The Question You Aren’t Asking About Surgery (That You Should)

Announcer (00:02):
You are listening to Alabama the Beautiful with cosmetic surgeon, Dr. James Koehler and Kirstin Jarvis.

Kirstin Jarvis (00:08):
Welcome back. Come on in. You're listening to Alabama the Beautiful podcast. You wanted to talk about hospital versus office. Is there something that made you want to talk about that?

Dr. Koehler (00:21):
Well, I mean, I just wanted to maybe clear some things for patients. People have sometimes concerns about whether having surgery in the office setting is a safe thing. And so I just thought it might be good to kind of talk about the difference and where is the best place to have your surgery?

Kirstin Jarvis (00:42):
Why should someone pay attention to that, whether their surgery takes place in a hospital or an OR in the office or a surgery center even?

Dr. Koehler (00:51):
Well, it gets a little confusing for patients and they probably don't really truly understand. In fact, I mean if you asked doctors that aren't involved in doing surgery in their office, I'm sure most doctors didn't know the answers to these questions. And it varies state by state, but in the state of Alabama, if you want to do office-based surgery, you can do that. And it's not mandated by the state that you have an accreditation process, but you do need to notify the state that you are doing this. They need to be aware of it. But I mean, a lot of us that do surgery in our offices, we do go through an accreditation process. And I think it's very important to do. It sort of provides another layer of safety to the patients. So for instance, hospitals go through an accreditation process. They have to be accredited.

(01:46):
So if you want to have surgery done at the hospital, there are people that come and inspect that hospital on a regular basis to say yes, that the equipment's good, all the policies and procedures that you use to manage all these different situations is good. And so it's just a checks and balances to make sure that what is happening in that hospital is going to be the same regardless of whether you have it done in Huntsville or Birmingham or Fairhope. It doesn't matter. Everybody's got the same regulations that they have to follow. Now in the office-based setting, it's a little different because there's accreditation processes and like I said, not everybody gets accredited. And so then if you're not accredited, I mean you have to go, okay, well do I trust the doctor in the office that they're doing all the things that they should be doing?

(02:37):
And I think most people have very good intentions and are doing that. But when you have to go through accreditation, it forces you to dot your I's and cross your T's and make sure that all those things are in place and the way they're supposed to be. So to me, whether you do it in a surgery center or a hospital or office, as long as there's accreditation and people are doing the things they need to make sure that they are keeping up to the standard of care, I think either is fine, but there are some differences. So my hospital that I operate at, I don't, I don't work there every day, but I do think that is a very good place to take people who have serious health issues. So they want something elective done and sometimes if they have serious health issues, they're not even a candidate for something that's elective.

(03:33):
But there are situations where there's certain things that kind of cross that line between elective and necessary, and we won't get into all that. But the point is, if you've got certain health conditions and it may be safer for you to be in that setting. I know another example just for me personally is I don't do kids in the office. I do procedures on kids. I'll do otoplasty, ear pinning surgery and I'll do that on five-year-olds. I am not going to operate on a five-year-old in my office if I'm doing a five-year-old, it's at the hospital. And the main reason is anesthesia wise, if something happens, you want a team of people there and kids can decompensate pretty quickly and you want to have those people there. Or alternatively, it's a procedure that's so big that we don't want to send them home afterwards and we want to keep 'em overnight and have a nurse watch them. And it may just be overnight. It may be for a couple of days, and then they'll go home. So hospital's great, but it's also not perfect.

Kirstin Jarvis (04:39):
Yep.

Dr. Koehler (04:39):
Yeah, the hospital is for sick people and that's the reason I don't like going to the hospital. Not that I don't like sick people, but I don't like bringing healthy people getting elective procedures in a place where there's a bunch of sick people and we got to keep that in mind. So for me, that's one reason that I don't like being in the hospital. I got more.

Kirstin Jarvis (05:03):
Just one. At the hospital when joint commission comes, I worked at the hospital during a survey year for two different rounds and I had 70 people on my unit. So it was like it's a scramble and everybody doesn't have a specific job to do. It's just make sure stuff is clean and up off the floor and checks all the boxes that joint commission wants. But here with AAA HC, we're a much smaller office and all of our stuff's already done. Everybody has a job to do and it's done because there's not 70 people, there's 12 and there's a lot more accountability here. I feel like it's stressful when AAA HC comes, but it's not like we're trying to scramble and make sure everything is in its place because it just already is.

Dr. Koehler (05:46):
Yeah. I mean, and that's the thing. When you're doing it on a day-to-day basis, as long as you're following, if you're doing what you're supposed to be doing, then really accreditation, yes, there's some stress involved with going through the accreditation because some things change, they update some regulations or some things that they want you to do, and so you're like, oh, we weren't doing this, we need to be doing this. But those are usually minor things, but it's just again, checking boxes. So most of the time it really shouldn't be, you should be doing these things every single day. So it shouldn't be some big deal. But to me, and again, I love my hospital. I think Thomas Hospital has been very good to me. I think they've treated my patients very well over the years, and I like going there, but I do like my office more.

(06:31):
But the thing that's tough, because I am not there every single day, I do bring my scrub techs with me, so that's very helpful. But there's also a bunch of people that, I mean, depending which day I go, I may have new people every time I go that I'm working with. And I don't like that. And it's not that I don't like those people. But the thing about surgery, and I think that what makes, especially when it comes to cosmetic surgery is we do things very, very much the same way, not the same way, but we have systems in place and in my office when I do stuff, everybody knows exactly what we're going to do, what we need, how we're going to do it. There's no scrambling around. There's no question is what do we need? What do we have? Whereas at the hospital, my staff that come with me know what we're going to be doing, but everybody else has no clue what's going on.

(07:20):
And it's not because they just don't do it with me all the time. And even if they do it with me, it might be a few months or several months before they do it again, and they totally forgot how we did it last time. They work with other surgeons too, and they might do it differently. So to me, there's lots of advantages to being in the hospital, but there are disadvantages. And that's where when we do stuff here, I mean everybody knows exactly how we want to do it. And so it's just, it just moves like clockwork.

Kirstin Jarvis (07:49):
One thing that really amazed me when I first came here is to see the amount of teamwork that goes in. It's not just the scrub techs cleaning up the OR after a case. The RNs are in there mopping the floor. Your circulators are stocking the cabinets. I love the teamwork that everybody, it's not just like, oh, that's not my job. Everybody does the same job. I love it.

Dr. Koehler (08:09):
Well, and that's, I think something that maybe comes along with being, like you said, a smaller facility where there's a group of us. If we just said, oh, that's not my job description and left it. I mean, yeah, we'd get through the day, we have to wait, but you can only do so much as one person. And if we said, okay, your job's to clean the OR, we'd be sitting there forever. It takes a long time. There's a lot of things that have to be wiped down and everything has to be cleaned between surgery. So the teamwork approach is great, and I do love that we are a team like that. And the only way that that works is if people just put their egos aside and go, you know what? I'm here to help you. You help me. And as long as it's reciprocal, and then I think it works really well.

Kirstin Jarvis (08:51):
Yeah. Being that you have your own surgery center to work out of, was it difficult to get hospital privileges?

Dr. Koehler (08:58):
Hospital privileging is totally separate from what I do here, but when you get to get hospital privileges, you've got to show your training, your experience, and you go through a whole process for accreditation and they review all that and make a determination based on what you're applying for that you're qualified to do it. But here in the office, so you guess you don't have that. And so a lot of times people say, oh, you should make sure the doctor has hospital privileges for what they're doing in their office. And I think that's true, but nowadays, there's a lot of people that really don't want to, even, they're doing stuff in their office, they don't even want privileges at the hospital. They don't want to have to take call at the hospital or whatever. So there's other things there. So I wouldn't say it's a hard and fast rule, but yeah, if somebody has privileges at their hospital and they're doing stuff in their office for things, they have privileges that's encouraging. But again, there's multiple things like is the office accredited and are they doing all the things they should be doing? And to me, it's the subtle things or the things that patients would never think about. And that's why I like accreditation because we've got a generator to make sure that if the power goes out in your surgery, we've got a generator that kicks on and you're fine. It's going to be fine. And we test that weekly. It's tested.

Kirstin Jarvis (10:12):
One thing that I do have to say about having privileges at the hospital, that was my job before I came here, was privileging all the physicians. So of all the doctors in the county, you're the guy I wanted to come work for. But number two, their bylaws, some of them are completely, I don't want to say ridiculous, but it's a lot to ask for somebody that has their own clinic that they operate out of 80 to 90% of the time, just to have a safer place for your patients that might have higher acuity or children. For you to be able to operate at the hospital, you have to call a lot throughout the month. You have mandatory meetings that you have to attend, you have to be on a committee, you have all these things that you have to do. So I think that says a lot about you, that you're willing to do all that just so you can have a safe place for those patients with little higher acuity or kids or other people that might not be great candidates in the office.

Dr. Koehler (11:07):
No, it's something that I'm glad to be a part of.

Kirstin Jarvis (11:12):
So we kind of touched on AAA HC and our certification here at the office, but can you tell us what that means and why does a patient care if we're AAA HC certified here? Or accredited? I'm sorry.

Dr. Koehler (11:25):
Yeah. Well, for us, it's several things. So it's making sure that the facility meets the requirements in terms of cleanliness, in terms of, like I mentioned earlier, having a backup generator. So if something was to happen and we were in the middle of a storm and that we could complete your surgery, and we don't start surgeries on backup generators, but if something happened, we've got that to finish a case. And we've got all the sterilization protocols are in place to make sure that your instruments are being cleaned and sterilized the exact same way, to the same level and quality that would be done if you had it done in the hospital. So we have all these things that people come and check, and then making sure we have all the emergency drugs and emergency equipment that we need. So in the event of an anesthetic emergency or a surgical emergency that we have the drugs and devices that we need to get you through. And so that's a key part of accreditation. And I think the thing that, again, if you put that trust in that doctor that they're doing it, even somebody who's completely well-intentioned that says, I want to do the absolute best for my patients. If they didn't go through the process of accreditation, I promise you there'd be things that they would've missed or overlooked because there's just so much, and

Kirstin Jarvis (12:46):
Because all their boxes weren't checked

Dr. Koehler (12:47):
Because all the boxes weren't checked. So I mean, we hate going through it, not hate, but it's a lot of work. It's not some easy thing. And some of it's kind of like, well, what's your policy on this? Or what's your policy on that? I mean, that stuff is kind of more paperworky kind of thing. But I mean, I'm talking about just all the nuts and bolts. Is your equipment inspected? How often is it inspected? When was the last inspection? Are all your drugs... There's no expired drugs. We have everything working and functioning the way it's supposed to. I mean, those things, again, you expect people to be doing that, but when you're forced to do it to make sure, because somebody's coming to check on you, you just make sure that yeah, you're doing it right. And a lot of times it's just affirming that you are doing it well.

Kirstin Jarvis (13:30):
Aside from accreditation, but also kind of going along with that, I love, you had said before that our anesthesia machine here is the same exact one that they use at the hospital because our anesthesia providers also work at the hospital, and you just wanted it to be second nature for them to, whatever they would use throughout their normal day is what they're going to come here and use. So their buttons and knobs and levers are all in the same places.

Dr. Koehler (13:58):
They put the quarters in the same spot on the machine. No, I did. So the hospital recently upgraded all their anesthesia equipment and got really nice anesthesia machines, but before that, I had the same one that they used at the hospital. And I did that on purpose, intentional for that reason. And it would be the same. It's like, you have a car, I have a truck, or whatever. We have vehicles. I could drive your vehicle, but I don't know where the AC is on there right away I could find it. But if you said, Hey, turn on the AC right now, I mean, it would take me a second to find out where your AC button is. And so I wanted the same thing for anesthesia. It's like when you are in a situation where you've got to do something, I want it to be instinctual. Like, okay, this knob, that knob this thing, I know where everything is. And again, it's just another level of safety. And that's not something that is required. That's just something I chose to do. Because again, I think people, when they're working with the same equipment and gear, they feel comfortable. And again, not to say anesthesia, people can work with any machine, just it takes some, for it to become instinctual, they got to use it regularly.

Kirstin Jarvis (15:07):
Yeah. Love it. You have anything else you want to say about office versus hospital?

Dr. Koehler (15:11):
Yeah, I mean, I think office-based surgery, actually in a lot of ways, I prefer to do my surgeries here, as much as I like the hospital. Even if, I don't know, they said, Hey, you can operate here every day. And I had block time every day at the hospital, which would be hard to get. But let's just say I did. Still this setting is, again, it's very controlled because we're just dealing with me and my surgeries. Not every doctor, every surgeon, every situation. So there are advantages, and again, sometimes I want to just sort of say, people got like, oh, you did surgery in the office? Is that safe? Yeah, it is. I think if you're doing the things that we talked about here, it's very safe. It's a great place to have something done, but you can't just make that assumption that every place that you might consider surgery has everything in place. And so I feel personally, accreditation is something that's important. And I think asking those questions of an office is, I mean, we welcome questions about that. In fact, I'm proud. Nobody ever asks us about accreditation, but I'm happy to talk about it.

Kirstin Jarvis (16:22):
Yeah. I do have to say, as a patient, I know my story's a little bit different because I'm an employee and I already knew everybody, but when I had surgery and just thinking about it from a patient perspective, they talk to Jessica in Denva on the phone in the beginning. They meet with Jessica in Denva in their consultation, they meet with you in their consultation. They come back for their pre-op, and they meet all the scrub techs and the nurses, and they kind of build a relationship because that appointment's long going over all their post-op instructions and pre-op instructions and medications and all that stuff. So they kind of get to know everybody. And then they come the morning of surgery, and it's all those faces again, it's no new random nurse or anything. It's all the people that they've already met. The morning of my surgery. I was not nervous. And you were like, why are you so quiet? I'm like, I don't know. I'm just so calm. I just felt very comfortable. So it says something to come to the office where you've already met all these people and know all their faces and know that you're going to be in an operating room with them.

Dr. Koehler (17:21):
Yeah, I mean, I think that is the familiarity of the people and the faces, and you've already met 'em before, so that definitely helps. But you know one thing you made me think about it, but I said to my staff, the staff in the back all the time, I'm like this operating room, if you wouldn't feel comfortable putting your own body on that table and getting a procedure done and doing it here, you need to speak up because that's exactly what this place should be. And obviously, I mean, I've had multiple staff members over the years get things done, and so they obviously felt comfortable with it, but it's not just taking care of patients, but would you be willing to be a patient on that table? Would you get on, are we doing it to that level? And the answer is, yes, we are. But I mean, I always tell people, that should be the way you answer that question.

(18:08):
And Am I cleaning this OR would you get on that table right now? Did you clean it well enough that you would get on that table?

Kirstin Jarvis (18:14):
Yeah.

Dr. Koehler (18:14):
But yeah, I guess the nuts and bolts of this is office-based surgery I think is fine. I think personally, make sure your office is accredited. I think that's important. And if you have questions about the facility, ask them. I mean, I've had people that are nurses, doctors, they work in operating rooms and they're like, can I see your operating room? I'm like, yeah, come on. Well, I'll show you what it looks like before surgery if you want to see it. I mean, there's nothing to hide here. Come on in.

Kirstin Jarvis (18:43):
Love it. Do you have a burning question for Dr. Koehler or me? You can leave us a voicemail on our podcast website at Alabama the Beautiful podcast.com. We'd love to hear from you. Thanks, Dr. Koehler.

Dr. Koehler (18:54):
Thank you. Kirstin,

Kirstin Jarvis (18:56):
Go back to making Alabama beautiful.

Dr. Koehler (18:58):
All right. I will. Have a good one.

Announcer (19:01):
Got a question for Dr. Kohler. Leave us a voicemail at Alabama the beautiful podcast.com. Dr. James Kohler is a cosmetic surgeon practicing in Fairhope, Alabama. To learn more about Dr. Kohler and Eastern Shore Cosmetic surgery, go to eastern shore cosmetic surgery.com. The commentary in this podcast represents opinion and does not present medical advice, but general information that does not necessarily relate to the specific conditions of any individual patient. If you enjoyed this episode, please share it and subscribe to Alabama the beautiful on YouTube, apple Podcast, Spotify, or wherever you like to listen to podcasts. Follow us on Instagram at Eastern Shore Cosmetic Surgery. Alabama the Beautiful is a production of The Axis , THE AXIS .io.