Hospital, Doctor’s Surgical Suite or Outpatient Surgery Center?
For over thirty years, much cosmetic surgery has been performed as an outpatient service (especially in Beverly Hills); that is, “in and out” the same day, no overnight hospitalization required. You may wonder what difference location makes if you are there for only a few hours. Based upon your medical history, the procedure(s) to be performed and other practical considerations, your doctor will recommend a facility. It will serve you best in terms of comfort and safety for you, and efficiency and risk reduction for the surgeon. A doctor must anticipate any problems that could arise and he must be confident in having access to the people and equipment necessary to make your surgery successful and complication free.
During 2000, the American Society of Plastic Surgeons noted that 37 percent of cosmetic procedures were performed in offices, 28 percent in hospitals and 35 percent in outpatient surgery centers. Regardless of where your procedure takes place, you should be aware of certain key standards of excellence and safety. Several national organizations provide the guidelines.
- Most, though not all, hospitals in the United States are accredited by the Joint Commission on Accreditation of Health Organizations, (JCAHO). Sponsored by the American Medical Association, the American College of Physicians, the American College of Surgeons and the American Hospital Association, JCAHO visits and evaluates the hospitals to determine if current standards are being met. A hospital found “in compliance” is recognized as “accredited.” Such accreditation must be renewed on a regular basis. Should your doctor plan to perform your procedure in a hospital, you should ask: “Is the hospital accredited by the Joint Commission?”
- Ambulatory surgicenters and office facilities should have identical standards of excellence. Here, too, there are organizations that establish high standards. Most prominent among these are the Accreditation Association for Ambulatory Health Care (AAAHC), the Joint Commission for Accreditation of Health Organizations, (JCAHO) and the American Association for the Accreditation of Ambulatory Surgical Facilities (AAAASF). If the ambulatory surgery center caters to a large number of elderly patients, it may also seek Medicare certification from the federal government.
- Licensure by the state health department is another credential held by many outpatient surgery centers. Such licensure denotes the meeting of state approved standards that match those of licensed hospitals. If the facility in which your surgeon intends to perform your procedure is Medicare-certified and/or state licensed, you can be comfortable that safety and care standards have met hospital standards.
Assuming a level playing field of equal accreditation, let’s explore the pros and cons of hospitals, surgery centers and doctors’ offices for cosmetic surgery:
Hospitals as a Location Choice
Unless you have a medical condition warranting hospital level service or are a patient under the age of fourteen (only hospitals are expected to have medications and equipment suitable for all ages), a hospital may not be your best choice. They are generally large and impersonal. They are expensive and more importantly, rarely focus on or specialize in, cosmetic surgery. Today’s hospitals are overtaxed by staff shortages and tight budgets. Their mission is to serve the needs of sick patients. The consequence is that cosmetic surgery patients are rarely treated in the attentive and comforting manner they expect.
Doctor Surgical Suites
Assuming they are duly licensed, certified or accredited, and thus meet the strict requirements of safety outlined above, doctors’ office surgical suites can be adequate and appropriate for cosmetic surgery. Optimally, the facility should be in a medical campus building because it is important to have other doctors available in case of emergency. At the least, there must be a nurse anesthetist or physician anesthesiologist on the surgical team. Charges for office facilities tend to be far less than hospitals and somewhat less than outpatient surgery centers.
Outpatient Surgery Centers
These are appropriate for nearly all cosmetic surgery procedures and are particularly suited for cosmetic procedures. Unlike hospitals, surgery centers offer niche or boutique services that can be exquisitely specialized. Since they typically have two to four operating rooms, there is usually plenty of capable support staff, a critical issue should there be any emergency. Nurses, surgeons and anesthesia specialists are on site at all times. Surgery centers are best located in buildings devoted to medical services or on a medical campus. Both provide safe, seasoned, secure places for medical procedures and professional environments for pre- and post-operation consultations.
Most importantly, surgery centers offer the patient privacy and anonymity in a tranquil, relaxed atmosphere. Fees are typically somewhere between those charged by a hospital and an office suite set up for outpatient procedures.
Firsthand Experience With Outpatient Surgery Centers
In the 1990s, I was involved with a state licensed, U.S. Government certified, outpatient surgery center. I participated in its design and served as Medical Director (chief quality control officer). This private, two operating room center, located on the ground floor of a major medical building in the heart of Beverly Hills’ “Doctors Row,” had a perfect safety record in its eight years of operation. Nearly 10,000 procedures were performed with NO significant complications. No deaths. No cardiac arrests. Only four patients transferred to a local hospital for observation and all four were discharged the next day. The secret of this successful run?
- Hand picked, top quality, professional staff. The surgeons were highly specialized and experienced. Most held university teaching positions. Staff privileges were given by invitation only and acceptance was predicated on meeting tight standards. Nurses were equally specialized. In the operating room, the surgical assistants were super-specialists. Many had been assisting in cosmetic surgery exclusively for over twenty years. The recovery room was staffed with Registered Nurses (RNs) familiar with the demands of intensive care and cardiac care and had experience treating problems during surgery or recovery.
- A safe facility. This center was designed by architects and space planners who limit their work to medical facilities; they don’t design houses, warehouses or office buildings. The center was built to the high standards necessary for state licensure and government certification. The facility employed specialized consultants for management and quality assurance programs. It was not easy to build and operate a quality, safe, outpatient surgery center; there is no more tightly regulated business. But that’s why you, as a patient, want to have your surgery performed in a similar credentialed, safe, surgery center; it has passed all the tests.
- Doctor anesthesiologists only. Our anesthesiologists were all super-specialists with deep experience in cosmetic surgery who were dedicated to the facility and its mission of excellence. They did little hospital work, primarily outpatient cosmetic procedures. They had the right personalities for this field: warm, friendly and caring professionals who took time to make the patients feel comfortable and confident. And that’s what set them apart from the average.
Traveling for Cosmetic Surgery
In our mobile, global society it is important to address traveling for cosmetic surgery. Some people travel within the United States, some come to the USA from foreign countries and some Americans go abroad.
Southern California has long been considered a Mecca for cosmetic surgery. People throughout the United States and beyond our borders make the journey to Southern California, particularly Beverly Hills, for surgery. The most common reasons cited include “highest safety standards,” “the most sophisticated treatments,” “best surgeons.” Indeed for many foreigners, cosmetic surgery’s art form is not as advanced in their homeland as it is in the United States.
While some “immigrate” for cosmetic surgery, some Americans “emigrate.” Recently, The New York Times published a catchy article about Americans combining foreign travel and cosmetic surgery. Our specialty has long been aware of this, but rarely has it been seen as news. What makes it newsworthy is that several countries, hungry for American dollars, are waging an aggressive marketing campaign to attract Americans seeking low cost cosmetic surgery. No question surgery costs less in Mexico, Costa Rica, Brazil, Thailand or Russia. We have had a little peek into this world from patients and prospective patients who have shared their experience or a friend with “foreign cosmetic surgery.” Some are happy. Some are disappointed. For you, if you consider this option, the dilemma lies in the “what if?” “What if” there’s a serious complication or unintended results? What is the contingency plan? What happens when you’re 10,000 miles from home?
In the U.S., we have a very stringent licensure and credentialing processes for doctors, hospitals, outpatient surgery center, clinics, etc. No other countries match our standards. This should concern you. In a third world country, proper sterilization techniques, safety of the blood supply and available, competent emergency care cannot be taken for granted. Most third world countries have nowhere near the safety standards, modern equipment or highly specialized personnel to which we’ve grown accustomed. There is some excellent work performed by foreign cosmetic surgeons (some American trained) who are operating in their homeland. There are also some patients who receive terribly botched surgery and must then return home for an American surgeon to do the necessary repair work. Certainly this double dose of surgery will erase any savings.
This is not to say problems and complications never occur in Beverly Hills, New York or Miami. But, consider the world class medical backup available here in the United States, if needed. As one patient commented, ” I do not turn over my face and potentially my life to the low bidder 8,000 miles from home.” If you want to visit an exotic locale, take a vacation. If you want cosmetic surgery, be cautious and analytical in your decision making.
8 Wise Questions For Americans Emigrating for Cosmetic Surgery
1. When I arrive, where will the consultation be and at what time?
2. Who performs the physical exam to assure my health is satisfactory for the operation(s) and anesthetic?
3. What if my desires are inappropriate and surgery cannot be done safely or satisfactory?
4. If I opt for the surgery, will there be a board-certified doctor anesthesiologist in attendance at all times?
5. What if I don’t feel comfortable with the surgeon, the anesthesiologist or the facility?
6. Can I get my money back and fly home without repercussion?
7. Who will care for me immediately after surgery?
8. What if something happens after my return home? Who manages the problem? Who pays?
ANESTHESIA Who is “at the Controls”?
Know the difference between an anesthesiologist and an anesthetist. Only one is a doctor.
ANESTHESIA IN SOME FORM IS REQUIRED FOR ALL COSMETIC SURGERY PROCEDURES. What you may find surprising, however, is the relative importance of the relationship between the type of anesthesia used and who is at the controls. There are three modes of anesthesia your surgeon will consider:
- Local anesthesia injected by the surgeon
- Local anesthesia with intravenous sedation
- General anesthesia. The patient is unconscious; vital signs are constantly monitored.
The Length And Type of Procedure Will Dictate The Choice of Anesthesia.
Local anesthesia, in which the patient is fully awake, is appropriate for only the most minor procedures. For example, a surgeon might consider it for mole removal. Local anesthesia for cosmetic surgery is like having Novocaine® at the dentist: you are aware of the procedure but the area is numb; you feel no pain.
Local anesthesia with sedation can be safely used for many common cosmetic procedures. Sedatives, painkillers and tranquilizers are administered intravenously for immediate effect. This procedure is similar to having sodium pentothal or a similar sedative for dental surgery, such as a wisdom tooth extraction. You will be asleep, unaware of the surgery and not remember or sense any of the procedure. A surgeon may consider this form of anesthesia for simple rhinoplasty, routine upper and lower eyelid surgery or cosmetic correction of the ears.
General anesthesia, once reserved for inpatient hospital cases, has become more common in outpatient practices. Indeed, technological and drug advances developed in recent years have made general anesthesia the choice for longer, more intricate cosmetic procedures. High-tech monitoring devices that continuously report on vital signs and associated data, coupled with newer anesthetic drugs, have greatly improved the safety of general anesthesia. These innovations allow even the longest operations (up to seven or eight hours) to present little risk to the patient. Under general anesthesia you are put into a state of unconsciousness. Your vital signs are constantly monitored. Facelifts, necklifts and combination procedures would be examples of cosmetic surgeries requiring general anesthesia. In most cases, local anesthesia is injected into the operative site after you are asleep to reduce the depth of general anesthesia (for safety) and to reduce bleeding.
So, who is most qualified to administer anesthesia in each of the above scenarios? Who should be in control?
Local anesthesia without sedatives, as in a dental office, is a low risk technique and requires minimal electronic monitoring. This is only suitable for the least invasive procedures, as a scar “touch-up” or mole removal. Administration by the surgeon is appropriate.
Sedation anesthesia (given intravenously for rapid onset), or general anesthesia, must be administered by an anesthesia specialist, not the surgeon. The surgeon’s priority is dealing with the details of performing the procedure. He will be far too preoccupied to also be responsible for the administration of anesthetics. When potent pain medications, tranquilizers and sedatives are introduced into the body, observation, monitoring and management of vital functions is a full time job.
Two different types of medical specialists are qualified to administer anesthesia: nurse anesthetists and doctor anesthesiologists. Nurse anesthetists officially work at the direction of the surgeon, but in practice, they perform their services independently. Nurse anesthetists are licensed registered nurses who have pursued additional specialty training in anesthesia; the nursing parallel of a physician’s residency.
Anesthesiologists are medical doctors who have trained a minimum of three years after medical school in their specialty, defined as “the practice of internal medicine in the operating and recovery rooms.” The doctor anesthesiologist is responsible for controlling key internal organ functions, particularly the heart and lungs.
It is important that you are comfortable with the anesthesia issue. Most likely, your surgeon will have a consistent routine for each procedure performed, including the type of anesthesia employed. Most super-specialist cosmetic surgeons prefer to work with a small cadre of anesthesiologists. By working together they develop consistent patterns and systems that reduce the chance of error much like a basketball team where each player can anticipate his teammates’ moves. Safety levels rise with team consistency. This level of familiarity and stability is more difficult to achieve if a surgeon is teamed with a new anesthesiologist for each operation.
You should ask what type of anesthetic the surgeon prefers, whether the administrator of the anesthetic will be an RN (registered nurse) anesthetist or an MD (medical doctor) anesthesiologist, and how well the surgeon knows this individual. Understanding the difference in education and training will help shape your preference. Your choice should be honored.
Understandably, there is some “rivalry” between nurse anesthetists and doctor anesthesiologists. Another medical turf battle. Read here the words of a doctor anesthesiologist who, prior to becoming a physician, was a nurse anesthetist. Her remarks were recently printed in the newsletter of The American Society of Anesthesiologists:
Can Nurse Anesthetists Replace Anesthesiologists? Only If They Become Doctors.
I was a nurse anesthetist for ten years. I was well trained; my academic performance and technical skills were significantly above average. I taught student nurse anesthetists and even directed a school of nurse anesthesia for a short while. Then I entered medical school. I did so with no interest in pursuing anesthesiology as a specialty. You see, I thought I knew everything there was to know about the administration of anesthesia. I was sure there would be a new, exciting and challenging career path beckoning brightly at the completion of my medical education.
My fourth year of medical school included a mandatory clinical rotation in anesthesiology: Ironically, I was assigned to the same hospital that had employed me as a nurse anesthetist. I knew nearly everyone, “This will be a snap,” I thought. But it wasn’t. Everything was familiar: an operating room I had worked in hundreds of times, equipment I had used. Then I was introduced to the patient. That patient was a completely different entity than the last patient I had anesthetized as a nurse anesthetist. It was as though I had always seen in black and white and suddenly had color vision! What an astonishingly complex and vulnerable being who was lying there! Why had I not appreciated this before? What had changed? Anesthesia Who is “at the Controls”? 185
I had, of course. I was a fourth-year medical student who had been a nurse anesthetist. I had the mind of a doctor now. I had struggled and learned all about pathology, histology, anatomy, pharmacology, internal medicine and surgery. I had mastered the basics of physical examination, clinical diagnosis and treatment. A stethoscope was no longer just something to check lung sounds and heart rhythm: it was one of many diagnostic tools at my disposal. With it I could identify murmurs, extra heart sounds, rubs, fine rules versus coarse rules, and normal and abnormal bowel sounds. Under supervision and sometimes overwhelmingly critical observation, I had treated patients with hypertension, diabetes, heart disease, lung disease and neurologic conditions. I had a clear understanding of how difficult all this was and that the outcome of one’s efforts could not be relied upon to be positive. So it was with this new perspective that I was viewing the patient lying before me in that operating room and I was terrified. How little I really knew! How much there was to learn!
I applied and was accepted as an anesthesiology resident in the same university hospital setting that had awarded me my nursing degree. I anticipated being “ahead of the pack,” for a bit, at the start of anesthesiology residency, confident that my technical skills would give me some advantage. That lasted about two weeks and then we were all on level ground again. I struggled along with everyone else for the rest of the three years. Now, I love being an anesthesiologist. I love the problem solving, the pharmacology, physics and physiology involved in every anesthetic. I thoroughly enjoy working closely with nurse anesthetists in a “team” setting that is defined by anesthesiologist supervision of nurse anesthetists.
Unfortunately, nurse anesthetists really do believe that they can do everything that an anesthesiologist can do, and do it better. I know I thought so. As a group, they mean well and I respect them enormously. But they have no idea how much they do not know. Nurses are not physicians. They cannot practice medicine. As nurses they require physician supervision.
So why remove the physician supervision requirement? The only answer I am aware of is that “anesthesia is safer now.” Really? Do patients believe that anesthesia is so safe that it doesn’t matter that a doctor may not be involved or have any responsibility for its administration?
I am one of the few who can see both sides of the issue clearly and, I hope, impartially. The nurse anesthetist who wants to be a doctor will have to do it the way I did the hard way.
-Kay S. Rost, MD
While the chance of a problem with anesthesia is minuscule, if a difficulty should arise, it could be catastrophic in the wrong hands. You should seek to reduce that risk to the lowest level possible. Decide whom you prefer to have administer you anesthetic. Make your feelings known, without equivocation to your doctor. It’s your body. It’s your life.
Now, Anesthesia Has Cosmetic Surgery Super-specialists!
The spectacular daily triumphs of coronary bypass, heart valve replacement, liver, kidney and joint replacement are not feasible without the astonishing capabilities of modern anesthesiology.
Anesthesiology has been a recognized physician specialty since the founding of the American Board of Anesthesiology in 1937.
Super-specialist Doctors who, by obtaining additional training beyond residency and board certification, practice only a narrow portion of their core specialty. Today, there exists analogous sub-specialization and even super-specialization within anesthesiology also: sub-specialty training in cardiovascular, pediatric, neurosurgical and obstetric anesthesiology. Also, available to fully trained anesthesiologists are fellowships in pain management and critical care.
The subdivision of anesthesiology is a very positive trend for all patients and particularly cosmetic surgery patients. Office and outpatient surgery center anesthesia demands techniques and medications that differ from major hospital in patient surgery.
Here is why anesthesiologists are migrating to the office and surgery center world. They live in a distinct practice environment: short, elective surgery performed on healthy, low-risk patients. Also, personally, it has attractive regular hours and freedom from night and weekend duty as well as less stress than emergency and other unpredictable hospital work. To provide continuing education for these sub-specialists, there are three societies: the Society of Ambulatory Anesthesia, the Society of Office-Based Anesthesiologists and the American Society of Anesthesiologists. Acceptance into these organizations is predicated upon demonstrated focus and experience in outpatient and office-based anesthesia respectively.
In our major cities, there is enough cosmetic surgery to allow some anesthesiologists to practice cosmetic surgery anesthesia exclusively. Anesthesia delivered by such super-specialists is ideal.
If you value the wisdom of selecting a super-specialist cosmetic surgeon, ask that doctor to select an anesthesiologist who is as specialized as he is. By doing so, you further enhance the prospect for having a safe, comfortable and positive anesthesia experience.