The recent death of a cheerleader in Florida after breast surgery at a doctor’s office has raised concerns about whether offices are appropriate for certain kinds of procedures and types of anesthesia.
The death of Boca Raton cheerleader Stephanie Kuleba was attributed to a bad reaction to anesthesia. Her death added to the concerns of a study published three weeks before her death showing that there are higher risks of death and complications in offices compared to outpatient surgery centers and hospitals.
The young woman died while under general anesthesia, and most doctors don’t do general anesthesia in their offices, says Dr. Randy Easterling, who practices family medicine and addiction medicine in Vicksburg. He is chairman of the board of the Mississippi State Medical Association (MSMA) and past president of the Mississippi Academy of Family Physicians.
“If you do use general anesthesia, you need a trained anesthesiologist to treat any complications that come up,” Easterling says. “As long as you have that, it is as safe as being in a hospital.”
Office surgery can be a good option for several reasons. Doctor’s fees are usually lower so patients can save a significant amount of money compared with hospitals and outpatient surgery centers. That can be particularly important when people are paying for elective cosmetic procedures.
On the increase
Office surgeries have increased dramatically in recent years. In 1980, an estimated 20% of 10 million U.S. outpatient surgeries were performed outside hospitals compared to approximately half of the 43 million procedures performed in 2007. Approximately half were in doctor’s offices and half in outpatient surgery centers.
Patients may also feel surgery in the doctor’s office is more private and personalized. Easterling says physicians like it because they have more control over their office than the hospital.
“I think physicians would always prefer to do what they can in their office,” Easterling says. “The doctor has little control over the hospital. Working in a hospital, you have to be subject to the hospital’s schedules, employees and equipment they have. Oftentimes that is not time or cost effective. Many minor surgical procedures can be done quickly, more efficiency and more cost effectively in the office than they can in the hospital. If you go into a doctor’s office, you are generally processed through admissions quicker. It is more comfortable and more personalized as opposed to a large hospital where you might be just a number. A large hospital might have 40 to 50 cases in one day, compared to doctor’s office that might do five or six.”
Another issue is the possibility of contracting an illness from other patients in a hospital. Hospitals have a conglomerate of a lot of different patients with diverse illnesses and infections. That can leave vulnerability to hospital-acquired infections.
“That doesn’t mean hospitals are bad,” Easterling says. “It just means you have a higher risk of that.”
One of the most important precautions is to be an informed healthcare consumer. Easterling advises making sure that the physician is board certified in the area of surgery being performed.
“Make sure that you are comfortable with that physician and that you know what type of equipment he has available,” Easterling says. “Ask a lot of questions. Be an informed patient. An informed patient is always the best patient. When you meet that criterion, you have gone a long way to make sure you have a good outcome.”
Dr. Dwalia S. South, president of the MSMA, also recommends asking questions about the procedure and the doctor’s training and experience. These answers will help patients and doctors make good decisions about the patient’s health care.
“Patient safety is the number one concern of every physician I know regardless of where surgery is performed,” South says. “Physicians doing office-based surgery are held to the highest standards by the State Board of Medical Licensure and must be nationally certified before insurers will authorize patients to use the facilities. The American College of Surgeons, the American Medical Association, the American Society of Anesthesiologists and dozens of surgical specialties diligently pursue the safest practices and set comprehensive standards for office-based surgery and anesthesia.”
There are major cost savings from doing office surgery. It costs three times more to perform surgery in a hospital than in an office-based setting.
“Most patients — and most doctors — are very happy to use outpatient facilities when they are medically appropriate and available,” South says. “In fact, many hospitals now have outpatient surgery centers in addition to hospital surgical suites because they, too, can cut costs in the outpatient setting.”
When deciding whether to have surgery in a doctor’s office as opposed to a hospital or outpatient surgery center, consider how serious the procedure is.
“There are certainly various degrees of procedures and degrees of invasiveness,” says Rachel Barron, clinical director of surgery, Mississippi Baptist Medical Center, Jackson. “Some procedures could be very safely performed in a doctor’s office, but there are also some that should only be done in a hospital. A lot of that also depends on the health of the patient pre operatively.”
A good example is that most often cataract surgeries are done either in a physician office or, most commonly, in an outpatient surgery center. But if the patient has a higher risk for adverse reactions to anesthesia, then those patients have surgery done in the hospital because of the risk.
“There are a lot of things to consider,” Barron says. “Some physician offices have personnel with advanced training and the availability of medical supplies that would certainly elevate their safety. And there are some physicians who have not taken those precautions. To say do it or don’t do it in an office depends. There are procedures that would be acceptable to do in an office, and some physicians have taken extra steps to provide appropriate care for healthy patients and can do so safely in their office.
One important thing to discuss with the physician is the contingency plan with a medical emergency. Barron recommends asking for a second opinion from another physician if there are concerns.
“And I think they should ask for a health screening prior to any surgery in the office to make sure the patient is an appropriate candidate,” Barron says.
Contact MBJ contributing writer Becky Gillette at firstname.lastname@example.org.