The president of Massachusetts General Hospital has long insisted that it was perfectly safe for some surgeons to oversee two operations at the same time. Dr. Peter Slavin told the Globe Spotlight Team in 2015 that hospital officials “haven’t found a single case where the concurrency has caused harm.”
But the hospital’s internal records, it turns out, tell a more complicated story.
As early as 2010, Mass. General’s medical director of operating rooms mentioned double-booking as a factor to be examined in the bleeding death of a patient whose surgeon was juggling two operations. In another case, a patient suffered a dangerous complication while the attending surgeon was in another operating room, leaving surgeons in training to seek guidance from a vendor of surgical equipment.
“As I mentioned, we need to address these issues,” Dr. Peter Dunn wrote to the hospital’s chief of orthopedic surgery in a Dec. 16, 2010, e-mail that described five troubling orthopedic cases, including three involving double-booked surgeons.
The e-mail, marked “confidential,” is written in terse medical shorthand — “attending surgeon in second room, question of oversight” — and appears in sharp contrast to Slavin’s confident assurance that double-booking “doesn’t harm patients.” It’s unclear whether Slavin ever saw the Dunn memo, part of the court file of a recently settled wrongful termination lawsuit against MGH.
Dunn offered a more direct judgment in a December 2018 deposition for that lawsuit in which he unmistakably named concurrent surgery as a contributing factor in the bleeding death.
“You also came to the view, did you not,” he was asked by Ellen Zucker, the plaintiff’s counsel, “that concurrency was a factor in her death?”
“Yes,” Dunn replied.
Elsewhere in his deposition, Dunn stressed that he was not part of the MGH quality assurance team that evaluated the case and drew formal conclusions about its handling.
Dunn’s testimony and other evidence in the court file may help explain why Mass. General unexpectedly agreed Nov. 7 to pay $13 million to Dr. Dennis Burke, who had challenged his firing as an orthopedic surgeon in 2015. Burke alleged he was dismissed by MGH for blowing the whistle on a handful of fellow surgeons who commonly scheduled two surgeries at once. MGH had long contended it fired Burke for improperly releasing hundreds of his own patient records, with names redacted, to the Globe Spotlight Team for a story that ran two months after the firing.
Mass. General agreed not only to pay Burke, but also offered him his job back and even launched a safety initiative in his name.
The startling reversal came just hours before a court hearing that could have led to the release of more internal records from the hospital. The judge in Burke’s case had been scheduled to decide whether MGH might have to make public the results of a confidential review of double-booking that the hospital commissioned former US attorney Donald Stern to prepare. The hospital has fought to keep the 2011 report and Stern’s backup materials confidential, while asserting he found no evidence that concurrent surgery is harmful.
Suzanne DelVecchio, a retired Superior Court judge who heard many medical malpractice and wrongful termination cases in 21 years on the bench, said she had no doubt that Dunn’s e-mail and testimony contributed to MGH’s decision to settle Burke’s claim.
“If I were MGH and I were in charge of this, there’s absolutely no way I would have let this go to trial with that kind of evidence coming in,” she said, adding that she thinks the June appointment of a new head of the hospital’s parent company led to the settlement.
The day that the settlement was announced, Dr. Anne Klibanski, the new chief executive of Partners HealthCare, praised Burke, saying, “We are very grateful for Dr. Burke’s efforts to shine a light on questions of surgical safety and quality that led to the development of important improvements in our institutional policies.”
However, Slavin and Dr. Timothy Ferris, who heads the hospital’s physicians’ organization, struck a decidedly different tone.
“Mass. General strongly defends and stands by the decisions it made along the way,” they said in an e-mail to the hospital community on the day the Burke settlement was revealed. They said, however, that the trial probably would not have begun until 2021, and “there has been a growing desire at the MGH to move beyond this lawsuit.”
Last week, the hospital said in a statement that it “stands by the information it provided to the Globe Spotlight Team in 2015 as well as decisions made throughout the course of this matter. The hospital is now eager to move beyond what has been a very difficult and prolonged situation and focus fully on the important work of delivering the highest quality and safest clinical care.”
Prior to the settlement with Burke, Mass. General waged a concerted campaign to defend the safety of double-booking. Hospital officials even recruited the head of the American College of Surgeons to publicly endorse revised policies for running two operating rooms that the hospital had approved in 2012 amid the controversy.
In April 2015, Dr. Andrew Warshaw, MGH’s former surgeon in chief who was then president of the college of surgeons, e-mailed the college’s executive director, Dr. David Hoyt. Warshaw told Hoyt that “it would be extremely helpful” if Hoyt reviewed MGH’s revised guidelines and wrote a letter saying “they meet or exceed national standards,” according to an e-mail in the court file.
“This investigation,” Warshaw wrote of the Spotlight Team inquiry, “is being fed by the personal vendetta of an MGH orthopedic surgeon, a malpractice suit, and the journalistic sharks smelling blood,” Warshaw wrote. He added that the matter “has the likelihood of blowing up into a national issue.”
Nine days later, Hoyt wrote a top Mass. General official that the hospital’s updated policies on concurrent surgery are an “example of best practice and certainly exceed national standards.” The hospital made that letter public.
Hoyt, who told the Globe in 2015 that no other hospital had ever asked him to assess its concurrent surgery policy as executive director, did not respond to an e-mailed request for comment.
Dunn himself defended the practice of concurrent surgery. He told the Spotlight Team in 2015 that overlapping operations was an efficient way to deploy the most talented physicians, allowing surgical trainees to perform routine tasks such as closing surgical wounds while attending surgeons moved on to other cases.
But Dunn’s 2010 e-mail and his sworn statements in two days of depositions show that he, one of the highest-ranking physicians at the renowned teaching hospital, had also expressed concern about possible harm to patients.
The e-mail to Dr. Harry Rubash, chief of orthopedic surgery from 1998 to 2016, summarized five recent orthopedic cases, including the three that involved double-booking as well as a death unrelated to double-booking. The hospital blacked out the names of patients and doctors and other identifying information before providing it to Burke’s counsel in the wrongful termination case.
The patient who bled to death was undergoing hip surgery, but her surgeon, assisted by a surgical fellow, had two operations going at once, according to Dunn’s e-mail. Fellows typically have finished general orthopedic surgery training and are learning a subspecialty.
During the hip operation, the patient lost a liter of blood, and continued to bleed after the operation. She was brought back to the operating room for a second procedure before being moved to the surgical intensive care unit, Dunn wrote. There, he wrote, she “expired.”
In the same 2010 e-mail, Dunn cited the case of another patient who suffered compartment syndrome during surgery on a broken shinbone. Compartment syndrome is a painful condition that can occur in surgery when pressure in the muscles builds to dangerous levels. If left untreated, it can necessitate amputation of the limb.
Dunn wrote Rubash that residents “performing [the] procedure” had “little oversight” and were “guided mostly” by a vendor of surgical equipment because the attending surgeon was working on a second patient.
“Surgeon running 2 rooms, oversight of residents and documentation of oversight is an issue,” Dunn wrote.
Sales representatives of orthopedic medical device firms sometimes observe operations, but Dunn said in his deposition that he found the circumstances of the case troubling, in part because the residents who had been left on their own were, as he put it in the e-mail, “unfamiliar with [the] technique” for measuring compartment pressures. The attending surgeon had to be summoned from the other operating room and another surgical procedure had to be performed to address the complication.
In the third double-booking case, Dunn cited a patient with significant health problems, including pneumonia and blockage in the carotid arteries, who underwent spine surgery. The lead surgeon had “cases scheduled in another room,” Dunn wrote.
Dunn gave no indication that the patient suffered harm, but asked Rubash whether “such a complex patient” should have been sharing a surgeon with another patient.
Despite the seriousness of the concerns Dunn raised in the e-mail, he testified in his deposition that it took him two months to get Rubash’s “attention.”
Burke, who previously complained to Dunn about the risks of double-booking, heard about the patient who bled to death and the patient with compartment syndrome soon after the operations. The surgical cases fueled efforts by him and several anesthesiologists to urge MGH leaders to stop letting surgeons run simultaneous operations.
Burke wrote Dr. David Torchiana, then head of MGH’s physicians’ group, in February 2011, that he had warned hospital leaders a patient might die because surgeons were dividing their attention between two patients.
“Shortly after that meeting, a 91 year old woman bled to death in the immediate post operative period following a routine elective orthopaedic procedure,” he wrote Torchiana. “The surgeon had two rooms running simultaneously.”
Cathy Minehan, who was chair of MGH’s board of trustees at the time of the death and only recently stepped down, said in a March deposition for the Burke lawsuit that she was never informed that double-booking had been implicated as a factor in a death or that a vendor guided residents as a patient suffered a complication.
“I was told that data suggests that the incidence of problems is the same between concurrent and nonconcurrent surgery,” she testified.
Minehan and the doctors mentioned in this story declined to comment, according to a hospital spokeswoman, Peggy Slasman.
Officials who responded to the Globe Spotlight Team’s questions in 2015 on behalf of the hospital were also aware of Dunn’s concerns about complications in double-booked cases, including the patient who bled to death, according to e-mails in the court file.
“According to Dunn, concurrency was a factor, as was resident oversight,” Justine Griffin, a crisis management consultant for Rasky Baerlein Strategic Communications, wrote Slasman on June 12, 2015, shortly after the Globe interviewed Slavin, said one e-mail.
In response to Burke’s campaign to halt simultaneous surgeries, the hospital hired Stern, the former US attorney, to investigate the practice.
Burke discussed 10 instances of concurrent surgery with Stern’s legal team in two meetings in July 2011, according to information gathered in 2015 by the Spotlight Team. Several of the cases had surgical complications.
Stern delivered his report to MGH leaders in December 2011, and Slavin told the Globe in 2015 that Stern “found no basis to support Dr. Burke’s concerns.” Slavin added that hospital officials “haven’t found a single case where the concurrency has caused harm, so I don’t think patients should be alarmed about it.”
But the Stern report has never been made public, although a Suffolk County judge this year ordered hospital lawyers to share a copy and backup materials with Burke’s legal team. The documents had yet to be turned over when the case settled.
Burke, 67, a hip and knee specialist, said on the day that the case settled that he was happy to put the dispute behind him. But he had no plans to return to MGH, where he worked for 35 years, because he is now happy practicing at Beth Israel Deaconess Hospital-Milton.
“There is much about this journey that has been challenging for me,” he said in a statement, “but I don’t regret the path I chose.”