they passed a national law mandating cameras in the operating room, particularly in cosmetic surgery clinics, because there were a lot of patients that would go see these superstar surgeons, and they thought they'd get their nose job or eyelid surgery by some really famous plastic surgeon and they would leave them to...
poorly trained or almost untrained people to do them so they could operate on three or four patients in a row. And the outcry got so great that they actually mandated visual observation for surgeons. And that is really where this is going to go. Like if we don't stop these abuses, guess what's going to happen? They're going to mandate cameras in the operating room, which is a totally different subject, which has been broached actually many times in the past. I would be interested to hear what you guys think of it. But.
If we can't regulate ourselves, someone else is going to regulate us.
Dr. Tong (15:29.292)
Thank you.
Dr. Sam Jejurikar (15:33.098)
I mean, I think it's already starting to happen in the United States. If you look at the medical tourism, let's talk about Brazilian butt lifts in the state of Florida. As I'm sure all of our listeners know, it's a lower cost model to fly to South Florida to get a Brazilian butt lift done substantially cheaper than any of the communities that we're in. And part of the reason for it is that in a given clinic,
It used to be that there would be 15 or 20 of these being done in a day. Clearly, when I do a Brazilian butt lift and I've done lots of Brazilian butt lifts, it takes me three hours to do. The math doesn't quite work up. There was not only surgeons just overseeing people doing it in other rooms, but there were patient fatalities happening because of this inappropriate lack of supervision. What the state of Florida actually mandated instead of...
Dr. Tong (16:23.764)
Thank you.
Dr. Sam Jejurikar (16:27.518)
banning the operation, which was under consideration, was they mandated that ultrasound guidance be done for all of the fat injections when it's put in and that portion be filmed for every case to prove that the surgeon was doing it and actually using a safe technique. So it's already started in the US and I'm sure it's going to expand more and more over.
And I honestly don't have a problem with them. Yeah, I don't have a problem with them.
Sam Rhee (16:50.234)
I think they also, I think they also, they mandated the number, you could limit the number of BBLs you could do in a day, right, as well, like in Florida.
Dr. Sam Jejurikar (16:59.47)
It's under, yeah, it's still five. We was three and I think they expanded it to five, which is still a lot, but, um, it's a start, but I mean, I don't have a problem ultimately with cameras. You know, I mean, if we think about like airline safety and pilots, I mean, there's a lot of trust that patients who are not conscious are putting in the medical community, the medical community has to have ways to be policed.
Dr. Tong (17:00.288)
Three, right? Or five?
Dr. Tong (17:23.04)
Well, hopefully it won't come to that because once you have, my opinion, cameras in the operating room, that opens up another can of worms because then it's, physicians will sort of feel like, you know, big brother is watching you all the time. I mean, yes, you're always going to, all the physicians will be doing the right things at all times, but nobody's a hundred percent perfect. And then so there's going to always be this fear that if you do one little thing wrong, you're going to get sued or you're going to get a,
and things like that. So I agree with Sam that we need to police ourselves so that we don't have to go to sort of these more extreme measures.
Sam Rhee (18:08.402)
What do you think, Sal?
SAL PACELLA (18:11.274)
Yeah, I mean, I think the idea of putting cameras in the operating room is gonna be a huge challenge for many facilities and many surgeons. It just, you know, that's a sacred environment and I just feel like, you know, the same thing goes for like, you know, family members watching surgery. Like if I'm doing a little office procedure and I...
I sort of have a family member that's insistent on watching or being there. You know, I am like, it makes me nervous, you know, like it's like any, any little, you know, move of my hand can be interpreted a different way by somebody that's watching it, you know, so I, I don't agree with the camera situation.
SAL PACELLA (18:58.146)
Very difficult.
Sam Rhee (18:59.734)
Yeah, I think just imagining myself operating with a camera over me would make me have to relearn everything I do so that I'm not operating for the patient, I'm operating for the camera, which is a totally different situation. I mean, I'm not saying that it's wrong. And I really hope, as Larry said, that we never get to that point where because what that implies really is a lack of trust, right?
you are trusting that person anytime or a medical provider for that matter, for any care, right? When people give me, they say, give me some advice about, you know, I have to go through the surgery. I got to go through a knee surgery. I have to go through a shoulder surgery. I have to go through whatever it is. I say, listen, find the person that you think is the best and trust them through the whole process, A to Z. Don't start.
worrying about things midstream. Don't worry about what happens, you know, before, during, after, like just put your trust in that person and run the course, whether there are complications or no complications or anything. Because if you don't trust that person, then that whole outcome is in question many times, you know, and, and we've all had that we've had patients who trusted us the entire time. Maybe it was a little rocky.
Maybe, but it is always a better outcome if you can trust that person 100%. And that's really what this is about is, are these patients trusting surgeons? So when you read these articles, when you talk to surgeons, you have to feel comfortable that you're trusting them. And maybe if you're already teaching hospital or a large institution, maybe it's a hard question to ask, but you have to ask like, what is your surgery schedule like?
Do you feel comfortable about how things are set up? Maybe you have to talk to them about it a little bit and make sure that you trust that person that they're doing the right thing for you. Otherwise, these sort of issues are gonna get worse. And yeah, I really don't want big brother looking down at me as I play my music and sort of hang out and do my, you want your surgeon to be relaxed and...
Sam Rhee (21:21.606)
Performing optimally and I think that that's going to be a very hard thing to do if there's a camera sitting right in front Of me with it. That's all
Dr. Sam Jejurikar (21:29.574)
Well, I'll be the voice of dissent as I always am. I think our interactions with patients are different than the cases that you're talking about, right? We see a relatively small number of patients. We do aesthetic surgery in an outpatient setting. It's a one-on-one thing in an outpatient surgery center, at least for Larry and Sam and me. And Sal, I know you do some insurance stuff, but still there's a very sort of boutique feel to what we're doing. Yeah, I don't think we need to have
camera in the operating room and our outpatient surgery centers watching us do aesthetic surgery. I think the purposes of cameras like you brought them up in South Korea, like in Florida, or even in some hospitals I've heard of in Dallas, Fort Worth, is to prevent fraud. They're not filming the operation. They're filming movement in and out of the room. Because in these cases that you're talking about, which are multi-million dollar settlements with prestigious facilities, there's rampant fraud.
And what we didn't touch upon is in many academic medical centers, surgeons take home compensation is based on the number of relative value units or RVUs that they have, which is based off their productivity. So if they have an army of people that's underneath them and they have the cases, they're going to be incentivized to do more cases so they can take more, more money home. So I'm not talking about operating like you would for TikTok or for Instagram. I'm saying just to make sure that people that are supposed to be in the room at relevant times are actually there.
So I think like it or not, I think it's coming in hospitals, particularly ones that do a heavy volume. It's just, that's the way patient safety typically goes.
Sam Rhee (23:34.716)
Anyway, thank you very much gentlemen. That was a great episode a lot of great issues and questions brought up As always, thank you very much. Dr. Jharkar. Dr. Tong. Dr. Pacella and we'll see you next time
