Thoughts on the AIDS/HIV 30th

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. 

The first reports of the infection which would come to be known as AIDS appeared in the June 5, 1981 issue of CDC’s MMWR.  The 5 cases reported in the MMWR involved young homosexual men being treated for Pneumocystic carinii pneumonia.  All were in Los Angeles, California during the period October 1980-May 1981.

I did not become aware of this disease until the fall of 1982 as an intern in Baton Rouge, LA.  Our patient presented with Kaposi sarcoma.

Last week I had a short discussion with a friend who is an HIV expert here in Little Rock, AR.  He graduated from medical school a year ahead of me.  He first recalls hearing of HIV when the NEJM article appeared in December 1981.  He mentioned taking note of the article and thinking he would never see any of those cases.

We both marveled over how the diagnosis of HIV has gone from an automatic death sentence to a chronic disease the person can live with.  LIVE with HIV.

He noted the change came in the 1995 with the introduction of highly active antiretroviral therapy (HAART).  My friend went from feeling like he might need to give up treating AIDS/HIV patients (too many deaths were taking it’s toil on him) to feeling hopeful for his patients.

We both noted that prevention continues to fail.  He mentioned he often will have a patient with a birth date of 1987 or so who will present to his office.  Not good as this age group has always had HIV prevention discussed in the media, etc during their lifetime.

Even though HIV is not the death sentence it once was, prevention needs to remain a major focus.

It is important to know your HIV status so that treatment can begin early. It is especially important to be tested yearly if you participate in any of these behaviors:

• Have injected drugs or steroids or shared equipment (such as needles, syringes, works) with others
• Have had unprotected vaginal, anal, or oral sex with men who have sex with men, multiple partners, or anonymous partners
• Have exchanged sex for drugs or money
• Have been diagnosed with or treated for hepatitis, tuberculosis (TB), or a sexually transmitted disease (STD), like syphilis
• Have had unprotected sex with someone who could answer yes to any of the above questions

If you test positive for HIV, then it is important to see a doctor, preferably one with experience treating people living with HIV.

REFERENCES
Pneumocystis Pneumonia --- Los Angeles: CDC MMWR, June 5, 1981 / 30(21);1-3

Gottlieb et al. Pneumocystis carinii pneumonia and mucosal candidiasis in previously healthy homosexual men. NEJM (1981) 305:1425-1430

Kent A. Sepkowitz, M.D.; AIDS — The First 20 Years; N Engl J Med 2001; 344:1764-1772

CDC:  HIV

Aging with AIDS: Living longer, living with loss; Linda Dahlstrom; MSMBC News, June 2, 2011

Bundling – What will it mean?

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

In a lot of the healthcare policy talk I feel like an outlier.  Most of the healthcare policy talk is directed more towards the primary care specialties.  As a “potential” patient and as a medical specialist, I watch and read with interest.   Often I am unsure as to the definitions being thrown around in the discussion.  Take bundling for example.  Currently, many of the surgical payments are already “bundled” in that the surgery and the first 90 days postop are linked or “bundled” together. 

When I do a breast reduction on a patient, the fee I receive covers the surgery itself and any visits during the first 90 days postoperative.   I see each of these patients the morning of surgery to do the preop marking and answer any new questions.  I then do the surgery and check on them in recovery.  Most breast reduction surgery is outpatient these days so there isn’t hospital rounds to make.   I call each of my patients the evening of surgery.  I see each of them at 5-6 days postop.  I try to get them to return at one month postop and then again at 3 months.  So the average patient will be seen 2-3 times in that post-operative time frame.  All this patient interaction, including all the office work for the insurance billing, is “bundled” into one fee.  If the patient needs or simply wants to be seen more often, it would still be included in the one fee.

So what are the policy wonks discussing in this new bundling talk?  I apparently am not the only one wondering as evidenced by this:

James Bentley, senior vice president of strategic policy planning at the AHA, says that to debate the merits and drawbacks of bundling, we need a clear definition of what bundling really is.

"Most people who talk about bundling talk about combining the physician payment and the hospital payment," but currently, the focus is on combining the acute payment with the postacute payment, he says. Bentley says fundamental questions like this spring up due to the lack of detail in the president's budget proposal, which Congress has already approved in principle. Details are expected to be worked out in conference between the two houses over the summer.

"Our membership is asking a lot of questions that we can't answer," Bentley says, including whether a new system would include all diagnosis-related groups, or just some, or whether the new formula will incorporate the historically wide disparity in Medicare payments per capita by region, for example.

One big potential problem with bundling payments is the assumption that much of the anticipated savings come from the idea that chronic care patients use lots of services and are high cost; but such chronic care services are the hardest to describe for bundling.
"If there are a lot of comorbid conditions, what's the primary condition, where does the bundle start and where does it end?" Bentley asks.

Are the new bundling talks aimed at the family practice doctors and internists?  Surgeons have been living with “bundling” for a while now.
How the policy wonks decide to “bundle” medical care for diabetics will be interesting.  What will that mean to the family practice clinics?

This next part is still on the health policy issue, but has nothing to do with bundling.  It is just interesting to me.
I am like Dr Bruce Campbell  who wrote in his post --Health Care, House Building and Ethics:

I am a novice in policy; every time I read a new editorial or column that proposes how to best pay for health care yet keep the costs under control, I am swayed. It seems that many commentators say something that seems to make sense to me. 

Read Dr Campbell’s entire post on his viewpoint of the recent article in the The New Yorker by surgeon-writer Atul Gawande, MD.

Finally, and potentially most important, Dr. Gawande shows us that HOW we pay for medical care will ultimately be less important than having a "culture of medicine" that is, above all, consistently ethical. If every test or procedure directly benefits the person who orders it, there is too much temptation. 

Then read this one (Gawande) by Dr Jeffrey Parks (Buckeye Surgeon) on his perspective of the same article by Dr Gawande:

I obviously think Dr Gawande has gone off the tracks just a bit with his analysis. In the beginning of the article, he chats with a family practice physician who says "...young doctors don't think anymore". But that line of thought is truncated. Instead, we wander off down the pathway of physician greed and intransigence and we never return. I'd like to revisit the idea of physician thinking…..
But I truly believe that this sort of unprincipled practice represents the exception rather than the rule. (Remember, McAllen itself is an outlier; most hospital systems hover around the mean in terms of health care expenditures.) Also, these proceduralists don't materialize out of thin air. Someone has to consult them. And this gets me to my point……….
But places like McAllen are rare. We've tripled the amount of health care spending in America since 1985 even without the McAllen model being common.

Should Doctors Say How Many?

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

Monday the WSJ Health Blog posted “Should Doctors Say How Often They’ve Performed a Procedure?” written by Jacob Goldstein.   It references another guest post by Adam Wolfberg, M.D -- “Test Poses Challenge for OB-GYNs”

Dr. Wolfberg writes:

None of the published studies of CVS pitted seasoned physicians against novices; what patient would agree to be randomly assigned to an inexperienced doctor holding a long needle? But several reports from individual hospitals demonstrate that the miscarriage rate declined over time as the hospital's staff became more experienced.

These reports point to a dilemma: CVS mavens got that way by practicing, so their present-day patients benefit at the expense of previous patients.

When I first began my solo practice 19 years ago, patients often asked how long I had been in practice.  They ask less often these days.  I have never failed to answer. 

Patients sometimes asks how many times I have done a procedure, but not often.  Early in my practice, and sometimes even now, if it is a procedure I feel a bit uneasy with or haven’t done in a while I will bring the subject up without being asked.  After all, some procedures you just don’t do every day or even every month.  Some diseases you don’t see every month or even every year.

In my mind, many of the procedures I do are built on basic surgical principles.  I withdrew my privileges for microvascular procedures more than 10 years ago.  I didn’t get enough patients referred to me to feel that my skills were kept sharp.  In private practice, unlike at a university, there are no labs to go do practice work in to maintain those rarely used skills.  I have no doubt that I could regain them given the chance, but at what cost (financially or complications). 

Because I gave up my privileges for microvascular procedures, it means I have limited my repertoire of reconstructive procedures important in hand, breast, and other work.  I tell my patients about them.  If a breast reconstruction patient wants a free TRAM flap, then she is referred to someone who does it.  If she  wants to keep me as her surgeon, is there the possibility she is short changing herself on the outcome?  I suppose, but I try (TRY) to be upfront and fair to each patient.

The question asked “should doctors say how often they’ve performed a procedure?” may seem an easy one to answer.   If asked, yes.  If not asked, should it be part of the consent form?  I’m not sure it should for most procedures, but for extremely complex ones, maybe.

What if I did 100 of one type of procedure, but my last one was over a year ago?  What if I have done 50 of a second procedure that is closely related in skill-set?  What if that number is only 15? What if I have never done one and don’t wish to now, but the patient needs the procedure and is not willing to travel to another hospital?  Is it okay that I have “informed” them, but they want to take the risk?  How do I define that risk for them? 

How many of which procedure is enough to become proficient?  How often does it need to be done to remain proficient?  Who gets to define proficient?  Who gets to define the “magic” number of how many is enough to be proficient?  Who get to define how often the procedure needs to be done to remain “proficient”?

As Dr Wolfberg noted

what patient would agree to be randomly assigned to an inexperienced doctor holding a long needle?

So how will these questions be answered?

Stress and Burnout Among Surgeons – an Article Review

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

There is an interesting article on stress and burnout in surgeons in this months issue of Archives of Surgery.  The authors state the goals of their article is to raise awareness of burnout and to encourage surgeons to “be proactive in their personal health habits.”  I will admit I sometimes struggle with trying to keep my life in balance so that I won’t become a “burned out” surgeon/human.  So I read these articles and look for that “magic cloak” that would protect me.  It’s not there.  It takes work and vigilance to prevent becoming a burned out cynic.

Their definition of “burnout”

Burnout is a form of personal distress that appears in a markedly more common fashion among physicians compared with depression, substance abuse, and suicide.

As a clinical syndrome, burnout is characterized by emotional exhaustion, depersonalization, and a decreased sense of personal accomplishment.

It is a syndrome that primarily affects individuals such as physicians, nurses, and social workers, whose work involves constant demands and intense interactions with people who have great physical and emotional needs.

Just as with “burned-out” individuals in any other profession, we need to be aware of the following symptoms:

treating patients and colleagues as objects rather than human beings

feeling emotionally depleted

physical exhaustion

 poor judgment

cynicism

guilt

feelings of ineffectiveness

a sense of depersonalization in relationships with coworkers or patients

The authors make the point that burnout in physicians/surgeons not only affect them personally, but can adversely affect patient safety, the quality of care we give to patients, and may contribute to medical errors.  This in turn (the increase medical errors and the decreased patient satisfaction) can then increase the threat of malpractice litigation. 

The increased stress/distress often lead to broken marriages, substance abuse, poor health, etc.

The article points out many of the contributing causes, including a lack of autonomy, imbalance between personal and professional life, excessive administrative tasks, long work hours, financial issues (overhead, poor insurance reimbursement, etc), and isolation from colleagues.

The article points out (and I would agree) that prevention is better than treatment of “burnout.”

Although recovery from burnout is possible, prevention is a better strategy.

Physicians who actively nurture and protect their personal and professional well-being on all levels—physical, emotional, psychological, and spiritual—are more likely to prevent burnout or at least to mitigate its consequences. 

The importance of mentorship cannot be underestimated

I limited my office hours so I could try to find a balance between being a “wife” and being a “physician/surgeon.”  This affects the finances and not always in a good way.  Being in solo practice can be isolating, even though it gives me the “freedom” to set my hours and not feel “guilty about not pulling my weight.”  I covet my daily walks with my dog.

REFERENCE

Stress and Burnout Among Surgeons: Understanding and Managing the Syndrome and Avoiding the Adverse Consequences;  Arch Surg. 2009;144(4):371-376; Charles M. Balch, MD; Julie A. Freischlag, MD; Tait D. Shanafelt, MD

Related Blog Posts

Doctors With Depression (September 24, 2009)

How Not to Do Buttocks Enhancement

 Updated 3/2017 -- all links removed as many no longer active and it was easier than checking each one.

In this day and age when physicians are facing being rated like the local plumber or restaurant on Zagat, it astounds me that anyone would allow a non-physician to perform cosmetic enhancement “injections” in their home.  That seems to be what women in Florida have done to the detriment of their health (ABC Action News).

Two women who wanted cosmetic injections to enhance their bottoms are now recovering in a Town N' Country Hospital with severe infections. 

Deputies say Andrea Lee and Zakiya Teagle thought they were getting injections that were safe and would provide them with the appearance they wanted.  Instead, the person who injected them apparently is on the run and detectives want to find her.

Hillsborough County Sheriff's office says Sharhonda Lindsay of Tampa is wanted for practicing medicine without a license. A warrant for her arrest was issued Monday.

They say Lindsay injected the women's buttocks several times and was paid hundreds of dollars for her efforts.   But after leaving her home, the two were in so much pain and had to go to the hospital for treatment.

On Monday night, one of the two women was in critical condition after her kidneys stopped functioning.

While there are safe ways to cosmetically enhance buttocks, silicone injections is not one of them.  Silicone injections into soft tissue in the United States has been illegal for many years now.  Silicone injections into the face and breasts were once used for enhancement in those areas, but led to many disfiguring problems.

When liquid silicone is injected into soft tissue (face, breasts, buttocks) it can migrate to other areas.  The body often reacts to the silicone by forming benign tumors called siliconomas.

Good physicians won’t do liquid silicone injections.  They will use fat injections.  They will do buttock implants.

Safe methods for buttocks enhancement include:

Micro-fat grafting

Buttock Reduction/Contouring

Gluteal Implants

Buttock Lifts

Combination of the Above

It is important to go to a well trained plastic or cosmetic surgeon.  Do not go to a friend who offers to do the injection in their home.

Sources

List of Legal Injectable Fillers (FDA)

Suture for a Living post on Buttocks Enhancement

Eight Too Many

 Updated 3/2017 -- all links removed as many no longer active and it was easier than checking each one.

I want to begin this post by basing it on “facts” reported in the news (ABCNews, Reuters, LA Times, Times Online):

• single 33 yo mother, self described “professional student”

Nadya Suleman, who describes herself as a “professional student” who lives off education grants and parental money, broke up with her boyfriend before the birth of her first child seven years ago.

• six children, ages 7 yo, 6 yo, 5 yo, 4 yo, 3 yo, and 2 yo twins
• residing with her parents in a three bedroom home 
• single mother’s own mother reports that her daughter used infertility treatments
• recently gave birth to EIGHT babies, 

  The babies were born by Caesarean section nine weeks premature and ranged from 1 pound, 8 ounces to 3 pounds, 4 ounces. The woman was carrying 24 pounds of baby.

• plans to breast feed (or more correctly use breast milk donated by other women to supplement her own)
• source of income  (see above) – education grants and parental money though recently reported

THE single mother of octuplets born in California last week is seeking $2m (£1.37m) from media interviews and commercial sponsorship to help pay the cost of raising the children.

• no mention of her insurance coverage, if there is any

I want to try to avoid the issue of fetal reduction and concentrate on some the other issues I find troubling.  
She seems (evidence is the six children she already has) to have had no need for infertility treatments.  So why did any fertility clinic take her own as a patient?  Were they more greed driven than patient driven?  That is my (outsider) view.
Human females were not made to have litters, and that is what eight babies to me is.  Sorry if I offend someone, but the risk of health issues related to such a pregnancy are multiple and serious: 

• miscarriage, pregnancy-induced hypertension/stroke, preeclampsia, gestational diabetes, acute polyhydramnios, vaginal/uterine hemorrhaging, and preterm labor & delivery.

The preterm labor and delivery is a “given”.    The length of pregnancy is usually 39 weeks for singletons, 35 weeks for twins, 33 weeks for triplets, and 29 weeks for quadruplets.  Generally, once the pregnancy reaches about 32 weeks, the complications associated with premature delivery are significantly reduced. 
Risks of complications to mother from premature delivery (incomplete list)

• Surgical and medical issues related to C-section
• Emotional issues
• Fatigue even if she has enough support

Risks of complication to each baby from premature delivery (incomplete list)

• Inability to breathe or breathe regularly on their own because of underdeveloped lungs
• Feeding and growth problems because of an immature digestive system
• Intracranial hemorrhage (bleeding into the brain)
• Hearing or vision problems related to immature nerves or treatment side effects
• Developmental delay and learning disabilities from brain damage related to immaturity
• Special problems for low birth weigh babies (less than 3.5 lbs)

Who pays for all of this and should we care?
Each one of these babies weighed less than 3.5 lbs.   Lets assume they all live (and I hope they do and that they beat the odds and don’t have any major long-term health issues). 
Median cost for NICU care (29 wk, 58 day stay in 1999) $61, 724 for each baby

The state of California is bankrupt.  The cost of each of these babies just for the first year of life is going to cost the California taxpayer more than I can imagine. 

I agree that the woman has the right to have more children, but I only agree to that IF she has the ability and resources to take care of them at the time she has them (I’m allowing for future unforeseen calamity).  I do not think she or anyone has the right to take money from my pocket that I could use to help my children (if I had any) or my nieces or nephews get their medical care or allow them to go to college.  Nor should I support her children instead of helping out my elderly parent.

Though it appears now from the Times Online that she is attempting to turn the birth of her eight babies into a source of income.  I hope she will remember to pay the hospital and doctors.  I hope she will put money into the continued health expenses these eight preemies will have. 

Although still confined to an LA hospital bed, she intends to talk to two influential television hosts this week - media mogul Oprah Winfrey, and Diane Sawyer, who presents Good Morning America.

Other Blog Posts on This Topic
Fat Doctor – Six and Eight
Medical Quack -- Obsessed with Having Babies?  Update on the Octuplets Story
Survive the Journey --Nadya Suleman's Octuplets -- How Many is too Many?
Dr Rob -- Don’t Forget the Kid(s)
NeoNurseChic – The Ethics of Octuplets
Moof -- Ooooopsie
Dr Cris – Making Babies or Saving Lives


REFERENCES
Multiple Pregnancies, Maternal Risks – Womens Health Channel
Multiple Birth Pregnancy – University of Pennslyvania
Premature Babies – Medline Plus
Premature Births – March of Dimes

Do Overs

Earlier this year I saw a breast reduction patient whose surgery I did early in my career and with her permission I am sharing this.

I did her breast reduction using an inferior pedicle technique for the safety of the blood supply to the nipple-areolar complex. She came back to see me because her nipple “sits too high”. Actually, the nipple doesn’t set too high. The distance from the sternal notch to the nipple (SN-N) is the correct length for her height. She has what we call “bottoming out”.

Notice how the breast tissue seems to have slipped down the chest and no longer sits behind the nipple/areolar complex.

When I saw her again, I couldn’t help but think about how I would do her surgery differently today. I am at a different point on the learning curve than I was then, so I have tried not to be too harsh on myself. Still, I would have used a superior-medial pedicle. That simple change would have (most likely) kept her from this visit. Superior-medial pedicles rarely if ever “bottom out”.

Another thing I would have done differently is the incision/scar. I used the Wise–pattern and she has an anchor-shaped (or inverted T) scar with a periareolar circle. She has a long (looong) inframammary scar. Today, even when I do need to use the Wise pattern incision, I can often half the length of that inframammary scar. Today, I do many more using just the vertical scar and periareolar circle so there is no inframammary scar. That technique has really only become popular and accepted as safe in the last 10 years.

I can’t go back and “do over” her surgery from the very beginning with my knowledge and skills of today. Fortunately (and I do feel blessed that she understands that), she doesn't blame or fault me. It is me doing the soul searching and wishing I could go back.

The best I can do for her is correcting the “bottoming out” which I find easy to do. I just wish there were no need for it.

To correct the bottoming out, I mark (as can be seen in the photos above) the true inframammary crease. I measure 6-7 cm from the nipple and plan a wide elliptical excision of the inframammary scar. In this woman’s case, the old scar fell near the center of the ellipse. I then excise skin only, do a minimal undermining superiorly, reshape the breast tissue with some heavy vicryl sutures, and then close the incision. Here are some post-procedure photos.

Plastic Surgery Posthumous

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

The recent article referenced below (HT to Kevin MD who HT’d Dr Tony Youn) reminded me of a conversation I had with a patient early in my career. She was a young widow. She was back in my office for a follow up visit after surgery. We got off on her grieving, her husband's illness, and other topics. He had died from a tumor in his lower face /upper neck that was inoperable due to the way it was connected and invading the structures nearby (think carotid and inferior jugular). It had left him very disfigured. She told me she regretted not being able to have an open casket funeral for him.

“I hope you don’t find this strange, but I wish the tumor could have been removed after he died. Then we could have had an open casket funeral.”

I blurted out "I would have removed for you."

"Really, you would?" she said.

"Yes, I would have."

"Thank you, Dr Bates. That would have meant the world to me."


Thinking back, I'm not sure why I blurted it out other than the connection we had at the moment. I don't regret saying it. I meant what I said to her. Inoperable tumors become operable after death because you don't have to worry about the blood supply to the brain anymore. You no longer have to worry about whether they might stroke out if you disrupt that supply. So debulking a tumor so the deceased looks "more normal" would be feasible. It would also be good practice for a young surgeon doing the dissection without worry of harming the person.

I don't think I would ever want to be part of doing a posthumous face lift or blepharoplasty or other cosmetic procedure, but I would be willing to debulk tumors if it would help families or individuals say "goodbye" more easily.

REFERENCE
Final Touch: A Cosmetic Lift for Your Funeral? by Diane Mapes; MSNBC, Dec 9, 2008
Hat Tip to Kevin MD: Do you want to look better dead than alive? who Hat Tipped Dr Tony Youn: Plastic Surgery by Morticians? Not Really....

Mama said there’d be days like this

Updated 3/2017--photo/video and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.  

(cartoon photo credit)

The above is a cartoon that was in the paper on December 2, 2008. In reviewing my twitters that morning (prior to reading the paper), I saw this one from Vijay to which I responded.

scanman wondering if @Bongi1, @rlbates & @DrCris have such days http://is.gd/a0dH :P

rlbates @scanman Regarding: have such days http://is.gd/a0dH Fortunately not in the OR, but with quilting and life. Worry about it sometimes.

This has been on my mind a lot lately. I have been trying to find a way to put it into words. Another female surgeon who sews, the Stitching Surgeon, recently had a day like this with her sewing.

stitchinsurgeon spent the last 3 hours with my embroidery machine...every project ruined! going to the YMCA to work out some of this frustration! 1:32 PM Dec 1st

Then the next day she posted some lovely work she had done and said this:

I set up my embroidery machine and while it is working I am hard at work on my Bernina.
I'm just "sew" efficient.

When I am sewing and I find that things aren’t going right, I’m ripping out every other or every seam and having to redo them or making cutting errors and “wasting” fabric, then I just put the project aside for the day. I go do something else just like Stitching Surgeon did. If I had a day like that in the operating room, I would not be able to do that. I would have to finish what I had started. It would have to be done right. I do think that there are days for me, both in the OR and in sewing, where things just seem easy, almost magical. There are other days when I seem to struggle more than I would like, but I haven’t had any days (thankfully) where I have felt like I would (and by extension, the patient would) be better off if I could do the surgery another day. Still the thought lingers with me.

So let me leave you with the song (video) the title was taken from

Work in Progress

I did my general surgery residency in Wheeling, WV. When this fabric was “issued” more than 10 years ago, I knew I “had to have it”. There were 33 different fabrics in the collection called “Victorian Wheeling” which was designed by Jennifer Simpson. I bought a set that included a fat quarter of each fabric. I put it away. Recently I decided I really needed to decide what to do with it.

After a false start, I settled on the spool block. It seems right to me. It combines my sewing (the spool of thread) and does a nice job of showing off the fabrics.
Each spool block is six inches square. I machine pieced each block, but when I sewed the blocks together by machine I didn’t like the way the “points” came together. I took them apart and sewed the blocks together by hand. The quilt is going to be a wall hanger. I’m going to add a black border with more spools in the corners. I think I may hand quilt this one, but am not sure yet.

Women in Surgery

 Updated 3/2017--photos and all links removed as many are no longer active and it was easier than checking each one.

I have noticed several posts / articles on women (or the lack) in surgery.
Women in Surgery; The Differential: Medscape Med Students; Lucia Li; August 1, 2008

In one of my regional placements, I met a surgeon who said that “women are killing surgery”; what he meant was that as the majority of medical graduates are now women, most of them will shun surgery for its stereotypes. This will reduce the number of good candidates going into surgery, lowering its standards. Surgery needs to attract women for continued excellence in practice. I am uncertain about the benefits, or even the need, for positive discrimination, but educational initiatives which promote surgery as a realistic career option for women are vital.

WSJ article: Women Remain Scarce in Neurosurgery; Jacob Goldstein; August 14, 2008
WSJ article: For Female Surgeons, Barriers Persist; Jacob Goldstein; August 16, 2008
Mothers Don't Let Your Daughters Grow Up to be Doctors; posted by Fizzy, Mothers in Medicine Blog; August 18, 2008 [not just don't let them be surgeons, but don't let them be doctors]

I went looking for more information:
Women in Neurosurgery, WINS
Association of Women Surgeons
Women in surgery: do we really understand the deterrents?; Arch Surg. 2006 Apr;141(4):405-7; Gargiulo DA, Hyman NH, Hebert JC

MAIN OUTCOME MEASURES: Potential deterrents to a surgical career.

RESULTS: Men and women had a similar interest in a surgical career before their surgical rotation (64% vs 53%, P = .68). A similar percentage developed a mentor (40.0% vs 45.9%, P = .40). Women were far more likely to perceive sex discrimination (46.7% vs 20.4%, P = .002), most often from male attending physicians (33.3%) or residents (31.1%). Women were less likely to be deterred by diminishing rewards (4.4% vs 21.6%, P = .003) or workload considerations (28.9% vs 49.0%, P = .02). They were also less likely to cite family concerns as a deterrent (47.8% vs 66.7%, P = .02) and equally likely to be deterred by lifestyle during residency (83.3% vs 76.5%, P = .22). However, women were more likely to be deterred by perceptions of the "surgical personality" (40.0% vs 21.6%, P = .03) and the perception of surgery as an "old boys' club" (22.2% vs 3.9%, P = .002).

Women in General/ Trauma Surgery; The Student Doctor Network Forum; thread began in 2007 and continues
Women in Surgery--Past, Present and Future; Dixie Mills MD; Department of Surgery, Maine Medical Ctr; Sept 2003 (PDF)
Website of the week--Women in surgery; BMJ. 1999 September 25; 319(7213): 860; Douglas Carnall
Women in Non-Traditional Residencies; P&S Journal: Spring 1995, Vol.15, No.2; By Kristen Watson

The daughter of a neurosurgeon, Dr. Epstein claims that following in her father's footsteps was a "congenital defect." Aspiring to be a surgeon since age 4, ..........

Dr. Epstein says most women in medicine do not pursue academic posts because they are actively discriminated against in the university setting. She also claims that female neurosurgical attendings in university positions are assigned less interesting cases and are given less operating time. "You have to have tremendous determination and work twice as hard for the recognition," Dr. Epstein says. And she does work hard, with more than 80 published works to her credit, some in collaboration with her father.

"We need more women to go into surgery and stay in it," Dr. Epstein says, "women who don't choose the 'mommy track'-working 9 to 5 just three days a week. We need more women in surgery full time." Dr. Epstein says it is not impossible for female doctors to manage both a full-time career and a family, but, like most of her peers, she has no children.

There are many more articles, but I'll stop there. It would appear that things have not changed much over the course of time.   I'm not sure I agree with Dr Epstein on managing a full-time career and a family.  As with the male surgeon, I think that would greatly depend on your spouse.  I do think it has to be very tough to do, but balancing life's responsibilities is tough anyway you look at it. 

I can't say that I was encouraged to become a surgeon. There was one female general surgery resident, one female orthopedic resident, one female ENT resident, no female urology residents, and no female neurosurgery residents at UAMS when I was a student and no female surgeons on staff in any surgery department. [I left out the Ob-Gyns simply because they are in a department of their own, not because I don't consider them surgeons.]  Currently at UAMS the dean is a female pediatrician, Debra Fisher MD. Here are the current female surgeons on staff at UAMS.

General Surgery

• V. Suzanne Klimberg, M.D. (Surgical Oncology--Breast)
• Anne Mancino, M.D. (Surgical Oncology -- Breast)
• Diane H Rhoden, M.D. (General/Endoscopic Surgery)
• Ronda Henry-Tillman, M.D. (Surgical Oncology -- Breast)

ENT (Otolaryngology)

• Lisa Buckmiller, M.D.

Ophthalmology

• Laurie Gray Barber, M.D.
• Romona L. Davis, M.D.
• Inci I. Dersu, M.D.
• Bhairavi V. Kharod, M.D.
• Nicola M. Kim, M.D.

Orthopedic --

• Ruth L. Thomas, M.D.

Urology -- None
Plastic Surgery (there wasn't a plastic surgery dept when I was a student and still no residency program)--None
Neurosurgery -- none

When I was a student, I looked up to the two female surgery  residents (the general and orthopedic mentioned above). I did receive a small amount of mentoring from the orthopedic resident, but had no true contact with the general surgery (she was finishing up when I was a 3rd year student). I fell in love with surgery as a third year student. I wish I had used the female ortho resident more as a mentor and maybe found a staff surgeon to use as a mentor. I wish there had been more encouragement along the way, but there is no reason to rehash the past here.

I would encourage any female student interested in surgery to actively find a mentor (male or female). Don't let anyone talk you out of it.  We need good surgeons, male or female.

A Surgeon's Outburst

 Updated 3/2017--all links removed as many are no longer active and it was easier than checking each one.

I'd like to comment on the recent Boston Globe article on surgeons' outbursts and also on Maggie Mahar's post, Surgeons and Other Physicians: A Cultural Divide.  Both seem to be painting surgeons as the ogres or bullies of the medical community.  I'd like to think that I am neither.  There are better examples of surgeons than the Alex Baldwin character in the movie Malice. 

I agree it is not good form or good for the patient for these outbursts to occur, but generalizing to the point that most of your readers would think that 90% or more of surgeons behave this way is wrong. I have never thrown any equipment and rarely gotten angry to point of raising my voice or screaming in the OR. Each time I did, the nurse told me I was right.

I have witnessed some of the examples given in the article. Yes, those surgeons should be counseled and most likely should even be required to go to anger management classes. BUT maybe the reason for their anger should also be sought.

Was the faulty equipment putting the patient at risk? It is very frustrating to try three pair of scissors before you get one that will cut tissue or to have the electrocautery machine not work so the circulating nurse (bless her) has to go find one that does. Perhaps the hospital is at fault for not updating and replacing defective instruments and equipment.

Did the surgeon have to finally say "no more" to extraneous people entering the room? I have done that a few times. Someone comes in looking for a piece of equipment stored in the room you are working in (why wasn't it taken to the other room before my surgery got started?). Someone comes in to ask where such and such is (usually a new person who hasn't been properly oriented). My tolerance is such that I can take several (justified) interruptions in one case, but there is always a tipping point. Raising my voice to get the crew who is supposed to be helping me with my case refocused is my way of dealing with it, not throwing things. Still I would prefer to not have the issue.

Did the surgeon have to ask the nurse (or another crew person) to make their personal calls later? I have had to do this a few times, especially now that everyone has a cell phone. I try to be considerate when that person has a loved one in the hospital and are trying to get updates. Still, if they can't focus on their work (someone else's loved one) then maybe they should have taken the day off.

Those are just a few examples. I agree that we should never throw anything in the OR, but I do expect the equipment the hospital provides to work. I do expect the personnel they use to be professional and properly trained. I think of myself as part of the team, but that means we ALL have to put the patient first and work together.

Now let me give you some better examples of surgeons

• Dr. Eli Blumfield (played by Alan Arkin) from the movie The Doctor.  The one that William Hurt's character picked to do his surgery.   He was not only a great surgeon, but a good person.
• Benjamin Franklin "Hawkeye" Pierce (Alan Alda) from MASH, don't recall ever seeing him throw anything in the OR.  He mostly directed his anger at the policy makers, not the OR staff or patients.
• BJ Hunnicutt (Mike Farrell) from MASH, a gentle soul who missed his wife and daughter.  He didn't disrupt the OR with temper tantrums either.
• Sherman T Potter (Harry Morgan) from MASH, who kept Hawkeye and the others in line.  A good surgeon and administrator.
• Dr Richard McCarthy (real-life orthopedic spine surgeon) who was featured in an episode of Extreme Surgery back in 2004.  I was a medical student when I first meet him at Arkansas Children's Hospital.  He is a very good surgeon and a gentle man.  He is very highly regarded by all -- administration, nursing staff, colleagues, patients, etc.  I tried to find the episode link so you could see him in action, but failed.
• Dr. Sanjay Gupta, neurosurgeon and CNN correspondent.  Though I have never been in an OR with him, he doesn't seem as if he would be the type to throw tantrums.
• Dr Bruce Campbell, ENT and fellow blogger.  I have not been in the OR with him either, but you get the sense of a someone who is respectful and civil when reading his posts.
• David A. Kappel, MD, a plastic surgeon in Wheeling, WV.  I was influenced by him as a general surgery resident.  Someone who is very good at what his does, treats his OR crew well, and is a wonderful human being.
• Dr Dale Morris who was a general surgeon here in Little Rock, AR for years.  He has retired and is missed.  He was/is a very kind and skilled surgeon who always treated everyone well.

Let me also say that I am blessed to have had several good nurses and OR scrubs over the years teach me how to work as a team.    To name a few -- Jeannette Murphy, Vivian Mitchell, Joe Roe, Becky Bennett, and on and on.

You may also want to read this article from the WSJ and it's comments from last month on "Better Hospital Manners by Mandate".

Comfort

My friend's dad died this past Thursday. His death was not unexpected, as he had severe Parkinson's Disease (previous post). I have known this family for nearly 40 years now. My friend and I have been friends since we both moved to Vilonia in the fourth grade. Her mother taught business classes there. We took her typing class.

My friend lives in Rowlett, TX and was due to arrive at her parent's home Saturday afternoon. So I drove up to visit with her and her family. I beat my friend by a few hours. I ended up spending several hours there, watching people come and go. Mrs. R and I were the only two there for an hour or so. Her words "I'm going to go to the back room and make some more calls. I don't feel bad about leaving you in here alone, because you're family. You know what I mean?" She left me to make some calls for her to local hotels asking about rates for out-of-town family and friends.

I was struck by all the food that visitors brought. I was enlisted to help put some of it into zip-lock bags or other containers so that it could be frozen. We cleared the kitchen counter of pies, cakes, rolls, and casseroles that would freeze. They told me they had already done this once. And yet with the next wave of folks, more food came. The counters quickly filled up again.

I didn't take food. I had read somewhere about 5 years ago (Hints for Heloise or Ann Landers) that families with illness or deaths in the family often needed supplies/staples. It listed items like toilet paper, paper towels, paper plates/utensils, Kleenexes, coffee/creamer, note cards with stamps, etc. So that is what I have begun to do.

Mrs R encouraged all her visitors (would-be-comforters) to eat. Then she would try to get them to fix themselves a plate or two of food to take home. Part of this was simply her good nature of caring for folks. Even in this time of her grief, she was trying to take care of others. Part of it was as she explained, the need to reduce the food in the house. The family was feeling overwhelmed by the food and didn't want it to be wasted or go bad before they could eat it. Yet they were running out of freezer space. Mrs R at one point asked "Why do they all feel they need to bring us food?"

Here in the south, that seems to be the way we are raised. Funerals and the family visitations seem to be a time of feeding and by extension eating. Food is very much associated with comfort. We don't seem to be able to just go and sit and listen and tell stories and share photos/memories without taking something to the family. We want to "feed" them as a way of trying to ease "this difficult time". I would have felt "guilty" or as if I had let my own mother down if I had not taken something. But I think for my friends, they would have been happy for me just to have come as I did and spent time.

It felt funny to me to leave with a plate of food, but it made Mrs R feel better. She wanted me to take two or three plates.

Thoughts on this July 4th

A recent post by Bongi and our upcoming July 4th has had me thinking about our Civil War. More accurately the fact that I am very glad that my country is still a united country.

My husband is a Civil War buff. In fact for his 40th birthday, we had a "period" dinner party at Marlsgate Plantation. We all dressed in Civil War period clothing. Some friends (a husband and wife) who did re-enacting helped outfit us all. She helped us women with our hair and jewelry. He brought his banjo and played for us after dinner. It was a wonderful evening. At the end of this post you will find some photos from that night.

My husband's fascination with the Civil War is the guns (the actual machinery, engineering, etc), the battles and strategy. None of that matters to me. The reading I tend to gravitate towards regarding that time period focuses on the home front, the ones left to tend the farms and keep the communities going. It is a period in America's history when many soldiers died, but so did many civilians. Most of the battles and therefore the destruction of homes and farms took place in the south. Both armies were unkind in how they conscripted (took, commandeered, stole)supplies, often taking the last chicken or cow from a family. Yes, the soldiers were starving, but so were the civilians. And often the civilian was killed (or if female, raped and then killed) if they resisted and tried to save that last cow so their children would have milk. Anyway.........

I won't/don't downplay the slavery issue, but another major reason for the war was the struggle over state versus federal rule. Because of the Civil War, it doesn't really matter that California passes a state law legalizing medical marijuana. The federal law supercedes the state law.

Recently this played out again with the Supreme Court ruling that it is not legal to use the death penalty for rape, even of a child. So the federal ruling overturns the state.

Many states struggle with the right (or wish to cancel that right) of legal abortion. The federal law supersedes the states. States try to find way around this. We as a country manage to do this by peaceful (mostly) means these days. New laws are passed and then challenged in court. Much ranting is done in blogs/letters to the newspaper and not by violence (mostly--I know there are still some clinic bombings).

Then there is the struggle of personal versus state/federal rights. In medicine, we are touched by this in struggles with the right to die (think Terri Schiavo).

The struggles continue. The push, the pull. We don't always agree on what is right. I don't think a pharmacist should have the right to NOT sell a drug that that federal/state laws say are legal for me to write a prescription and the patient to take. Still that is a current struggle.

I love that in this country we can disagree with each other, and at the same time still respect others rights to be different from us. I love that we can hold an election and have a change in the White House without riots in the street. I know we Americans are not perfect, but I still love my country and its people.

Happy Birthday America!

A Few Book Recommendations:

Civil War Women, the Civil War seen through women's eyes in stories by Louisa May Alcott and others; edited by Frank McSherry Jr, Charles G Waugh, and Martin Greenberg

Yankee Women, Gender Battles in the Civil War by Elizabeth D Leonard
Women in the Civil War by Mary Elizabeth Massey
The Civil War Diary Quilt: 121 Stories and the Quilt Blocks They Inspired by Rosemary Youngs
Pattern Source:  Period Impression Patterns

This is my husband, Brett Herndon, and I (1996). I made his uniform (the vest and pants you see and a jacket) and shirt. I also made my dress. Thank God the sewing machine had been invented. I did the button holes by hand (to be authentic, as my husband put it).

Buddy and Brenda McCutcheon. They were also into re-enacting. She actually helped "dress" all the ladies and did our hair so that we would look like we were from the 1860's.

Our neighbors and friends, Amy and Bill Gatewood. Don't they look like they just stepped out of the past? 

Letica and Ralph White. We were a "civil" party with both sides represented.

Raymond and Caroline Boyles. Raymond has gone to a few re-enactments with Brett.

Jay and Vickie Morgan. His pants are a little short because they were my husband's. Still I think they both look wonderful.

Hi!

Updated 3/2017-- video and all links (other than to my own posts) removed as many no longer are active and it was easier than checking each one.

Dr Rob's recent post, Hi Doc! got me musing about my encounters with patients outside of the office. Very often the reactions to a plastic surgeon aren't the same as the reactions to the family physician.

I get some who readily want to acknowledge that they know me. This can be in the "groupie/fan" kind of way or "friend (want-to-be)" kind of way.

The "fan" is happy to tell anyone who is present "This is the doctor who did my breasts. They are just perfect. Dr Bates' is the one I've been telling you to go see." This one I sometimes enjoy, even though I often am embarrassed by their gushing. I have had to stop a few of these from showing off their scars in the store. One even offered to show my husband "my work" (which I did not allow).

The "friend" -- "Hi Ramona. JB, this is my plastic surgeon. The one who did my scar. She's the one we need to go see for our BOTOX." In the back of my mind, I can't help wondering if this one is "fishing" for a discount for bringing me business.

Then there are the ones who don't want to acknowledge they know me professionally. "Didn't I meet you at that charity event?" "I remember meeting you at C and D's." I try to play along without resorting to bald-faced lies. They don't want whoever is with them to know they have seen a plastic surgeon. They might have to explain why.

There are some who don't even want to acknowledge they have met me in any capacity. You can see the fear in their eyes begging "don't know me, don't know me". These I will just smile at and once again taking their lead take the "friendly stranger" interaction. They really don't want anyone to know they have seen a plastic surgeon. They can't think of any other reason they should know me to give to their friends/colleagues. The one I remember the most was a young reporter years ago. I had done a breast reduction for her and happened to see her in a store where she was setting up to broadcast a report.

For this last patient, it helps that I don't really look like most peoples idea of a plastic surgeon. In fact, if I was to be on the game show, Identity, I would probably be a stumbling block for most. When you run into me at Wal-Mart of Kroger, I will often be in jeans or shorts and look like I could use Stacy and Clint's help with my wardrobe.

I'm happy to acknowledge you if we meet in the public eye, but if you don't want to acknowledge me that's okay too.   If you do want to talk to me, let's try to keep it social.  Remember I'm "off work".  As Lynyrd Skynyrd puts it "if you want to talk fishin, I guess that'd be okay"  or in my case dogs or quilting.

The Philoctetes Project

Updated 3/2017-- all links removed as many no longer active as it was easier than checking each one.

Yesterday I received my Phi Beta Kappa "The Key Reporter" spring 2008 issue in the mail. There was an article titled "The Difficult Patient, a Problem Old as History (or Older) by Abilgail Zuger. It was linked to the next article "About The Philoctetes Project" by Bryan Doerries.

If you happen to live near enough to Bard College (Annandale-on-Hudson, NY), you can attend for free this Saturday, March 22, 2008, at 2:00pm. There will be a dramatic reading at Bard College's Richard B. Fisher Center for the Performing Arts, featuring: Michael Stuhlbarg, Jesse Eisenberg, John Schmerling, and Adam Ludwig, followed by a panel discussion with: Norman Austin, Daniel Mendelsohn, Alice Quinn, and Jonathan Shay.

If like me, you live too far away, you may Click here to watch a recent performance of Philoctetes. It is well worth it!!!
Click here to participate in the ongoing discussion about The Philoctetes Project.

Check out Dr Sid Schwab's recent post: Time for Tears, Tears for Time

What are the odds?

It was a quiet late summer Saturday afternoon. The pager went off. The message--Call TT at 555-5555.

I always do a mental check list of possible problems when I recognize the patient's name. This one had had a tummy tuck done 6 weeks previously. She had healed with no problems or issues. She hadn't asked for a refill on pain medication. All of her follow up visits had been routine. I couldn't begin to image why she was having me paged.

"TT, this is Dr. Bates. How can I help you?"
"Dr. Bates, my incision has popped open!"
"Slow down and take a deep breath. Try to stop crying and repeat what you just said. I'm not sure I understood you."
"I fell when I stepped out of the boat. I landed on some gravel and my incision on my right side has opened up."

"Okay, where are you and how long do you think it would take to get to my office? The building is locked because it's Saturday, but I can get us in. I'll look at you there and if I can I'll fix it for you there, I will." No need to further stress her with the possibility of surgery at the hospital. She was already thinking of the added cost of this, having maxed out her savings and credit to have the initial surgery. "Just come on"

"It'll take us about two hours. I'm all dirty. I need to change clothes."
"Don't worry about your clothes, just come."

Boy, was I surprised! As my husband likes to say, "you can't make this stuff up". This is not a "complication" that you warn patients about after surgery. This is different from wound dehiscence. This literally was a healed wound that had incurred the pressure of the fall onto one rock with the point of maximum force right over the healed scar at her right hip. Scars at 6 weeks are only at approximately 55% of the final strength that will be reached at approximately 10-12 weeks post-injury. Even then scars only have 80% of the tensile strength of uninjured skin. But what are the odds.........

When they arrived at my office, I found an open wound about 18 cm long, gaping nearly 5 cm at the widest point. It was centered over the right anterior hip bone. There was dirt, grass, and small gravel in the wound. There was no active bleeding . I got her to lay down on the exam table and did a local block using 0.5% Lidocaine with Epi and 0.5% Marcaine without Epi. Then I thoroughly cleaned the wound out with normal saline and Betadine solution, picking out the grass and gravel. Cleaned some more. Then I closed the wound with vicryl and PDS. I reassured her that most likely in two years, we wouldn't be able to tell which part of the scar had been reopened. I sent her home on antibiotics, but she declined pain medicine (had some left over from the surgery). Both TT and I were relieved that it wasn't any more serious than it was.

Now when patients ask for 100% guarantees of their postop courses, I use this example of how even best laid plans can be changed by "life", the "universe", whatever. Some things are not in our control. I tell them I will do everything I can to ensure a good outcome. I ask them to help me by following instructions and using common sense. But what are the odds.....

Review of Medical Expenses--Update

This review was first posted on December 14, 2007.  I have added a couple of paragraphs at the end, as well as some (blue ink) changes in the chart.

My friend who incurred the self-inflicted gun shot wound to his right forearm has gotten his medical bills. I ask him to allow me to review them. I was interested in what was billed and what the insurance company actually allowed. Notice how long it has taken to get everything (well not everything--ambulance services still pending review) through insurance review (late August until today). Here is the breakdown.

Service Rendered		Billed	Insurance Allowed	Patient Responsibility
Ambulance-- ALS Emergency Mileage ALS Pulse Oximetry IV Supplies Disposable Supplies		$488.00 $146.25 $36.00 $42.00 $42.00	$463.00 $     9.00 $ 27.00 $ 39.00 $ 16.00	EMT service has no contract with insurance company, so no reduction-- $754.25
Hospital Charges Radiology- Emergency Room Drugs		$836.32 $213.93 $554.39 $ 68.00	$459.98 (insurance didn't break it down on their statement)	$459.98
ER Doctor Charges		$273.00	just received (12-22-07) & sent to insurance	Paid $273 while waiting for insurance
X-Ray Reading		$28.00	$12.18	$12.18
Generic Pain Med		$4.06	$4.06	$4.06
Secondary Wound Closure (done in office)		$650	not actually billed (maybe $356 on hosp % reimburse)	not actually charged (maybe $356 as based on ER reimbursement)
At home dressing supplies		not covered by insurance $30.06	not covered $30.06	$30.06 (Coban, guaze, etc)
Total Expenses		$2,575.69	$1,416.28*	$1,889.53*

My friend has a Medical Savings Account so has a high deductible ($5700). The insurance coverage did decrease his actual out-of-pocket responsibility by "not allowing" $392.16 (more depending on the ambulance bill outcome). This is also money that the hospital and ambulance service did not receive. I know he is grateful for the savings. I, however, also see the other side. A reduction of nearly 50% seems absurd. Is the medical community really overcharging that much? Or are we charging fairly to cover the expenses of the hospital/office? Just as Wal-Mart has a built in "padding for loses" for each item sold (covers losses due to theft /shop lifting), the hospitals/offices need to be able to have the same "padding" to cover the services that aren't paid for by the patient (under-payment by Medicare/Medicaid, no insurance, simply doesn't pay, etc).

 

Update 12-27-2007

My friend received a bill from the ER doctor which is (apparently) separate from the hospital charge.  This bill arrived on December 22, 2007, nearly 4 months after the injury!  It had not even been sent to the insurance company first, even though I am sure the ER doctor had access to this information. 

Turns out the EMT (ambulance service) does not have a contract with his insurance so they balance bill for the entire amount. 

Marking

Updated 3/2017-- all links removed as many are no longer active and it was easier than checking each one.



Marking is very important in both my quilting and my surgery work. I don't mean the kind of marking that gives you "yellow snow" (nod to Frank Zappa) or the kind that leaves you a trail of crumbs to find your way home (Hansel and Gretel).

In plastic surgery, a lot of time can be spent in the preop area marking your patient. So you want a marker that won't wash off so easily that it is gone with the scrub. For breast and body "work", I use (and the nurses tell me so do most of the others) a black Sharpie.

It is marketed as a permanent marker, but I still find that I have to remind the person prepping the patient to not "scrub too hard" or "that's enough". When you have marked the patient standing or bending in different ways to be sure you get the most skin removed, these positions and maneuvers can't be duplicated in the operating room. During the procedure, I use whatever marker the hospital has, usually the Accu-line products. Those are also what I use when I need a really fine line (ie eyelid) when marking.

The skin marker should be nontoxic and non-allergenic. If used during the procedure, then it must be sterilizable. The ink must have a visible color and must be non-reactant  with other chemicals used on the skin (e.g., povidone iodine). The ink must be resistant to mechanical cleaning but removable in time.

The photo to the right is from the first article referenced below. Note how the ink "disappears" with the scrub. Their skin marking ink (1) and frequently used skin markers (2, methylene blue dye; 3, Securline, a surgical skin marker; 4, red permanent marker; 5, black permanent marker; and 6, Viscot, a surgical skin marker). (Center) Skin prepared with povidone iodine solution and scrubbed five times. (Below) Skin prepared with Betadine and scrubbed five times. Their marking ink --The formula consists of basic fuchsin (1.3 g of dye material), 5.6 ml of acetone (resolvent), 11 ml of alcohol (dissolvent), and 100 ml of distilled water. This formula may be diluted by adding alcohol.

In quilting, you want a marker that will stay long enough to see the pattern you are quilting. You want to be able to either "brush" it off gently later (as with chalk pencils) or to wash it out. The different colors of fabrics used can sometimes make this more challenging. For the quilt I am preparing for hand quilting, I used the blue washable marker on the "mustard" (light fabric) and a silver chalk pen on the brown (dark fabric). Here are some links to tips by experts like Ami Simms (blue washable marker), and Sharon Darling (Quilter's Choice Marking Pencil, Miracle Chalk).

REFERENCES
Skin Marking in Plastic Surgery; Plastic & Reconstructive Surgery, 115(5):1450-1451, April 15, 2005; Ayhan, Meltem M.D.; Silistreli, Ozlem M.D.; Aytug, Zeynep M.D.; Gorgu, Metin M.D.; Yakut, Macide M.D.
Quilt Tips From Quilters Around The World--Marking Tips
Appalachian Mountain Quilters Marking Techniques by Kimberly Wulfert

UAMS--my medical school

 Updated 3/2017-- photos and all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.


This weekend is my medical school's Alumni Weekend. My class graduated 25 years ago--1982. So my thoughts today are on my school and my classmates. I went to the University of Arkansas Medical School. Granted it is not Harvard or Yale or Stanford, but my classmates and I received a good education. I am proud of my school.

In 1879, eight physicians each invested $625 to secure the charter from Arkansas Industrial University (which later became the University of Arkansas). Together, they purchased the first physical facilities, the Sperindio Restaurant and Hotel located at 113 West Second Street, for $5,000. The school opened on October 7, 1879 with 22 students. In 1880, Dr. Tom Pinson became the first graduate of the Medical Department program.

Continued UAMS HistoryTimeline here:

The current UAMS campus looks like this. Current tuition/student expenses per year are approximately $33,920. I don't remember what it cost in 1978-1982, but I do know it was much less.

In September 2006, Debra Fiser became the first female Dean of UAMS. She had devoted her career to the University of Arkansas for Medical Sciences and the College of Medicine, her medical school alma mater. She had served 11 years as professor and chair of the Department of Pediatrics and was one of our staff physicians when we were medical students.

The student dorm that we lived in as students was imploded on February 19, 2006 to make room for new construction. The Jeff Banks dormitory was 45 yrs old. Many friends and memories were made in that student dorm. Medical students, nursing students, pharmacy students, etc all lived together in that building. I am looking forward to seeing all the ones who come to our pig roast and will miss the ones who are not able to come.