A recent study in the state of Florida showed a 10-fold increase in the number of deaths among patients who had surgery performed in a physician’s office instead of in an ambulatory surgical center or hospital was seen from 2000 through 2002 in Flordia. Hector Vila, M.D., Chief of anesthesiology, H. Lee Moffitt Cancer Center, University of South Florida, Tampa, and fellow researchers reported the startling results on the safety of office-based surgical procedures in the September 2003 issue of the Archives of Surgery. The study created an immediate stir, becoming a national story, with newspapers, magazines and Web sites trumpeting the dangers of office-based surgeries. Dr. Vila’s study and the ensuing media coverage, coupled with other events including high-profile deaths in California and recent 90-day moratoriums imposed by the state of Florida on office-based surgeries, energized a growing movement toward more oversight of office-based surgeries. Currently, the level of regulation and oversight varies from state to state, with only a handful of states closely monitoring offices. However, more and more legislatures are taking a hard look at this issue and results of those efforts may mean drastic changes in the way office-based surgeries are performed and who is allowed to perform them. “Many states, as well as the American Medical Association (AMA), have pushed for increasing the requirements for office surgery so that the office surgery environment mimics that of an ambulatory surgery center,” says Dr. Vila, who believes that office surgery is good for patients and surgeons when properly performed. “Basically you will have the same standard of care in an office as you would have in an ambulatory surgical center.” At the very least, dermatologists may find themselves being forced by medical licensing boards or legislatures to seek accreditation to continue to perform routine surgeries, and they must be prepared for the additional cost, equipment, staffing and paperwork that such accreditation requires. Unfortunately, many physicians feel that accreditation, while not necessarily a bad thing, may not do anything to increase patient safety, which is the real issue in the debate over office-based surgeries. The Issue of Patient Safety Brett Coldiron, M.D., a dermatologic surgeon in private practice in Cincinnati is vocal in his criticism of Dr. Vila’s findings. "I have spent a great deal of time reviewing Dr. Vila’s findings and the data simply do not support his conclusions," says Dr. Coldiron. "Many of the deaths that Dr. Vila included should not have been counted, including one that fell outside of the study’s time frame, one case that was actually performed at an ambulatory surgery center, four that were delayed deaths and would not have been reported by an ambulatory surgery center, and four deaths that were performed in offices that use only local anesthesia. Offices using only local anesthesia were not included in estimates of number for procedures performed in Dr. Vila’s calculation. This means 10 of the 13 deaths reported by Dr. Vila were not valid for comparison purposes with ambulatory surgery centers. If you eliminate these 10 deaths there is no difference in death rates between the two sites." his most adamant reactions for the end result of Dr. Vila’s study. “Unfortunately, too many people, including the public, politicians and physicians with their own agendas, now have something to hang their hats on. Dermatologists, who have a remarkable history of performing safe and effective office-based surgery, will now find ourselves fighting off efforts to restrict what we do in the office, based on what I believe to be bad science.” Dr. Coldiron is equally fervent in his call for an immediate and unequivocal response by dermatologists to the efforts that are gaining momentum around the country to place restrictions on office-based surgery. “We have to get much more involved in our medical boards and do more to inform the public and our legislatures that what we do in the office has always been safe, is safe now and will remain safe,” says Dr. Coldiron. “We cannot stand idly by and allow our profession to be painted by the same broad brush. We have the data on our side; it’s our job to educate the folks that need to be educated. And we have to do it before its too late.” Echoing Dr. Coldiron is Ronald Wheeland, M.D., Head of Dermatology at the University of Arizona College of Medicine and Chairman of the American Academy of Dermatology’s Office-Based Medicine Task Force. “Every year, dermatologists safely perform hundreds of thousands of procedures in their offices,” Dr. Wheeland says. “However, patient safety is a white hat issue with politicians and it only takes a few deaths and studies like Dr. Vila’s to get people calling for restrictions.” Dr. Wheeland also calls for dermatologists to take a more active role in the debate over patient safety and office-based surgery. In his role as chairman of the Office-Based Medicine Task Force, Dr. Wheeland has seen the problem from the inside. “More and more states are looking at imposing restrictions, and its all a reaction to perceptions, or perhaps misperceptions about patient safety,” says Dr. Wheeland. “The risks for the type of surgeries dermatologists typically perform are incredibly small, but the reality is that political bodies tend to paint in broad strokes and dermatologists could end up paying for the mistakes of others.” Dr. Wheeland reports, though, that his office has been successful in getting the real story told. “In at least three cases, we have gone to state medical boards, they have listened to our point of view and understood that additional regulation, restrictions and things, such as accreditation, will not improve patient safety one bit.” Dr. Wheeland would like to see more dermatologists become involved with their state medical boards and be more proactive in dealing with the issue of restrictions to office-based surgeries. Improving Patient Safety So what will improve patient safety? Dr. Wheeland has some clear ideas that he feels will do more to improve patient safety than any regulation or restriction. “First, we need to eliminate general anesthesia in an office setting,” Dr. Wheeland says. “So many of the problems that we are seeing would simply go away if we took that one simple step.” A second step that he recommends is to stop performing multiple procedures during a single surgical session, and especially the combination of liposuction with other procedures. “Doctors should really stop performing multiple procedures that keep a patient under anesthesia for hours, in any setting,” Dr. Wheeland says. “And combining liposuction with other procedures is really never a good idea. Again, so many of the problems would be eliminated with these simple steps, and quite frankly, the impact on physicians would be minimal.” Ken Beer, M.D., a cosmetic surgeon in private practice in West Palm Beach, Florida, is concerned about what he sees as misinformation concerning the level of surgical skills that dermatologists have and the impact on patient safety. “I think we are seeing a muddling of statistics. For instance, a recent New York Times article on the dangers of liposuction had the plastic surgery people telling the public that untrained doctors, such as dermatologists, were killing patients,” says Dr. Beer. “In reality, no patient has been killed by a dermatologist doing tumescent liposuction and almost all the patient deaths reported in that article occurred during surgeries performed by plastic surgeons or general surgeons and not dermatologists.” One organization that is pushing for improved patient safety is the Center for Medical Consumers in New York. Art Levin, the center’s director, feels that if a physician is performing surgical procedures in his or her office, than that physician’s office should be subject to many of the same requirements that surgical centers and hospitals have. “It is irrational to require a hospital or an ambulatory surgical center to be subject to strict standards and criteria and not to have the same requirements of physicians’ offices where they may be performing the same procedures. This is especially illogical in view of the fact that there is often less help at the physician’s office in the event of a medical emergency,” says Mr. Levin. “If you really want to improve patient safety, we need some type of credentialing of physicians, we need to ensure that the physician has a relationship with a local hospital so that if there is an emergency, the physician has a place to take a patient in stress, and we need to make sure that the office has in place the staff, equipment and training needed to rescue a patient who gets into trouble.” But, few dermatologists are convinced that accrediting or licensing office-based dermatologic surgeons will do much, if anything, to improve patient safety. “Dermatologists have been performing safe office-based surgeries for a long time and there really is no need to restrict those procedures because someone else with limited data argues that those surgeries may be unsafe,” says Ronald Moy, M.D., a practicing physician in private practice in Los Angeles and President of the American Society of Dermatologic Surgery (ASDS). “Getting accredited may allow you to charge more for your services, but it does nothing to address the questions of patient safety that studies like Dr. Vila’s raise. There are better, simpler steps to take, like simply eliminating multiple procedures or restricting some lengthy procedures. Those will do more to address the problem than calls for universal accreditation or licensing.” Mr. Levin does not think that a requirement to be accredited is overly burdensome for physicians and sees it as a way to improve patient safety. “In terms of the individual practitioner, what makes the most sense is that physicians need to be credentialed or privileged to do what they do in their office, so that there is peer review and oversight,” says Mr. Levin. “At the very least, we need to impose reporting requirements on physicians, especially for adverse events, because we simply do not have any empirical basis for making a decision that office-based surgeries are safe, or at least as safe as a hospital setting.” Dr Coldiron counters this argument stating that there’s no evidence that unqualified individuals are practicing in their offices because they could not obtain hospital privileges or are not properly credentialed. “The Florida data, which is the only data that releases the physician’s identities, show that 98% of the physicians involved were board certified in an appropriate specialty and 99% had hospital privileges,” he says. “What this argument usually boils down to is requiring operating room privileges, which dermatologists can never obtain because surgeons control these privileges. This is a veiled way of eliminating competition and has nothing to do with patient safety.” Dr. Beer was at one time accredited, but dropped his accreditation. “I initially sought accreditation because at the time it looked like Florida was going to require it. However, the cosmetic surgery that I do is largely liposuction and fat transfer and these are relatively low risk, and accreditation was an expense that did nothing to improve patient safety,” says Dr. Beer. “We added a small amount of equipment to get accredited, but it turns out that our office was already complying with most of the requirements so getting the accreditation did not really improve things.” Now, Dr Beer uses a certified risk management company, Barbara Dame and Associates, to monitor office procedures and help manage risk. According to Dr. Vila, data from Florida during 2002-2003 did show a decrease in the number of reported injuries and deaths from office surgery with a rise in the number of accredited offices. “This early data suggests there may be a measurable benefit to accreditation,” Dr. Vila says. (See charts.) It’s important to note that most state office surgery regulations provide for minimal regulation of offices performing superficial surgery with only local anesthesia (level I). More regulations including office accreditation are required for complex procedures done under sedation or general anesthesia (levels II and III). The Need for Reporting In the contentious debate over office-based surgery, there is at least one issue that nearly all sides agree on, and that is the need for more extensive reporting on office procedures. In most states, there are few, if any, requirements for physicians to report on office-based surgeries, regardless of the outcome. “No one knows the full story and until we have accurate data, the issue of office-based surgery and its safety will remain a controversial one,” says James Thompson, M.D., President and CEO of the Federation of State Medical Boards. “I don’t think that it is unreasonable for a state medical board to require the same level of reporting from a physician performing surgery in his or her office as is required from a hospital or a surgical center.” Many physicians agree with the need for additional reporting and see data collection as an important tool that will work to the advantage of physicians who want to continue to perform office-based surgery. “The data is on our side and we need to do all that we can to gather that data and present it to medical boards, legislature and the public,” Dr. Coldiron says. “Dermatologists have always offered safe in-office surgery and we need to be able to demonstrate that and the way to do it is to accurately report what we are doing and what the results are.” The Move Toward Accreditation While many can agree on the need for reporting, there is no better way to stir the blood in the debate over office-based surgery than to mention the word accreditation. Currently, fewer than 10% of all non-hospital surgical centers and practices are accredited, though that is likely to change since a number of states are looking at requiring accreditation for office-based surgery. Last year, it became law in Ohio that all office-based surgical practices that use conscious sedation or deeper anesthesia must be accredited by the year 2007. Regardless of what new laws may be passed, the trend toward accreditation may be gaining momentum. “More and more patients are getting actively involved in their own care and they are increasingly going to demand that their physicians have an accredited facility,” says Michael Kulczycki, Executive Director of the Office-Based Surgery Accreditation Program for the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). “In addition, both the AMA and the American College of Surgeons have endorsed guidelines for office-based surgery practices that call for office-based surgical practices to become accredited.” In addition to the program at JCAHO, other services offering accreditation for office-based surgeries include the Accreditation Association for Ambulatory Health Care (AAAHC), and the Association for the Accreditation of Ambulatory Surgery Facilities (AAAASF). “Our office-based surgery accreditation is a comprehensive 1-day survey conducted by an experienced clinician that is designed for private practices with four practitioners or less,” says Mr. Kulczycki. “What accreditation offers is a focus on the entire business processes of a practice in addition to patient safety issues. We sell nearly eight times as many of our accreditation manuals as we have practices that seek accreditation. We know that a lot of practices are adopting the standards in the manual as a way of conducting their practices.” “In terms of the profession as a whole, dermatologists need to follow the model of the American Society of Plastic Surgeons, which made it a requirement that all member practitioners either practice in a Medicare-certified setting or a facility that is accredited by one of the recognized accrediting bodies,” says Mr. Kulczycki. “Regardless of the level of surgery being performed — even laser surgeries have safety issues, such as the risk of fire and eye injury — dermatologists must take the steps necessary to ensure the safety of their patients and their staff.” However, the American Society of Plastic Surgery does not require office accreditation for members who do not use conscious sedation or general anesthesia in their offices, and very few dermatologists use conscious sedation or general anesthesia for their procedures. In addition, dermatologists cannot be accredited by AAASF because they have not completed a surgical residency as defined by the AAASF. For many physicians, especially those in smaller practices, a consideration for accreditation is the cost. “It is a common misperception that it is costly to pursue accreditation. If they are doing patient procedures where there are fewer than four patients incapacitated at one time, then the equipment requirements are extremely limited. There are no additional staffing requirements for accreditation,” says Mr. Kulczycki. “The cost of accreditation for a practice with four or fewer doctors is $3,975 for a 3-year accreditation, which covers the cost of the manual and the survey.” Dr. Wheeland disagrees with the assessment of costs for accreditation. “The fees that the accrediting services charge are just the start. It can cost up to $25,000 for a practice to prepare for and obtain accreditation, especially if you use a consulting service as many do. Beyond those costs are the ongoing costs of additional staffing, training and equipment, which virtually every practice will need. The costs, in money, time and effort, are by no means trivial.” One practice that has embraced accreditation is the Dermatology Associates of Rochester, who have been accredited by JCAHO since 2000. Ann Marie Ebling, M.S.N., nurse practitioner, drove the initial accreditation effort and the recent renewal. “Coming from a university hospital background, I saw real benefit in the accreditation process, both in terms of operational efficiency and patient safety,” Ms. Ebling says. “Our costs beyond the JCAHO fees were minimal, but it made a big difference because it standardizes everything — paperwork, charts, procedures — and I think it really reduces the chances for mistakes.” The practice performs the standard array of office cosmetic procedures, most under conscience sedation, and uses its accreditation as a selling point. “We are the only practice in the area to have accreditation,” Ms. Ebling says. “I think our patients are more comfortable with that. Because of the accreditation process, we have a plan for emergencies, a good relationship with the local hospital and even a plan with the local pharmacy that maintains a supply of prophylactic HIV medications for us.” Office-Based Versus Hospital or Surgical Center Approximately 2 million surgical procedures are performed every year in office-based settings, and that number is going to continue to climb. For many patients, the cost, the convenience and the additional feeling of privacy and confidentiality that a private physician’s office has to offer is simply too great to consider having surgery performed anywhere else. When you consider the number of office-based surgeries that are performed, it is clear that while restrictions may be imposed in the coming year, it is not very likely that the number of office-based surgeries will be reduced. “There simply is not the capacity in this country now to take all of the out-patient surgeries and put them in the hospitals,” says Phillip Williford, M.D., Associate Professor and Director of Dermatologic Surgery at Wake Forest University School of Medicine. “Nor would you want to, since many are low-risk procedures performed under local anesthesia. On the other hand, most of the recent well-publicized liposuction deaths occurred in accredited surgical centers and hospitals with board-certified plastic surgeons.” According to Dr. Williford, there is too high a level of distrust among various specialties, and too many are quick to assume that dermatologists are not qualified to do some of the surgeries that they perform. “Our dermatology residents spend at least a half day each week training on a range of surgical procedures, including a 3-month course of continuous intensive training,” says Dr. Williford. “They cannot do gall bladders, but do develop a broad range of surgical skills. They’re not learning this stuff on weekends like some would have you believe, or want to believe themselves. Despite that training, too many surgeons simply refuse to recognize the skill of dermatologic surgeons.” Dr. Williford is hopeful that the recent recognition of a procedural dermatology fellowship by the Accreditation Council for Graduate Medical Education will help start to dispel the attitude among surgeons and other specialties that dermatologists cannot perform complex surgeries. What Dermatologists Must Do Dr. Moy fears that dermatologists are not doing enough to educate lay people or their fellow medical colleagues about the true nature of the type of office-based surgical procedures that they are performing. “It’s too easy for people who want to force surgeries back into hospitals and surgical centers to point to the relatively unregulated nature of office-based surgery and say that it stands to reason that these facilities are not as safe as an accredited surgical center or a hospital.” Dr. Moy promotes the use of the term dermasurgery to differentiate what a dermatologist is doing from what other surgeons might be performing. “There are those who want to restrict the length of sedation for office-based surgeries, but certain dermasurgical procedures can take a long time, for example Mohs surgery, but it is still appropriate to do those surgeries in an office setting.” Dr. Moy sees the call for restriction on office-based surgeries as often based less on genuine concerns for patient safety and more on economic factors and protectionism. “When you have a hospital-based surgeon or anesthesiologist calling for all physicians who do office surgery to have credentials at a local hospital, and they control who gets those credentials, the potential for abuse is too high,” says Dr. Moy. Moreover, Dr. Moy is not convinced that having hospital credentials or accreditation will do anything to improve patient safety. “I like to believe that most medical professionals are thoughtful people, but even in our profession, there are individuals with agendas who take data and interpret it in a way that best supports their point of view,” says Dr. Williford. “Dermatologic surgeons are not meat hackers, as some may believe, but are highly trained practitioners.” Dr Williford cautions that dermatologists have an uphill battle in their effort to retain control over their surgical practices. “A few years ago, the National Institute of Health sponsored a conference on office-based surgery at Wake Forest to study the data that was available on office surgeries. Unfortunately, many specialties resisted participating seemingly fearing that they might have their minds changed,” Dr. Williford says. “In this debate, the level of suspicion, and even hostility, is so large that until that changes, few people will be interested in the kind of meaningful dialogue that will result in an appropriate oversight approach for the type of surgery that dermatologists routinely perform.”
What is the Future of Office-Based Surgery?
A recent study in the state of Florida showed a 10-fold increase in the number of deaths among patients who had surgery performed in a physician’s office instead of in an ambulatory surgical center or hospital was seen from 2000 through 2002 in Flordia. Hector Vila, M.D., Chief of anesthesiology, H. Lee Moffitt Cancer Center, University of South Florida, Tampa, and fellow researchers reported the startling results on the safety of office-based surgical procedures in the September 2003 issue of the Archives of Surgery. The study created an immediate stir, becoming a national story, with newspapers, magazines and Web sites trumpeting the dangers of office-based surgeries. Dr. Vila’s study and the ensuing media coverage, coupled with other events including high-profile deaths in California and recent 90-day moratoriums imposed by the state of Florida on office-based surgeries, energized a growing movement toward more oversight of office-based surgeries. Currently, the level of regulation and oversight varies from state to state, with only a handful of states closely monitoring offices. However, more and more legislatures are taking a hard look at this issue and results of those efforts may mean drastic changes in the way office-based surgeries are performed and who is allowed to perform them. “Many states, as well as the American Medical Association (AMA), have pushed for increasing the requirements for office surgery so that the office surgery environment mimics that of an ambulatory surgery center,” says Dr. Vila, who believes that office surgery is good for patients and surgeons when properly performed. “Basically you will have the same standard of care in an office as you would have in an ambulatory surgical center.” At the very least, dermatologists may find themselves being forced by medical licensing boards or legislatures to seek accreditation to continue to perform routine surgeries, and they must be prepared for the additional cost, equipment, staffing and paperwork that such accreditation requires. Unfortunately, many physicians feel that accreditation, while not necessarily a bad thing, may not do anything to increase patient safety, which is the real issue in the debate over office-based surgeries. The Issue of Patient Safety Brett Coldiron, M.D., a dermatologic surgeon in private practice in Cincinnati is vocal in his criticism of Dr. Vila’s findings. "I have spent a great deal of time reviewing Dr. Vila’s findings and the data simply do not support his conclusions," says Dr. Coldiron. "Many of the deaths that Dr. Vila included should not have been counted, including one that fell outside of the study’s time frame, one case that was actually performed at an ambulatory surgery center, four that were delayed deaths and would not have been reported by an ambulatory surgery center, and four deaths that were performed in offices that use only local anesthesia. Offices using only local anesthesia were not included in estimates of number for procedures performed in Dr. Vila’s calculation. This means 10 of the 13 deaths reported by Dr. Vila were not valid for comparison purposes with ambulatory surgery centers. If you eliminate these 10 deaths there is no difference in death rates between the two sites." his most adamant reactions for the end result of Dr. Vila’s study. “Unfortunately, too many people, including the public, politicians and physicians with their own agendas, now have something to hang their hats on. Dermatologists, who have a remarkable history of performing safe and effective office-based surgery, will now find ourselves fighting off efforts to restrict what we do in the office, based on what I believe to be bad science.” Dr. Coldiron is equally fervent in his call for an immediate and unequivocal response by dermatologists to the efforts that are gaining momentum around the country to place restrictions on office-based surgery. “We have to get much more involved in our medical boards and do more to inform the public and our legislatures that what we do in the office has always been safe, is safe now and will remain safe,” says Dr. Coldiron. “We cannot stand idly by and allow our profession to be painted by the same broad brush. We have the data on our side; it’s our job to educate the folks that need to be educated. And we have to do it before its too late.” Echoing Dr. Coldiron is Ronald Wheeland, M.D., Head of Dermatology at the University of Arizona College of Medicine and Chairman of the American Academy of Dermatology’s Office-Based Medicine Task Force. “Every year, dermatologists safely perform hundreds of thousands of procedures in their offices,” Dr. Wheeland says. “However, patient safety is a white hat issue with politicians and it only takes a few deaths and studies like Dr. Vila’s to get people calling for restrictions.” Dr. Wheeland also calls for dermatologists to take a more active role in the debate over patient safety and office-based surgery. In his role as chairman of the Office-Based Medicine Task Force, Dr. Wheeland has seen the problem from the inside. “More and more states are looking at imposing restrictions, and its all a reaction to perceptions, or perhaps misperceptions about patient safety,” says Dr. Wheeland. “The risks for the type of surgeries dermatologists typically perform are incredibly small, but the reality is that political bodies tend to paint in broad strokes and dermatologists could end up paying for the mistakes of others.” Dr. Wheeland reports, though, that his office has been successful in getting the real story told. “In at least three cases, we have gone to state medical boards, they have listened to our point of view and understood that additional regulation, restrictions and things, such as accreditation, will not improve patient safety one bit.” Dr. Wheeland would like to see more dermatologists become involved with their state medical boards and be more proactive in dealing with the issue of restrictions to office-based surgeries. Improving Patient Safety So what will improve patient safety? Dr. Wheeland has some clear ideas that he feels will do more to improve patient safety than any regulation or restriction. “First, we need to eliminate general anesthesia in an office setting,” Dr. Wheeland says. “So many of the problems that we are seeing would simply go away if we took that one simple step.” A second step that he recommends is to stop performing multiple procedures during a single surgical session, and especially the combination of liposuction with other procedures. “Doctors should really stop performing multiple procedures that keep a patient under anesthesia for hours, in any setting,” Dr. Wheeland says. “And combining liposuction with other procedures is really never a good idea. Again, so many of the problems would be eliminated with these simple steps, and quite frankly, the impact on physicians would be minimal.” Ken Beer, M.D., a cosmetic surgeon in private practice in West Palm Beach, Florida, is concerned about what he sees as misinformation concerning the level of surgical skills that dermatologists have and the impact on patient safety. “I think we are seeing a muddling of statistics. For instance, a recent New York Times article on the dangers of liposuction had the plastic surgery people telling the public that untrained doctors, such as dermatologists, were killing patients,” says Dr. Beer. “In reality, no patient has been killed by a dermatologist doing tumescent liposuction and almost all the patient deaths reported in that article occurred during surgeries performed by plastic surgeons or general surgeons and not dermatologists.” One organization that is pushing for improved patient safety is the Center for Medical Consumers in New York. Art Levin, the center’s director, feels that if a physician is performing surgical procedures in his or her office, than that physician’s office should be subject to many of the same requirements that surgical centers and hospitals have. “It is irrational to require a hospital or an ambulatory surgical center to be subject to strict standards and criteria and not to have the same requirements of physicians’ offices where they may be performing the same procedures. This is especially illogical in view of the fact that there is often less help at the physician’s office in the event of a medical emergency,” says Mr. Levin. “If you really want to improve patient safety, we need some type of credentialing of physicians, we need to ensure that the physician has a relationship with a local hospital so that if there is an emergency, the physician has a place to take a patient in stress, and we need to make sure that the office has in place the staff, equipment and training needed to rescue a patient who gets into trouble.” But, few dermatologists are convinced that accrediting or licensing office-based dermatologic surgeons will do much, if anything, to improve patient safety. “Dermatologists have been performing safe office-based surgeries for a long time and there really is no need to restrict those procedures because someone else with limited data argues that those surgeries may be unsafe,” says Ronald Moy, M.D., a practicing physician in private practice in Los Angeles and President of the American Society of Dermatologic Surgery (ASDS). “Getting accredited may allow you to charge more for your services, but it does nothing to address the questions of patient safety that studies like Dr. Vila’s raise. There are better, simpler steps to take, like simply eliminating multiple procedures or restricting some lengthy procedures. Those will do more to address the problem than calls for universal accreditation or licensing.” Mr. Levin does not think that a requirement to be accredited is overly burdensome for physicians and sees it as a way to improve patient safety. “In terms of the individual practitioner, what makes the most sense is that physicians need to be credentialed or privileged to do what they do in their office, so that there is peer review and oversight,” says Mr. Levin. “At the very least, we need to impose reporting requirements on physicians, especially for adverse events, because we simply do not have any empirical basis for making a decision that office-based surgeries are safe, or at least as safe as a hospital setting.” Dr Coldiron counters this argument stating that there’s no evidence that unqualified individuals are practicing in their offices because they could not obtain hospital privileges or are not properly credentialed. “The Florida data, which is the only data that releases the physician’s identities, show that 98% of the physicians involved were board certified in an appropriate specialty and 99% had hospital privileges,” he says. “What this argument usually boils down to is requiring operating room privileges, which dermatologists can never obtain because surgeons control these privileges. This is a veiled way of eliminating competition and has nothing to do with patient safety.” Dr. Beer was at one time accredited, but dropped his accreditation. “I initially sought accreditation because at the time it looked like Florida was going to require it. However, the cosmetic surgery that I do is largely liposuction and fat transfer and these are relatively low risk, and accreditation was an expense that did nothing to improve patient safety,” says Dr. Beer. “We added a small amount of equipment to get accredited, but it turns out that our office was already complying with most of the requirements so getting the accreditation did not really improve things.” Now, Dr Beer uses a certified risk management company, Barbara Dame and Associates, to monitor office procedures and help manage risk. According to Dr. Vila, data from Florida during 2002-2003 did show a decrease in the number of reported injuries and deaths from office surgery with a rise in the number of accredited offices. “This early data suggests there may be a measurable benefit to accreditation,” Dr. Vila says. (See charts.) It’s important to note that most state office surgery regulations provide for minimal regulation of offices performing superficial surgery with only local anesthesia (level I). More regulations including office accreditation are required for complex procedures done under sedation or general anesthesia (levels II and III). The Need for Reporting In the contentious debate over office-based surgery, there is at least one issue that nearly all sides agree on, and that is the need for more extensive reporting on office procedures. In most states, there are few, if any, requirements for physicians to report on office-based surgeries, regardless of the outcome. “No one knows the full story and until we have accurate data, the issue of office-based surgery and its safety will remain a controversial one,” says James Thompson, M.D., President and CEO of the Federation of State Medical Boards. “I don’t think that it is unreasonable for a state medical board to require the same level of reporting from a physician performing surgery in his or her office as is required from a hospital or a surgical center.” Many physicians agree with the need for additional reporting and see data collection as an important tool that will work to the advantage of physicians who want to continue to perform office-based surgery. “The data is on our side and we need to do all that we can to gather that data and present it to medical boards, legislature and the public,” Dr. Coldiron says. “Dermatologists have always offered safe in-office surgery and we need to be able to demonstrate that and the way to do it is to accurately report what we are doing and what the results are.” The Move Toward Accreditation While many can agree on the need for reporting, there is no better way to stir the blood in the debate over office-based surgery than to mention the word accreditation. Currently, fewer than 10% of all non-hospital surgical centers and practices are accredited, though that is likely to change since a number of states are looking at requiring accreditation for office-based surgery. Last year, it became law in Ohio that all office-based surgical practices that use conscious sedation or deeper anesthesia must be accredited by the year 2007. Regardless of what new laws may be passed, the trend toward accreditation may be gaining momentum. “More and more patients are getting actively involved in their own care and they are increasingly going to demand that their physicians have an accredited facility,” says Michael Kulczycki, Executive Director of the Office-Based Surgery Accreditation Program for the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). “In addition, both the AMA and the American College of Surgeons have endorsed guidelines for office-based surgery practices that call for office-based surgical practices to become accredited.” In addition to the program at JCAHO, other services offering accreditation for office-based surgeries include the Accreditation Association for Ambulatory Health Care (AAAHC), and the Association for the Accreditation of Ambulatory Surgery Facilities (AAAASF). “Our office-based surgery accreditation is a comprehensive 1-day survey conducted by an experienced clinician that is designed for private practices with four practitioners or less,” says Mr. Kulczycki. “What accreditation offers is a focus on the entire business processes of a practice in addition to patient safety issues. We sell nearly eight times as many of our accreditation manuals as we have practices that seek accreditation. We know that a lot of practices are adopting the standards in the manual as a way of conducting their practices.” “In terms of the profession as a whole, dermatologists need to follow the model of the American Society of Plastic Surgeons, which made it a requirement that all member practitioners either practice in a Medicare-certified setting or a facility that is accredited by one of the recognized accrediting bodies,” says Mr. Kulczycki. “Regardless of the level of surgery being performed — even laser surgeries have safety issues, such as the risk of fire and eye injury — dermatologists must take the steps necessary to ensure the safety of their patients and their staff.” However, the American Society of Plastic Surgery does not require office accreditation for members who do not use conscious sedation or general anesthesia in their offices, and very few dermatologists use conscious sedation or general anesthesia for their procedures. In addition, dermatologists cannot be accredited by AAASF because they have not completed a surgical residency as defined by the AAASF. For many physicians, especially those in smaller practices, a consideration for accreditation is the cost. “It is a common misperception that it is costly to pursue accreditation. If they are doing patient procedures where there are fewer than four patients incapacitated at one time, then the equipment requirements are extremely limited. There are no additional staffing requirements for accreditation,” says Mr. Kulczycki. “The cost of accreditation for a practice with four or fewer doctors is $3,975 for a 3-year accreditation, which covers the cost of the manual and the survey.” Dr. Wheeland disagrees with the assessment of costs for accreditation. “The fees that the accrediting services charge are just the start. It can cost up to $25,000 for a practice to prepare for and obtain accreditation, especially if you use a consulting service as many do. Beyond those costs are the ongoing costs of additional staffing, training and equipment, which virtually every practice will need. The costs, in money, time and effort, are by no means trivial.” One practice that has embraced accreditation is the Dermatology Associates of Rochester, who have been accredited by JCAHO since 2000. Ann Marie Ebling, M.S.N., nurse practitioner, drove the initial accreditation effort and the recent renewal. “Coming from a university hospital background, I saw real benefit in the accreditation process, both in terms of operational efficiency and patient safety,” Ms. Ebling says. “Our costs beyond the JCAHO fees were minimal, but it made a big difference because it standardizes everything — paperwork, charts, procedures — and I think it really reduces the chances for mistakes.” The practice performs the standard array of office cosmetic procedures, most under conscience sedation, and uses its accreditation as a selling point. “We are the only practice in the area to have accreditation,” Ms. Ebling says. “I think our patients are more comfortable with that. Because of the accreditation process, we have a plan for emergencies, a good relationship with the local hospital and even a plan with the local pharmacy that maintains a supply of prophylactic HIV medications for us.” Office-Based Versus Hospital or Surgical Center Approximately 2 million surgical procedures are performed every year in office-based settings, and that number is going to continue to climb. For many patients, the cost, the convenience and the additional feeling of privacy and confidentiality that a private physician’s office has to offer is simply too great to consider having surgery performed anywhere else. When you consider the number of office-based surgeries that are performed, it is clear that while restrictions may be imposed in the coming year, it is not very likely that the number of office-based surgeries will be reduced. “There simply is not the capacity in this country now to take all of the out-patient surgeries and put them in the hospitals,” says Phillip Williford, M.D., Associate Professor and Director of Dermatologic Surgery at Wake Forest University School of Medicine. “Nor would you want to, since many are low-risk procedures performed under local anesthesia. On the other hand, most of the recent well-publicized liposuction deaths occurred in accredited surgical centers and hospitals with board-certified plastic surgeons.” According to Dr. Williford, there is too high a level of distrust among various specialties, and too many are quick to assume that dermatologists are not qualified to do some of the surgeries that they perform. “Our dermatology residents spend at least a half day each week training on a range of surgical procedures, including a 3-month course of continuous intensive training,” says Dr. Williford. “They cannot do gall bladders, but do develop a broad range of surgical skills. They’re not learning this stuff on weekends like some would have you believe, or want to believe themselves. Despite that training, too many surgeons simply refuse to recognize the skill of dermatologic surgeons.” Dr. Williford is hopeful that the recent recognition of a procedural dermatology fellowship by the Accreditation Council for Graduate Medical Education will help start to dispel the attitude among surgeons and other specialties that dermatologists cannot perform complex surgeries. What Dermatologists Must Do Dr. Moy fears that dermatologists are not doing enough to educate lay people or their fellow medical colleagues about the true nature of the type of office-based surgical procedures that they are performing. “It’s too easy for people who want to force surgeries back into hospitals and surgical centers to point to the relatively unregulated nature of office-based surgery and say that it stands to reason that these facilities are not as safe as an accredited surgical center or a hospital.” Dr. Moy promotes the use of the term dermasurgery to differentiate what a dermatologist is doing from what other surgeons might be performing. “There are those who want to restrict the length of sedation for office-based surgeries, but certain dermasurgical procedures can take a long time, for example Mohs surgery, but it is still appropriate to do those surgeries in an office setting.” Dr. Moy sees the call for restriction on office-based surgeries as often based less on genuine concerns for patient safety and more on economic factors and protectionism. “When you have a hospital-based surgeon or anesthesiologist calling for all physicians who do office surgery to have credentials at a local hospital, and they control who gets those credentials, the potential for abuse is too high,” says Dr. Moy. Moreover, Dr. Moy is not convinced that having hospital credentials or accreditation will do anything to improve patient safety. “I like to believe that most medical professionals are thoughtful people, but even in our profession, there are individuals with agendas who take data and interpret it in a way that best supports their point of view,” says Dr. Williford. “Dermatologic surgeons are not meat hackers, as some may believe, but are highly trained practitioners.” Dr Williford cautions that dermatologists have an uphill battle in their effort to retain control over their surgical practices. “A few years ago, the National Institute of Health sponsored a conference on office-based surgery at Wake Forest to study the data that was available on office surgeries. Unfortunately, many specialties resisted participating seemingly fearing that they might have their minds changed,” Dr. Williford says. “In this debate, the level of suspicion, and even hostility, is so large that until that changes, few people will be interested in the kind of meaningful dialogue that will result in an appropriate oversight approach for the type of surgery that dermatologists routinely perform.”
A recent study in the state of Florida showed a 10-fold increase in the number of deaths among patients who had surgery performed in a physician’s office instead of in an ambulatory surgical center or hospital was seen from 2000 through 2002 in Flordia. Hector Vila, M.D., Chief of anesthesiology, H. Lee Moffitt Cancer Center, University of South Florida, Tampa, and fellow researchers reported the startling results on the safety of office-based surgical procedures in the September 2003 issue of the Archives of Surgery. The study created an immediate stir, becoming a national story, with newspapers, magazines and Web sites trumpeting the dangers of office-based surgeries. Dr. Vila’s study and the ensuing media coverage, coupled with other events including high-profile deaths in California and recent 90-day moratoriums imposed by the state of Florida on office-based surgeries, energized a growing movement toward more oversight of office-based surgeries. Currently, the level of regulation and oversight varies from state to state, with only a handful of states closely monitoring offices. However, more and more legislatures are taking a hard look at this issue and results of those efforts may mean drastic changes in the way office-based surgeries are performed and who is allowed to perform them. “Many states, as well as the American Medical Association (AMA), have pushed for increasing the requirements for office surgery so that the office surgery environment mimics that of an ambulatory surgery center,” says Dr. Vila, who believes that office surgery is good for patients and surgeons when properly performed. “Basically you will have the same standard of care in an office as you would have in an ambulatory surgical center.” At the very least, dermatologists may find themselves being forced by medical licensing boards or legislatures to seek accreditation to continue to perform routine surgeries, and they must be prepared for the additional cost, equipment, staffing and paperwork that such accreditation requires. Unfortunately, many physicians feel that accreditation, while not necessarily a bad thing, may not do anything to increase patient safety, which is the real issue in the debate over office-based surgeries. The Issue of Patient Safety Brett Coldiron, M.D., a dermatologic surgeon in private practice in Cincinnati is vocal in his criticism of Dr. Vila’s findings. "I have spent a great deal of time reviewing Dr. Vila’s findings and the data simply do not support his conclusions," says Dr. Coldiron. "Many of the deaths that Dr. Vila included should not have been counted, including one that fell outside of the study’s time frame, one case that was actually performed at an ambulatory surgery center, four that were delayed deaths and would not have been reported by an ambulatory surgery center, and four deaths that were performed in offices that use only local anesthesia. Offices using only local anesthesia were not included in estimates of number for procedures performed in Dr. Vila’s calculation. This means 10 of the 13 deaths reported by Dr. Vila were not valid for comparison purposes with ambulatory surgery centers. If you eliminate these 10 deaths there is no difference in death rates between the two sites." his most adamant reactions for the end result of Dr. Vila’s study. “Unfortunately, too many people, including the public, politicians and physicians with their own agendas, now have something to hang their hats on. Dermatologists, who have a remarkable history of performing safe and effective office-based surgery, will now find ourselves fighting off efforts to restrict what we do in the office, based on what I believe to be bad science.” Dr. Coldiron is equally fervent in his call for an immediate and unequivocal response by dermatologists to the efforts that are gaining momentum around the country to place restrictions on office-based surgery. “We have to get much more involved in our medical boards and do more to inform the public and our legislatures that what we do in the office has always been safe, is safe now and will remain safe,” says Dr. Coldiron. “We cannot stand idly by and allow our profession to be painted by the same broad brush. We have the data on our side; it’s our job to educate the folks that need to be educated. And we have to do it before its too late.” Echoing Dr. Coldiron is Ronald Wheeland, M.D., Head of Dermatology at the University of Arizona College of Medicine and Chairman of the American Academy of Dermatology’s Office-Based Medicine Task Force. “Every year, dermatologists safely perform hundreds of thousands of procedures in their offices,” Dr. Wheeland says. “However, patient safety is a white hat issue with politicians and it only takes a few deaths and studies like Dr. Vila’s to get people calling for restrictions.” Dr. Wheeland also calls for dermatologists to take a more active role in the debate over patient safety and office-based surgery. In his role as chairman of the Office-Based Medicine Task Force, Dr. Wheeland has seen the problem from the inside. “More and more states are looking at imposing restrictions, and its all a reaction to perceptions, or perhaps misperceptions about patient safety,” says Dr. Wheeland. “The risks for the type of surgeries dermatologists typically perform are incredibly small, but the reality is that political bodies tend to paint in broad strokes and dermatologists could end up paying for the mistakes of others.” Dr. Wheeland reports, though, that his office has been successful in getting the real story told. “In at least three cases, we have gone to state medical boards, they have listened to our point of view and understood that additional regulation, restrictions and things, such as accreditation, will not improve patient safety one bit.” Dr. Wheeland would like to see more dermatologists become involved with their state medical boards and be more proactive in dealing with the issue of restrictions to office-based surgeries. Improving Patient Safety So what will improve patient safety? Dr. Wheeland has some clear ideas that he feels will do more to improve patient safety than any regulation or restriction. “First, we need to eliminate general anesthesia in an office setting,” Dr. Wheeland says. “So many of the problems that we are seeing would simply go away if we took that one simple step.” A second step that he recommends is to stop performing multiple procedures during a single surgical session, and especially the combination of liposuction with other procedures. “Doctors should really stop performing multiple procedures that keep a patient under anesthesia for hours, in any setting,” Dr. Wheeland says. “And combining liposuction with other procedures is really never a good idea. Again, so many of the problems would be eliminated with these simple steps, and quite frankly, the impact on physicians would be minimal.” Ken Beer, M.D., a cosmetic surgeon in private practice in West Palm Beach, Florida, is concerned about what he sees as misinformation concerning the level of surgical skills that dermatologists have and the impact on patient safety. “I think we are seeing a muddling of statistics. For instance, a recent New York Times article on the dangers of liposuction had the plastic surgery people telling the public that untrained doctors, such as dermatologists, were killing patients,” says Dr. Beer. “In reality, no patient has been killed by a dermatologist doing tumescent liposuction and almost all the patient deaths reported in that article occurred during surgeries performed by plastic surgeons or general surgeons and not dermatologists.” One organization that is pushing for improved patient safety is the Center for Medical Consumers in New York. Art Levin, the center’s director, feels that if a physician is performing surgical procedures in his or her office, than that physician’s office should be subject to many of the same requirements that surgical centers and hospitals have. “It is irrational to require a hospital or an ambulatory surgical center to be subject to strict standards and criteria and not to have the same requirements of physicians’ offices where they may be performing the same procedures. This is especially illogical in view of the fact that there is often less help at the physician’s office in the event of a medical emergency,” says Mr. Levin. “If you really want to improve patient safety, we need some type of credentialing of physicians, we need to ensure that the physician has a relationship with a local hospital so that if there is an emergency, the physician has a place to take a patient in stress, and we need to make sure that the office has in place the staff, equipment and training needed to rescue a patient who gets into trouble.” But, few dermatologists are convinced that accrediting or licensing office-based dermatologic surgeons will do much, if anything, to improve patient safety. “Dermatologists have been performing safe office-based surgeries for a long time and there really is no need to restrict those procedures because someone else with limited data argues that those surgeries may be unsafe,” says Ronald Moy, M.D., a practicing physician in private practice in Los Angeles and President of the American Society of Dermatologic Surgery (ASDS). “Getting accredited may allow you to charge more for your services, but it does nothing to address the questions of patient safety that studies like Dr. Vila’s raise. There are better, simpler steps to take, like simply eliminating multiple procedures or restricting some lengthy procedures. Those will do more to address the problem than calls for universal accreditation or licensing.” Mr. Levin does not think that a requirement to be accredited is overly burdensome for physicians and sees it as a way to improve patient safety. “In terms of the individual practitioner, what makes the most sense is that physicians need to be credentialed or privileged to do what they do in their office, so that there is peer review and oversight,” says Mr. Levin. “At the very least, we need to impose reporting requirements on physicians, especially for adverse events, because we simply do not have any empirical basis for making a decision that office-based surgeries are safe, or at least as safe as a hospital setting.” Dr Coldiron counters this argument stating that there’s no evidence that unqualified individuals are practicing in their offices because they could not obtain hospital privileges or are not properly credentialed. “The Florida data, which is the only data that releases the physician’s identities, show that 98% of the physicians involved were board certified in an appropriate specialty and 99% had hospital privileges,” he says. “What this argument usually boils down to is requiring operating room privileges, which dermatologists can never obtain because surgeons control these privileges. This is a veiled way of eliminating competition and has nothing to do with patient safety.” Dr. Beer was at one time accredited, but dropped his accreditation. “I initially sought accreditation because at the time it looked like Florida was going to require it. However, the cosmetic surgery that I do is largely liposuction and fat transfer and these are relatively low risk, and accreditation was an expense that did nothing to improve patient safety,” says Dr. Beer. “We added a small amount of equipment to get accredited, but it turns out that our office was already complying with most of the requirements so getting the accreditation did not really improve things.” Now, Dr Beer uses a certified risk management company, Barbara Dame and Associates, to monitor office procedures and help manage risk. According to Dr. Vila, data from Florida during 2002-2003 did show a decrease in the number of reported injuries and deaths from office surgery with a rise in the number of accredited offices. “This early data suggests there may be a measurable benefit to accreditation,” Dr. Vila says. (See charts.) It’s important to note that most state office surgery regulations provide for minimal regulation of offices performing superficial surgery with only local anesthesia (level I). More regulations including office accreditation are required for complex procedures done under sedation or general anesthesia (levels II and III). The Need for Reporting In the contentious debate over office-based surgery, there is at least one issue that nearly all sides agree on, and that is the need for more extensive reporting on office procedures. In most states, there are few, if any, requirements for physicians to report on office-based surgeries, regardless of the outcome. “No one knows the full story and until we have accurate data, the issue of office-based surgery and its safety will remain a controversial one,” says James Thompson, M.D., President and CEO of the Federation of State Medical Boards. “I don’t think that it is unreasonable for a state medical board to require the same level of reporting from a physician performing surgery in his or her office as is required from a hospital or a surgical center.” Many physicians agree with the need for additional reporting and see data collection as an important tool that will work to the advantage of physicians who want to continue to perform office-based surgery. “The data is on our side and we need to do all that we can to gather that data and present it to medical boards, legislature and the public,” Dr. Coldiron says. “Dermatologists have always offered safe in-office surgery and we need to be able to demonstrate that and the way to do it is to accurately report what we are doing and what the results are.” The Move Toward Accreditation While many can agree on the need for reporting, there is no better way to stir the blood in the debate over office-based surgery than to mention the word accreditation. Currently, fewer than 10% of all non-hospital surgical centers and practices are accredited, though that is likely to change since a number of states are looking at requiring accreditation for office-based surgery. Last year, it became law in Ohio that all office-based surgical practices that use conscious sedation or deeper anesthesia must be accredited by the year 2007. Regardless of what new laws may be passed, the trend toward accreditation may be gaining momentum. “More and more patients are getting actively involved in their own care and they are increasingly going to demand that their physicians have an accredited facility,” says Michael Kulczycki, Executive Director of the Office-Based Surgery Accreditation Program for the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). “In addition, both the AMA and the American College of Surgeons have endorsed guidelines for office-based surgery practices that call for office-based surgical practices to become accredited.” In addition to the program at JCAHO, other services offering accreditation for office-based surgeries include the Accreditation Association for Ambulatory Health Care (AAAHC), and the Association for the Accreditation of Ambulatory Surgery Facilities (AAAASF). “Our office-based surgery accreditation is a comprehensive 1-day survey conducted by an experienced clinician that is designed for private practices with four practitioners or less,” says Mr. Kulczycki. “What accreditation offers is a focus on the entire business processes of a practice in addition to patient safety issues. We sell nearly eight times as many of our accreditation manuals as we have practices that seek accreditation. We know that a lot of practices are adopting the standards in the manual as a way of conducting their practices.” “In terms of the profession as a whole, dermatologists need to follow the model of the American Society of Plastic Surgeons, which made it a requirement that all member practitioners either practice in a Medicare-certified setting or a facility that is accredited by one of the recognized accrediting bodies,” says Mr. Kulczycki. “Regardless of the level of surgery being performed — even laser surgeries have safety issues, such as the risk of fire and eye injury — dermatologists must take the steps necessary to ensure the safety of their patients and their staff.” However, the American Society of Plastic Surgery does not require office accreditation for members who do not use conscious sedation or general anesthesia in their offices, and very few dermatologists use conscious sedation or general anesthesia for their procedures. In addition, dermatologists cannot be accredited by AAASF because they have not completed a surgical residency as defined by the AAASF. For many physicians, especially those in smaller practices, a consideration for accreditation is the cost. “It is a common misperception that it is costly to pursue accreditation. If they are doing patient procedures where there are fewer than four patients incapacitated at one time, then the equipment requirements are extremely limited. There are no additional staffing requirements for accreditation,” says Mr. Kulczycki. “The cost of accreditation for a practice with four or fewer doctors is $3,975 for a 3-year accreditation, which covers the cost of the manual and the survey.” Dr. Wheeland disagrees with the assessment of costs for accreditation. “The fees that the accrediting services charge are just the start. It can cost up to $25,000 for a practice to prepare for and obtain accreditation, especially if you use a consulting service as many do. Beyond those costs are the ongoing costs of additional staffing, training and equipment, which virtually every practice will need. The costs, in money, time and effort, are by no means trivial.” One practice that has embraced accreditation is the Dermatology Associates of Rochester, who have been accredited by JCAHO since 2000. Ann Marie Ebling, M.S.N., nurse practitioner, drove the initial accreditation effort and the recent renewal. “Coming from a university hospital background, I saw real benefit in the accreditation process, both in terms of operational efficiency and patient safety,” Ms. Ebling says. “Our costs beyond the JCAHO fees were minimal, but it made a big difference because it standardizes everything — paperwork, charts, procedures — and I think it really reduces the chances for mistakes.” The practice performs the standard array of office cosmetic procedures, most under conscience sedation, and uses its accreditation as a selling point. “We are the only practice in the area to have accreditation,” Ms. Ebling says. “I think our patients are more comfortable with that. Because of the accreditation process, we have a plan for emergencies, a good relationship with the local hospital and even a plan with the local pharmacy that maintains a supply of prophylactic HIV medications for us.” Office-Based Versus Hospital or Surgical Center Approximately 2 million surgical procedures are performed every year in office-based settings, and that number is going to continue to climb. For many patients, the cost, the convenience and the additional feeling of privacy and confidentiality that a private physician’s office has to offer is simply too great to consider having surgery performed anywhere else. When you consider the number of office-based surgeries that are performed, it is clear that while restrictions may be imposed in the coming year, it is not very likely that the number of office-based surgeries will be reduced. “There simply is not the capacity in this country now to take all of the out-patient surgeries and put them in the hospitals,” says Phillip Williford, M.D., Associate Professor and Director of Dermatologic Surgery at Wake Forest University School of Medicine. “Nor would you want to, since many are low-risk procedures performed under local anesthesia. On the other hand, most of the recent well-publicized liposuction deaths occurred in accredited surgical centers and hospitals with board-certified plastic surgeons.” According to Dr. Williford, there is too high a level of distrust among various specialties, and too many are quick to assume that dermatologists are not qualified to do some of the surgeries that they perform. “Our dermatology residents spend at least a half day each week training on a range of surgical procedures, including a 3-month course of continuous intensive training,” says Dr. Williford. “They cannot do gall bladders, but do develop a broad range of surgical skills. They’re not learning this stuff on weekends like some would have you believe, or want to believe themselves. Despite that training, too many surgeons simply refuse to recognize the skill of dermatologic surgeons.” Dr. Williford is hopeful that the recent recognition of a procedural dermatology fellowship by the Accreditation Council for Graduate Medical Education will help start to dispel the attitude among surgeons and other specialties that dermatologists cannot perform complex surgeries. What Dermatologists Must Do Dr. Moy fears that dermatologists are not doing enough to educate lay people or their fellow medical colleagues about the true nature of the type of office-based surgical procedures that they are performing. “It’s too easy for people who want to force surgeries back into hospitals and surgical centers to point to the relatively unregulated nature of office-based surgery and say that it stands to reason that these facilities are not as safe as an accredited surgical center or a hospital.” Dr. Moy promotes the use of the term dermasurgery to differentiate what a dermatologist is doing from what other surgeons might be performing. “There are those who want to restrict the length of sedation for office-based surgeries, but certain dermasurgical procedures can take a long time, for example Mohs surgery, but it is still appropriate to do those surgeries in an office setting.” Dr. Moy sees the call for restriction on office-based surgeries as often based less on genuine concerns for patient safety and more on economic factors and protectionism. “When you have a hospital-based surgeon or anesthesiologist calling for all physicians who do office surgery to have credentials at a local hospital, and they control who gets those credentials, the potential for abuse is too high,” says Dr. Moy. Moreover, Dr. Moy is not convinced that having hospital credentials or accreditation will do anything to improve patient safety. “I like to believe that most medical professionals are thoughtful people, but even in our profession, there are individuals with agendas who take data and interpret it in a way that best supports their point of view,” says Dr. Williford. “Dermatologic surgeons are not meat hackers, as some may believe, but are highly trained practitioners.” Dr Williford cautions that dermatologists have an uphill battle in their effort to retain control over their surgical practices. “A few years ago, the National Institute of Health sponsored a conference on office-based surgery at Wake Forest to study the data that was available on office surgeries. Unfortunately, many specialties resisted participating seemingly fearing that they might have their minds changed,” Dr. Williford says. “In this debate, the level of suspicion, and even hostility, is so large that until that changes, few people will be interested in the kind of meaningful dialogue that will result in an appropriate oversight approach for the type of surgery that dermatologists routinely perform.”
