As interest in plastic surgery grows, so do the patient’s options in the various surgical methods and techniques offered by their doctors. Unfortunately, not all methods are in the patient’s best interest, even when it comes to your anesthesia. Today, I sat down with Dr. Soto to get a better understanding of why some doctors are apparently disregarding patient safety by promoting awake, in office plastic surgery options for patients.
Q: “Dr. Soto, I wanted to talk to you about how some patients believe that being awake with local anesthesia for plastic surgery is safer than being under general anesthesia. What do you tell these patients?”
A: “Yeah, that’s a really deep and dark pool of water. Here’s the thing, to really understand this problem you have to understand what’s going on in the overall health care environment. Most people know that health care is in financial crisis... For the past 20 years, we have all been hearing about how the cost of health care is going up. Businesses can’t afford to insure their employees and people are going bankrupt because they can’t afford their healthcare.
Beginning in the 70’s, one of the things that occurred is that insurance companies turned everything on it’s ear with the establishment of HMOs. Prior to the formation of these health management organizations or HMO’s, doctors were paid on what was called a fee for service kind of a paradigm. This meant that whether you wanted a facelift or your gallbladder removed you found a doctor, the doctor billed for the service he or she provided, and you either paid it or your insurance company paid it according to the doctor's fee. The idea was that doctor's fees would vary with their skill and reputation. Unfortunately, there were some physicians that did take advantage of this system and directly contributed to elevated healthcare costs.
With the formation of HMO’s, the insurance companies basically took over the power and decision making and started cutting doctor’s pay. That was all done supposedly in order to diminish cost in the healthcare system- which clearly has not occurred. Even a cursory examination of the system would explain why- executives at insurance companies are making huge salaries, and paying themselves astronomical bonuses, with hospitals charging $200 for a single dose of aspirin- and blaming doctors for the ongoing increases in costs even as the reimbursement to physicians goes down.
Combine this with the well-understood toll taken on the profession and the environment by the wild-west medical malpractice culture, and understanding how costs are so high is not difficult.
Beginning in the 70’s, one of the things that occurred is that insurance companies turned everything on it’s ear with the establishment of HMOs. Prior to the formation of these health management organizations or HMO’s, doctors were paid on what was called a fee for service kind of a paradigm. This meant that whether you wanted a facelift or your gallbladder removed you found a doctor, the doctor billed for the service he or she provided, and you either paid it or your insurance company paid it according to the doctor's fee. The idea was that doctor's fees would vary with their skill and reputation. Unfortunately, there were some physicians that did take advantage of this system and directly contributed to elevated healthcare costs.
With the formation of HMO’s, the insurance companies basically took over the power and decision making and started cutting doctor’s pay. That was all done supposedly in order to diminish cost in the healthcare system- which clearly has not occurred. Even a cursory examination of the system would explain why- executives at insurance companies are making huge salaries, and paying themselves astronomical bonuses, with hospitals charging $200 for a single dose of aspirin- and blaming doctors for the ongoing increases in costs even as the reimbursement to physicians goes down.
Combine this with the well-understood toll taken on the profession and the environment by the wild-west medical malpractice culture, and understanding how costs are so high is not difficult.
“Over the period in question, the cost of healthcare has continued to increase astronomically while insurance company executives have increased their income many fold. Some of these guys are making bonuses in the multiple millions of dollars annually. So while the overall cost of healthcare has not gone down, what has gone down is the compensation to physicians. Relative to the overall inflation rate and the cost of living, the average doctor who bases their practice on taking care of insured patients has experienced a significant decline in their income and in their lifestyle. Most doctors still make a pretty good living, so should we really feel sorry for them? It’s hard for us, as an average person, to feel sorry for people who are still making a pretty good income.”
“On the other hand, we need to remember that the average physician has worked very hard over a period of 15-20 years to become a well trained and educated, responsible physician. Most people who have gone to school for that long and have trained for that long expect there to be a reward at some point. If you went to college and worked hard, and then you went to medical school and worked hard to receive the best education you could, and then did residency training, and at the end of all that the investment and hard work somebody tells you that insurance companies and the government are going to cut your pay and you are going to make less and less money and need to see more and more patients, all while constantly suffering the threat of (often) frivolous malpractice suits, it becomes really difficult to not feel frustrated and cheated.
What this has caused is an environment where we have lots and lots of disaffected and frustrated doctors in the United States.
People who have spent years and years learning and training in ways to take good care of people really are not that interested in taking care of people anymore because they don’t feel well compensated. When you combine that with the fact that most people in the country, including all of these unhappy and frustrated doctors, know that insurance and the government don’t pay for cosmetic surgery, the leap form being a trained family practice doctor, a trained gynecologist or even as we have here in Orlando - an eye doctor wanting to do plastic surgery in order to make more money - is not that big of a leap. And so what has happened, unfortunately, is that a lot of these frustrated and unhappy doctors have decided that even though they are not trained to do it, they are going to start doing some cosmetic surgery. This way they can cut the insurance company and the government out of the loop, increase the amount of money that they make, work less hard, and overall have a better lifestyle - the lifestyle they felt they were promised when they first went to medical school.”
What this has caused is an environment where we have lots and lots of disaffected and frustrated doctors in the United States.
People who have spent years and years learning and training in ways to take good care of people really are not that interested in taking care of people anymore because they don’t feel well compensated. When you combine that with the fact that most people in the country, including all of these unhappy and frustrated doctors, know that insurance and the government don’t pay for cosmetic surgery, the leap form being a trained family practice doctor, a trained gynecologist or even as we have here in Orlando - an eye doctor wanting to do plastic surgery in order to make more money - is not that big of a leap. And so what has happened, unfortunately, is that a lot of these frustrated and unhappy doctors have decided that even though they are not trained to do it, they are going to start doing some cosmetic surgery. This way they can cut the insurance company and the government out of the loop, increase the amount of money that they make, work less hard, and overall have a better lifestyle - the lifestyle they felt they were promised when they first went to medical school.”
“So on the one hand, is it fair to completely blame the doctors who are irresponsibly performing plastic surgery without plastic surgery training? My personal belief is yes, it is.
But some people would argue no, and some people would argue that the responsibility rests on all of society.
We created this environment; therefore, we shouldn’t blame these doctors who in response to the environment we created are doing these things.
On the other hand, doctors are smart people - they wouldn’t be doctors if they weren’t. All of us are supposed to be ethical people too. At some level, all of these people who are performing plastic surgery without plastic surgery training know that what they are doing is wrong. They are doing it because they want to make more money. I have no problem with somebody finishing their training as an eye doctor, an ophthalmologist, such as Dr. Roger Bassin here in town, who then decided that they really wanted to be a plastic surgeon. But if you finish your training for ophthalmology and decide you want to be a plastic surgeon, do it right. Be honest. Go back and get training in plastic surgery. Then you can hang out your shingle and call yourself a plastic surgeon - honestly and ethically. I do have a problem with people finishing training in ophthalmology or in ER medicine. These people are ER doctors and they want to do cosmetic surgery? I think that’s unethical. I think it’s also irresponsible, and I think it’s bordering on fraud. I think they do deserve to be held responsible when things don’t go well because they aren’t trained to do the cosmetic surgery that they are doing. Hopefully, at least with that explanation we can all understand why they are doing it. I think it’s wrong, unethical, irresponsible and it ought to be illegal, but I think that those are the reasons why they are doing what they do.”
But some people would argue no, and some people would argue that the responsibility rests on all of society.
We created this environment; therefore, we shouldn’t blame these doctors who in response to the environment we created are doing these things.
On the other hand, doctors are smart people - they wouldn’t be doctors if they weren’t. All of us are supposed to be ethical people too. At some level, all of these people who are performing plastic surgery without plastic surgery training know that what they are doing is wrong. They are doing it because they want to make more money. I have no problem with somebody finishing their training as an eye doctor, an ophthalmologist, such as Dr. Roger Bassin here in town, who then decided that they really wanted to be a plastic surgeon. But if you finish your training for ophthalmology and decide you want to be a plastic surgeon, do it right. Be honest. Go back and get training in plastic surgery. Then you can hang out your shingle and call yourself a plastic surgeon - honestly and ethically. I do have a problem with people finishing training in ophthalmology or in ER medicine. These people are ER doctors and they want to do cosmetic surgery? I think that’s unethical. I think it’s also irresponsible, and I think it’s bordering on fraud. I think they do deserve to be held responsible when things don’t go well because they aren’t trained to do the cosmetic surgery that they are doing. Hopefully, at least with that explanation we can all understand why they are doing it. I think it’s wrong, unethical, irresponsible and it ought to be illegal, but I think that those are the reasons why they are doing what they do.”
“Understanding that there are these people who are not trained in plastic surgery wanting to do plastic surgery, we have to understand what they need to do in order to accomplish that. One of the things in the United States that has always limited what a doctor could do, is the hospital credentialing process.
In other words, I am a board certified plastic surgeon and I have every credential a plastic surgeon could have, but what if one day I decided I wanted to do heart surgery? What if I thought those heart surgeons are making a lot of money. Maybe I would like to do some heart surgery and make some more money myself. What’s to keep me from doing that?
Well traditionally, what has been in place to limit doctor’s practices is hospitals.
In the past, you couldn’t get permission to do an operation in a hospital unless you could prove to the hospital’s credentialing committee that you had legitimate training in that procedure. So when I apply for privileges at any hospital they ask me in written form what operations I want to do there, and then they make me produce proof that I have been trained to do those operations. They then decide if they are going to give me permission to do those operations in the hospital or not. So if one day I decided that I wanted to do heart surgery and I found a nice patient who was willing to let me do heart surgery on her, what would stop me from actually completing that irresponsible plan is that the hospital would never give me permission to do it. They would say, ‘Dr. Soto you are a plastic surgeon. You can’t be doing heart surgery. I don’t care if the patient is willing to let you do it and I don’t care if you want to do it. You are not trained in heart surgery, so we are not going to let you do it.’ ”
In other words, I am a board certified plastic surgeon and I have every credential a plastic surgeon could have, but what if one day I decided I wanted to do heart surgery? What if I thought those heart surgeons are making a lot of money. Maybe I would like to do some heart surgery and make some more money myself. What’s to keep me from doing that?
Well traditionally, what has been in place to limit doctor’s practices is hospitals.
In the past, you couldn’t get permission to do an operation in a hospital unless you could prove to the hospital’s credentialing committee that you had legitimate training in that procedure. So when I apply for privileges at any hospital they ask me in written form what operations I want to do there, and then they make me produce proof that I have been trained to do those operations. They then decide if they are going to give me permission to do those operations in the hospital or not. So if one day I decided that I wanted to do heart surgery and I found a nice patient who was willing to let me do heart surgery on her, what would stop me from actually completing that irresponsible plan is that the hospital would never give me permission to do it. They would say, ‘Dr. Soto you are a plastic surgeon. You can’t be doing heart surgery. I don’t care if the patient is willing to let you do it and I don’t care if you want to do it. You are not trained in heart surgery, so we are not going to let you do it.’ ”
“Well unfortunately, there’s nothing to keep doctors from doing whatever they want if they can do it in their office. If you have this eye doctor, or if you have an ER doctor or a gynecologist, and they are willing and able to convince a nice patient that they are able to do a tummy tuck on them in their office (because as I said they would never be able to get permission to do it in a hospital), there’s nothing to stop them. There’s no law that says gynecologists can’t do tummy tucks, or heart surgery for that matter, if they can do it in their office on a patient who is willing to let them do it.
So how do you do these things in the office if you don’t have a board certified anesthesiologists and you don’t have a certified operating room to do it in? Well you have to somehow convince people that doing this operation under local anesthesia is the right way to go.
In the office, under local anesthesia, you don’t need an anesthesiologist, you don’t need an accredited operating room, and you definitely don’t need the permission of a bunch of other doctors and hospital administrators.
So, over the past few years, we’ve seen a number of all types of doctors who are not plastic surgeons telling their patients that general anesthesia is dangerous and local anesthesia is much safer. ‘Why don’t you let me do your cosmetic surgery. We’ll do it right here in the comfort and convenience of my office. You won’t be subjected to the risks of general anesthesia.’ And they scare them by talking about dying, heart attacks and such. They tell them it’s much safer in their office and much easier. ‘You’ll have local anesthesia and you can go home the same day.’ ”
So how do you do these things in the office if you don’t have a board certified anesthesiologists and you don’t have a certified operating room to do it in? Well you have to somehow convince people that doing this operation under local anesthesia is the right way to go.
In the office, under local anesthesia, you don’t need an anesthesiologist, you don’t need an accredited operating room, and you definitely don’t need the permission of a bunch of other doctors and hospital administrators.
So, over the past few years, we’ve seen a number of all types of doctors who are not plastic surgeons telling their patients that general anesthesia is dangerous and local anesthesia is much safer. ‘Why don’t you let me do your cosmetic surgery. We’ll do it right here in the comfort and convenience of my office. You won’t be subjected to the risks of general anesthesia.’ And they scare them by talking about dying, heart attacks and such. They tell them it’s much safer in their office and much easier. ‘You’ll have local anesthesia and you can go home the same day.’ ”
“Well here’s the thing - First of all, they are being disingenuous. If doing things like tummy tucks and breast augmentations were safer under local anesthesia, every board certified plastic surgeon in the country would be doing it that way too. The truth is it is not safer to do it that way. Those things introduce a lot of risks that the average patient wouldn’t take if they knew they were taking them.
The fact is is that general anesthesia is a much safer way to perform these operations. And the fact is that the vast majority of patients who have unfortunately died during cosmetic plastic surgery over the past 5-10 years nationally have died as a result of excess or toxic levels of local anesthesia. Most of the time, the doctors offering local anesthesia for awake plastic surgery do not share that fact with their patients. They also don’t tell them that they are not plastic surgeons and they are really eye doctors, but I guess we already covered that.”
The fact is is that general anesthesia is a much safer way to perform these operations. And the fact is that the vast majority of patients who have unfortunately died during cosmetic plastic surgery over the past 5-10 years nationally have died as a result of excess or toxic levels of local anesthesia. Most of the time, the doctors offering local anesthesia for awake plastic surgery do not share that fact with their patients. They also don’t tell them that they are not plastic surgeons and they are really eye doctors, but I guess we already covered that.”
“So the fact is, awake plastic surgery is really not something you should consider, unless you are thinking about a minor procedure. If you are talking about having a tooth removed or maybe even a little eyelid surgery where the area of the operation is a very small area and you are only going to get a little bit of local anesthesia, that is really not a problem. I do those things myself here in my office. But if we are talking about a large operation where you are going to be manipulating muscles and putting implants in and doing things of that nature, that simply can’t be done safely, effectively, or ethically, in my opinion, on an awake patient under local anesthesia.”
