For the first 22 years of my career as a plastic surgeon, I performed all surgeries at the local hospital. I had access to a dedicated operating room and staff five days a week, 52 weeks a year.
Then, in the late 1990s, the hospital went through a merger and the tide started to change. The new administration would not guarantee access to the operating room or staff. I was no longer able to set my own fees for elective surgeries. With the hospital putting a price tag on these procedures, I worried about being priced out of the market with prospective patients shopping for — and getting — the same services elsewhere for less money.
At the same time, I had been reading predictions about the growth of outpatient surgery. The outpatient surgery market was already exploding, and prognosticators were predicting that more surgeries would migrate to ambulatory settings. In 2005, the total number of outpatient surgeries in the United States was expected to hit approximately 40 million, of which 20 million would be performed in the hospital outpatient department and the other 20 million would be equally divided between ambulatory surgery centers and physician offices.Becoming office-based
Serendipitously, as performing surgery in a hospital setting became less appealing and in-office procedures seemingly more intriguing, space in the building where my practice was located opened up.
I decided to open up an office-based cosmetic surgery practice. Although I felt that this was the right career move, it was not an easy decision, as it came with a number of worries that I never had to consider before. For example, I now had to fret over office space configuration, equipment, supplies and staff.
Although much of this was new to me, there was only one concern that stopped me cold in my tracks: the anesthesia challenge. I wanted to make sure that I could provide the highest level of anesthesia quality to my patients in a cost-effective manner. But as I considered my options, I worried that meeting this goal might not be possible in the office setting — and could be what would ultimately sink my office-based cosmetic surgery practice aspirations.
My first thought? I needed to tap the expertise of the anesthesiologists who I had worked with at the hospital for the past two decades. Although these doctors — many of whom were my friends and were interested in working in the outpatient arena — had proved themselves time and again in the hospital setting, I had my reservations.
First, I realized that a different orientation was required to deliver anesthesia in the outpatient setting. I wanted anesthesiologists:
In the hospital setting, anesthesiologists typically have limited involvement in the pre-operative preparations and the leave right after the surgery, as the recovery room personnel monitor patients' recoveries. And, the anesthesiologists usually do not have a personal stake in the efficiency of the operating room suite.
Most importantly, though, I was concerned with patient safety. And, while the hospital anesthesiologists were certainly qualified, I worried that some of them just might not have the panache to handle emergencies without the many common back-up resources available in hospitals, including a bevy of other anesthesiologists and emergency medicine specialists. In essence, I needed an anesthesiology provider who was thoroughly trained in outpatient anesthesiology and could single-handedly handle any emergency situations.
My second thought? Hiring certified registered nurse anesthetists (CRNAs) into my practice. Although I had worked with many CRNAs in the hospital setting and had confidence in their skills and abilities, using one in the office setting brought marketing and legal concerns.
First off, my practice serves highly affluent patients. As such, I thought that most of my patients would balk when told that a nurse — not a doctor — would administer their anesthesia. So, using CRNAs might hurt me when trying to market my elective cosmetic services, which accounts for the lion's share of my business.