If it's true that it's always the few that give the black eye to the many, then we can blame the latest shiner office-based surgery is sporting on any number of usual suspects, including rogue surgeons performing procedures they're not qualified to perform and RNs administering anesthesia they're not qualified to administer. We can also point to a lack of equipment and personnel, lack of set procedures, the inability to deal with emergencies and so on.

But to say that office surgery is in the troubled state that it finds itself because dentists are doing breast augmentations and nurses are pushing propofol is to ignore a much larger, systemic problem: Office surgery suites are not held to the same basic standard as other surgical facilities. Unless and until assuring verifiable quality care with definable standards becomes a matter of when and not if, office surgery will continue to disintegrate, just as, in the words of E.B. White, a home disintegrates unless someone in the family sets standards of good taste, good conduct and simple justice.

As you'll see in "Troubling Times for Office Surgery" on page 28, the lack of oversight is shocking. As a private physician, you can do whatever you want in your office, including overstep your bounds. Clearly, stronger regulatory oversight, such as licensure, certification and accreditation, is needed. I heard somebody say the other day that plumbers and hot dog vendors are more regulated by state laws than surgery performed in a doctor's office. He wasn't kidding. Consider that

• only 22 states have some regulations or guidelines on office-based surgical procedures; and
• only a handful (1,337) of the estimated 50,000 office-based surgery practices in the United States are accredited: 934 (up from 621 in 2001) by the American Association for the Accreditation of Ambulatory Surgery Facilities (AAAASF), 300 by Accreditation Association for Ambulatory Health Care and 103 by the Joint Commission on Accreditation of Healthcare Organizations, which launched its Office-Based Surgery accreditation program in January 2001.

"That means there are 48,000 unaccredited facilities who are doing office-based surgery of various complexities. That is frightening. Pretty scary," says Jeff Pearcy, executive director of the AAAASF. "Is surgery more dangerous in an office-based setting? That's one of those kinds of things that takes on a life of its own regardless of whether it's true."