Explaining the controversy surrounding concurrent surgery

By Melissa Sirois

In the fall of 2015, a small group of reporters for The Boston Globe published an exposé on the surprisingly little-known phenomena of concurrent, or overlapping, surgeries—namely, those occurring at Massachusetts General Hospital (MGH).

The investigative piece has since provided talking points for several malpractice lawsuits and begs the question, “Is it right or safe for surgeons to run two operations at once?” Concurrent surgery is considered acceptable by some prestigious hospitals and banned at others.

In order to understand why the story and the lawsuits have been so controversial, it’s important to first get a sense of what concurrent surgery is and how it can impact public health.

Dr. Aziz Benbrahim is a surgeon at Midstate Medical Center in Meriden, Connecticut. Midstate is part of the parent practice Hartford Healthcare Medical Group, which is also affiliated with Hartford Hospital, the Hospital of Central Connecticut, Windham Hospital and Backus Hospital.

Benbrahim said concurrent surgeries occur when a surgeon works on more than one patient at a time with the support of a team of medical professionals, sometimes other surgeons, to mainly assist with preparatory tasks and the opening and closure of wounds.

He said this often occurs in situations where patients are undergoing orthopedic surgery, that pertaining to the musculoskeletal system, or cardiac surgery.

According to Benbrahim, there is also a subset of concurrent surgery, something that The Boston Globe’s “Clash in the name of care” may have missed.

“Consecutive surgeries” occur when a surgeon has one or more surgeries booked immediately after one another. When the surgeon finishes stitching up one patient, he or she immediately moves on to the next open room, where all instruments and materials are already sterilized and the patient has just been wheeled in.

In the case of consecutive surgeries, medical staff is much less involved in the actual performance of the surgery and instead work to ensure that the surgeon avoids waiting for a newly cleaned room by simply making two available.

The Boston Globe’s story primarily focuses on Benbrahim’s first definition of “concurrent” surgeries, and it provides arguments from medical professionals and experts on both sides of the issue.

Benbrahim said he doesn’t personally practice concurrent surgery because the work that he does is technically challenging. But those who do practice it, he said, cite the optimization of time and patient volume as driving factors.

Dr. Michael DeBakey, a popular heart surgeon mentioned in “Clash in the name of care,” was an example of someone who often did practice concurrent surgery. It wasn’t unusual for DeBakey to work on three or four patients at a time, the story said, and a fair amount of people in the field said his practices were successful.

Indeed, a concurrent surgery page on MGH’s website cites “timeliness and availability of vital services” and “optimal use of rooms and surgical teams” as a few of its reasons for implementing concurrent surgery practices.

Another reason, according to MGH, is that concurrent surgery allows for greater access to preventative, life-saving services in times of large patient traumas. The website lists the 2013 Boston Marathon bombings as an example of when such “multitasking” was beneficial in maximizing the number of patients treated in the shortest possible time.

There’s also the weight of education. Benbrahim said concurrent surgeries are more likely to occur in teaching hospitals, where residents are being educated and trained.

The Boston Globe said MGH officials “described the practice as an extension of the teaching hospital’s team approach, pairing senior doctors with residents—surgical trainees—and fellows…”

Still, Benbrahim remains unconvinced and continues to question the risk factors associated with performing concurrent surgeries. “The most important patient in a day is the one in the operating room,” he said.

And what happens when a relatively simple surgery goes wrong? Some pending malpractice lawsuits cite concurrent surgery’s role in complications.

According to Benbrahim, patient care, safety and positive outcomes are most important when it comes to performing surgeries. He said he personally doesn’t agree with the idea of concurrency because it seems like “short-changing” patients.

To be clear, though, he said it is not entirely unimaginable that a set of concurrent surgeries could be performed without a hitch. Two important factors need to line up for it to work: a predictable procedure and a “well-oiled machine.”

Benbrahim said that concurrent surgeries are most often streamlined procedures that feature frequently reproduced techniques that very rarely go wrong — obesity and orthopedic surgeries, for example.

Perhaps even more crucial is the effectiveness of the medical team working on the patient — the “well-oiled machine.” He said concurrent surgeries require “an excellent team, all the time, every time,” in order to ensure successful, positive patient outcomes.

While The Boston Globe has undoubtedly uncovered the details of a newly controversial practice, Benbrahim said that generally, “Patients trust the system a lot.”

Over the phone, he mentioned that he had some down time at work after just finishing a robotic surgery.

“Maybe that’s the future,” he said with a chuckle.

Melissa Sirois is a senior journalism major at Quinnipiac University. She is writing about public health this spring. She can be reached at melissa.sirois@quinnipiac.edu.

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In board rooms and doctor’s offices, Connecticut embraces ‘mindfulness’

By Melissa Sirois

Perhaps it wasn’t being practiced or talked about in decades’ past, or perhaps it was still in the process of being socially constructed, and we hadn’t come up with a name for it yet.

Either way, it didn’t appear as prominently in the public sphere. Today, though, “mindfulness” is everywhere.

It’s on the New York Times’ Best Sellers list in the form of Dan Harris’ 10% Happier, a story of the Nightline co-anchor’s experiences with meditation. It’s practiced and praised by everyone from Anderson Cooper, to Katy Perry, to Derek Jeter. It’s even being implemented across Silicon Valley at tech giants such as Apple and Google.

But what, exactly, is mindfulness? And why do people care?

The Capitol Region Education Council (CREC) out of Hartford promotes mindfulness as “paying attention in a particular way: on purpose, in the present moment, non-judgmentally.” Essentially, mindfulness is being consciously and acutely aware of your senses and living in the present moment, away from the usual distractions.

Emily Rosen is an educational technology and mindfulness specialist at CREC and has been working in the world of mindfulness for 12 years. She said the practice is about learning how to disconnect and take a pause.

“You could be mindful about anything,” she said. “You could be mindful about doing the dishes. It’s a question of putting your mind and your senses and your attention all in one place.”

Jennifer Berard, chair of Pratt & Whitney’s Military Engines Health and Wellness Committee, echoed this sentiment — that mindfulness can be practiced anytime, anywhere, even while doing things that may seem mundane.

Berard said that people who are truly happy live in the present moment and appreciate it for what it is. She sees a need for increased self-awareness, especially among people in the corporate working environment. “You’re spread across thin,” she said. “You’re in the past, and you’re in the future. You’re not in the moment.”

Both Rosen and Berard stressed that mindfulness is more than just meditation, yoga and breathing exercises. Rather, mindfulness is the larger umbrella that encompasses these tactics, and it is a skill that manifests itself differently in people.

The practice of mindfulness is not only helpful for short-term focusing and attentiveness. Extensive research by neuroscientists has documented that consistent mindfulness practices can result in increased feelings of calm and empathy for others, improved impulse control and emotional regulation and decreased levels of stress, anxiety and depression.

Historically, psychologists have used mindfulness as an approach to therapy for those who have experienced emotional trauma and extreme, prolonged stress.

Rosen said that mindfulness is different than the traditional approach to therapy, “but it’s kinder and gentler in some ways. It’s a process. It’s not a quick fix for sure.”

New Haven Insight is a meditation community that hosts group sessions every Monday and Thursday evening in the Dwight Hall Chapel on Yale University’s old campus. According to an informational brochure, the group, founded in 2008, is “dedicated to the practice of mindful awareness and compassion with the goal of decreasing (and ending) stress and suffering for all.”

Connecticut is also home to the mindfulness retreat center that is Copper Beech Institute. Based out of West Hartford and founded by a University of Notre Dame alumnus, Copper Beech offers daylong and overnight retreats, meditation groups, mindfulness education courses and workshops with mindfulness experts.

According to its website, “Copper Beech Institute envisions a future where mindfulness and contemplative practice are transforming education, health care, business, government, and every level of society affecting a healing shift in how we relate to one another and the earth…. Copper Beech Institute strives to awaken us to the fullness of our potential.”

In December, Central Connecticut State University (CCSU) hosted a two-day mindfulness conference, organized by Rosen and three others. The event brought together CREC educators and CCSU professors, as well as psychologists, students and guest speakers.

“There’s more going on in this realm than any individual knew about,” Rosen said. “We just found a lot of people doing interesting work.”

The conference was so successful that Rosen and the team have been asked to host a second. “We’re trying to make the next conference a little more in-depth…whether you’re new to mindfulness or you’re a psychologist and you’re already using these tools and looking to learn more,” she said.

Hartford Hospital has also gotten involved in the mindfulness movement by hosting eight-week Mindfulness-Based-Stress Reduction (MBSR) courses intended to teach the basics of meditation, yoga and stress management.

The series is based on similar courses hosted by the University of Massachusetts Medical School’s Center for Mindfulness and features Jon Kabat-Zinn’s MBSR approach.

Kabat-Zinn established MBSR in the 1970s to help patients who were experiencing chronic pain, and in 2012, he spoke to Google employees about the method.

Today, Google’s “emotional intelligence” initiative is the more progressive type, offering employees access to about a dozen courses on mindfulness meditation and boasting a six-month wait list for its most popular class, “Search Inside Yourself.”

In contrast, Connecticut’s Pratt & Whitney, a Fortune 500 company that manufactures jet engines, hails from a more conservative culture, through which Berard said “the glorification of busy” often permeates.

Berard said the Pratt & Whitney culture fosters hard work, but “just because I’m busy doesn’t mean that I’m doing well or getting anything done.” She understands the importance of retention and keeping employees happy.

Since becoming chair of the Military Engines Health and Wellness Committee, Berard has made it her mission to develop a mindfulness initiative that will create “opportunity areas” for employees to improve both inside and outside of the work environment.

She received support from the president of Pratt & Whitney’s military engines division in establishing “meeting-free afternoons” after 2 p.m. on Fridays.

“Each person and meeting room in Microsoft Outlook now has a block on the calendar to dedicate time for personal development, organization, training and closing out the week and preparing for the next,” she wrote in a graduate admissions essay about her work.

In addition, Berard has held a handful of hour-long mindfulness seminars, ran a health fair and initiated the addition of outdoor seating to Pratt & Whitney’s East Hartford campus.

She has also encouraged “walking meetings” and outdoor meetings to increase blood circulation and foster creativity and has supported mindfulness efforts by UTC-4-Vets, an internal employee resource group for those who have served in the armed forces.

Overall, Berard said she is striving to create a culture of work-life integration. “I always say that when you hire a person, you hire the entire person. You hire people who have interests, hobbies, families, health concerns — and as a company we need to focus on our people,” she wrote in her essay.

For those who may be intimidated by the idea of practicing mindfulness, Berard and Rosen emphasized that no one person is an expert, and no two people are “mindful” in the same way. “It’s a personal practice thing,” Rosen said. “It doesn’t really have to do with career, specifically. It’s not just for people in the healthcare field.”

More importantly, they said, mindfulness is about being able to understand and regulate one’s own emotions, becoming self-aware, developing healthy, life-long survival skills and embracing the present moment.

“Can you really dedicate yourself fully to anything that you’re doing other than what you’re doing right now? The answer is no,” Berard said. “You really need to make time for yourself or else time is going to eat you.”

Melissa Sirois is a senior journalism major at Quinnipiac University. She is writing about public health this spring. She can be reached at melissa.sirois@quinnipiac.edu.

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Inconsistency seen in Connecticut’s handling of sex ed

By Melissa Sirois

“We’re freaking slammed everywhere—all over the culture and all of these billboards, commercials, everything! But then the minute it gets down to the real thing, no one wants to talk about it.”

So said Lilly Bosco, a member of Plainville High School’s graduating class of 2012 and a marketing student at the University of Hartford. She’s in the middle of her commute to school on a Sunday afternoon, and there is no hiding the fact that she is frustrated.

But it’s not the extra hours at the library that have got her speaking so passionately—at least, not this time. It’s the issue of the current state of sexual education curriculum in Connecticut.

Bosco says the system has not provided a comprehensive sexual education experience for students in middle and high schools. And she’s not alone in her opinions.

In 1987, the Center for Disease Control introduced a system for integrating health education practices into school settings across the United States. The approach, called “Coordinated School Health” (CSH), established the goal of improving the health of students in the hopes of also improving academic achievement.

According to the Connecticut Department of Education, the CSH blueprint is applied in partnership with support from the Department of Public Health and funding from the CDC. The DOE’s mission statement for the approach is “to nurture the physical, social and emotional health of the entire school community…and to promote and support the full implementation of a coordinated approach to school health…”

Connecticut’s sexual health education curriculum’s eight content standards, in line with the CSH program, include items such as “analyze factors that may contribute to a healthy and unhealthy relationship” and “discuss important health assessments, screenings and examinations that are necessary to maintain reproductive health.”

While a 2003 study sponsored by Advocates for Youth and The Parisky Group of Hartford showed 91 percent of all adults support sexual education in high school, some of the people most affected — students and their primary care providers — say not enough is being done to create an integrated approach to sexual education in the classroom.

Michael Corjulo is the former president of the Association of School Nurses of Connecticut and a pediatric nurse practitioner at the Children’s Medical Group in Hamden. He believes people at the DOE have good intentions and would probably be open to more collaboration with parents and primary care providers.

“I think the important thing is that we make a structured effort to try to ensure that we’re giving kids the same message about sexual education in schools as they would get by their primary care provider,” he said.

Bosco supports this notion, too. She said the education system should be more in tune with students’ sexual educational needs, which include the knowledge of resources and more transparent discussions around how to have consensual, safe, fun sex.

Of her sexual education experience in Plainville’s public school system, she said, “I don’t remember anything too significant…. I don’t think it was really taught in an effective way. They just wanted to get through it with us.”

“There was never any followup,” she said.

According to Corjulo, Bosco and thousands of other students like her have experienced a superficial approach to sexual education.

Statistics from the Connecticut School Health Profiles (SHP) for 2010 illustrate the discrepancies in sexual education curriculums. In 2010, 87 percent of health courses in grades six through 12 taught about HIV prevention; 88 percent about human sexuality; 78 percent about pregnancy prevention; and 87 percent about STD prevention.

That same year, 95 percent of high school sex ed teachers and 75 percent of middle school sex ed teachers taught abstinence as the best method of avoiding HIV infection.

By comparison, the report said educators were “less likely to provide instruction on ‘controversial’ methods.” For instance, 66 percent of teachers instructed on the importance of using condoms consistently and correctly, and only 56 percent taught students about how to obtain condoms.

Emma Bartley also attended junior high in Plainville, but spent her high school years at St. Paul Catholic High School in Bristol, where she graduated in 2015. She had a bit of a different experience as she moved from public to private school.

Bartley said she was exposed to sexual education in religion class at St. Paul under a faith-based approach, where she felt educators didn’t address the reality of the situation.

“They weren’t telling us what to believe — they would say, ‘Use protection,’ but I feel like at the same time they kind of acted so innocent and just acted like we were all waiting until marriage,” she said. “They were almost blind to what was actually going on, but they wouldn’t admit it.”

To be fair, Bartley said she feels as though St. Paul’s health curriculum generally worked pretty well for her. She learned the ins and outs of harmful drugs and alcohol, and she said there was a lot of focus on building healthy relationships and recognizing unhealthy dating practices.

Bosco said she sees obvious room for improvement and places blame on the overarching taboo culture surrounding sex — the one where sex sells, but we’re afraid to talk about it with our children.

“I think it really starts with kids, and they’re not having the proper conversations,” she said. “It’s totally being brought to them in an awkward way right from the beginning — that it’s weird, and it’s not a normal conversation [to have].”

On the awkward conversation front, Corjulo would agree. He said while some schools across the state probably handle sexual education very well, “It’s sort of hit or miss. It’s not a structured, intentional approach.”

A lot of this, he said, stems from unprepared faculty members — gym teachers, for instance — who are unaware of how to broach the topic with their students. “I don’t think that health educators in schools get down to that level of, ‘OK. You’re in this situation here…’,” he said.

Both Bartley and Bosco said they didn’t experience truly open conversations about sex until college, where free condoms are often distributed in student centers, and there are semester-long courses dedicated to discussions of human sexuality.

During her freshman year at University of Hartford, Bosco had her own sexual health scare, something she says high school health class did not prepare her for but should have.

Before she knew it, an STD had passed through three unknowing people, and she was one of them. Bosco said she was infected for three months before she even realized something was wrong and found the courage to ask for help.

“The dangers of sex that exist — they’re real. But they don’t have to become part of your sex life,” she said.

Melissa Sirois is a senior journalism major at Quinnipiac University. She is writing about public health this spring. She can be reached at melissa.sirois@quinnipiac.edu.

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