Joan Rivers and Office Based Surgery

This weekend, we say goodbye to the great comedian — Joan Rivers.  She said so many things that made us laugh.  My most favorite was  — “Can we talk.”

Joan Rivers
Joan Rivers

She often used those three little words while interviewing someone whom she felt was less than frank.  I can still see her leaning forward, as if to whisper, and saying with a crafty smile, “Can we talk.”  Those words immediately shifted the conversation to what was really important.  It was as if she said, “Ok let’s stop beating around the bush;” or  “Let’s get down to the juicy stuff.”  The words disarmed people in a simple, yet funny, way that made us see the real story.

Though no one could use those words the way she could, I often pilfered her expression to get others to say what they really meant.  In my many years in university academics, medical forums, and governmental service, I’ve attended countless meetings.  It’s always impressed me what people say in public compared to what they say immediately after the meeting, perhaps in a rest room, snack bar, or quiet corner.  Generally in the latter locations, their true sentiments explode with slang, profanity or worse.

Joan Rivers could cut through this politically correct “public speak” and get people to say what they really meant, which sometimes wasn’t always nice.  Yet Joan had a way to use self-deprecating humor to put folks at ease.  Almost as if to say, “See look at me, I’m not embarrassed and neither should you be.”

In matters of healthcare, truth is vital.  However, in this era of political sensitivity, freedom of speech appears extinct.  Unless we couch every sentence in words that couldn’t possibly offend anyone, we risk unmasking an unintended offense.  Discussing important matters under this camouflage begs for Joan Rivers and her three little words — “Can we talk.”  To speak otherwise elicits Winston Churchill’s admonition, “If you can’t say what you mean, how can you possibly mean what you say.”

From what I have read surrounding Joan Rivers’ death, it’s reported that the family suspects complications due to surgery performed in a non-hospital environment.  In other words, surgery/procedure carried out in an office.  Since others have also suggested this cause, the family is considering malpractice litigation.

It’s ironic that she died in this manner, considering the extensive debates over office-based surgery in New York State.  I can’t help but wonder if a little more “Can we talk,” — I mean really talk, would have helped.

The year was 1997, and I was Chairman of the New York State Public Health Council.  As a practicing surgeon at the time, I disagreed with the market driven recommendations to dismantle hospital based surgery and instead move so-called minor surgical procedures to a physician’s office.  I held that opinion for two reasons:

  1. There is absolutely no such thing as a minor surgery.
  2. And any surgery on me or you is never a minor procedure.

Whether it’s passing a tube down a person’s windpipe, or going up in the other direction, there are inherent risks dependent on many factors, age, co-existing medical illnesses, anxiety, and drug history to name a few.  I have seen complications from vocal cord spasms that stopped breathing, perforated livers and spleens from faulty colonoscopies, and collapsed lungs from a simple needle touching the lung.  Though these complications are admittedly few, their occurrence in those affected is 100%.

As Chairman of the Public Health Council, I had the privilege to recommend that the Council undertake a study to investigate the movement of surgical procedures to an office setting.  The Council supported this initiative and selected an all-star panel of medical experts from all sectors across New York.  That empowered committee then held public hearings in the major cities across the state to elicit comments from patients, business leaders and other interested stakeholders.

Over a several month intensive effort the committee forwarded to the Council its report, which was immediately endorsed and recommended to the New York State Commissioner of Health, Dr. Barbara DeBuono and the NYS Legislature for consideration of possible legislation.

Unfortunately we found that sometimes “Can we talk” just isn’t allowed.  The New York State Association of Nurse Anesthetists sued the Public Health Council and barred the report from becoming public.   Since the Council report was muffled by the lower court’s, New York State’s Health Department appealed the lower courts decision to the state’s highest court, the Court of Appeals.  Finally with the report requiring some “tweaking,” a decade later in 2007, the report was released.

I don’t believe Joan Rivers would have allowed ten years to pass, if only we could have talked.  And what exactly did we need to talk about, and why all the sensitivity about what and how to say it.

By 1997, healthcare costs were sky-rocketing and the wisdom of that decade was to unleash market forces on healthcare.  Surely if American competition made us wealthy, easily it could make us healthy.  Performing surgery in a hospital was expensive.  Why do we need this costly infrastructure for a “minor” procedure?

Many physicians rallied to this cry.  Some doctors argued that most of their routine surgery could be carried out in an office, if only the insurance company would pay them an augmented fee.  To many this was a win-win situation.  Insurance companies got to pay less than the hospital charge, and physicians got a raise.  The only downside was that equipping an office just like a hospital was expensive, so medical supply companies filled the gap by providing equipment which was nearly like the hospital’s.

Another advantage to market based decisions was that now non-physicians could perform services in an office which they formerly were not allowed to do in a hospital.  That was the key element of the litigation against the Public Health Council cited above.

According to market driven theory, this competition would greatly improve public health at a lower cost.  As we have suggested in an earlier blog, apparently this hasn’t yet achieved the intended result.

Perhaps Joan Rivers’ spirit acting through her family may trigger some meaningful changes as this investigation progresses.  However, it may not happen unless we ask — “Can We talk.”