Ageism and Plastic Surgery

 Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

I admit that over the years my idea of “how old is too old” has changed.  Part of that is my increasing age, but a bigger part has come from the patients themselves – the 72 year old woman with a deflated NS implant who wanted it replaced rather than removed, etc.

Never Too Old for Plastic Surgery  (photo credit) By Tara Parker-Pope

If you think you’re too old for a few nips and tucks, consider the story of 83-year-old Marie Kolstad. ……….

To learn more, read Abby Ellin’s article “The Golden Years, Polished With a Nip and a Tuck,” …….

Don’t forget to read the comments of Parker-Pope’s article.

Still I have mixed feelings about what I see as not “aging gracefully” and tend to agree more with bioethicist Carl Elliott who is mentioned in Gary Schwitzer’s post:  Some reactions to NY Times' "Never Too Old for Plastic Surgery"

Minnesota bioethicist Carl Elliott wrote a book, "Better Than Well: American Medicine Meets the American Dream." In it, he wrote:

"We need to understand the complex relationship between enhancement technologies, the way we live now, and the kinds of people we have become."

I asked for his comment on the NY Times story, and he wrote:

"Everyone agrees that one root of the problem is toxic social pressures. The problem is that giving in to these pressures just reinforces them. The more cosmetic surgery older people get, the more social pressure that other older people feel to get the surgery themselves. (And articles like this just make the problem worse.)

Also, does anyone really think that cosmetic surgery actually makes these people look younger? What it really does is make them look as if they've had work done. And having work done is not so much a marker of youth as it is of money."

When is someone too old for plastic surgery?  There’s not an easy answer.  I think it comes down to an individual.  To their health.  To their reasons.  To their expectations. 

Related posts:
Suitability  (January 3, 2008)
“Suitable” for Plastic Surgery? (January 14, 2010)
Psychological Considerations of the Bariatric Surgery Patient Undergoing Body Contouring Surgery--An Article Review (September 22, 2008)

Following Instructions

“Take one to two pain pills by mouth every 4 to six hours”

To me that is clear.  I was reminded recently that it isn’t to all patients. 

A patient complained of lack of relief from her pain medicines after surgery.  Her description of the pain didn’t suggest any complications so I ask how she was taking them.  I was looking for a way to safely use NSAIDS or tylenol as a boost rather than giving her something stronger.

“I take one pain pill and then wait an hour to take another one.”
I prompted her to tell me when she took the next dose.
“I wait four hours and then take one pain pill, but I wait for six hours to take the next one.”

Ah!

I had mentioned to her and her caregiver that due to her small size she should begin with just one, then wait for 30 minutes to an hour to see if she needed the second one.  They were doing that, but the other part wasn’t clear.

“Take one to two pain pills by mouth every 4 to six hours”

1.  Take one pain pill every 4 hours.

2.  Take two pain pills every 4 hours.

3.  Take one pain pill every 6 hours.

4.  Take two pain pills every 6 hours.

….

Oh, but there are really more options aren’t there:

1.  Take one and half pain pill every 4 hours.

2.  Take one pain pill every 5 hours.

….

So she was taking the medicine in a correct way, but it wasn’t the optimal one for her.  We had a short discussion which seemed to help.

……………………..

There is much discussion about patients and compliance in taking medicine.  It starts with the physicians, nurse, and pharmacists.  I have to write good instructions.  Sometimes this is difficult to do and keep them short enough to go on the label.

With pain medicines it is nice for patients to know there is a range of effective, safe dosages. 

U.S. Pharmacopeia has proposed labeling standards which can be viewed here. Comments on the proposed standards may be submitted to 17PrescriptionContainerLabeling@usp.org through March 31, 2011.  One of the changes is:

Give explicit instructions—Instructions should clearly separate the dose itself from the timing of each dose and use numeric characters (e.g., “Take 2 tablets in the morning and 2 tablets in the evening” rather than “Take two tablets twice daily”). …

Ambiguous directions such as ‘‘take as directed’’ should be avoided unless clear and unambiguous supplemental instructions and counseling are provided (e.g., directions for use that will not fit on the prescription container label)

Positive Feedback

Yes, I know it’s my job.  Yes, I know the patient paid me.  But I love receiving notes like this.  Thank you.

Nutrition and Wound Healing

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

Nutrition, or rather the new USDA Dietary Guidelines, have been in the news this week.  It seem apropos to take not of a recent article in the supplement to the January issue of the Plastic and Reconstructive Surgery Journal discussing nutrition and wound healing (full reference below).

The article presents an update on new developments in the field of nutrition and wound healing, not an exhaustive review of the field.

As the authors point out “most operations in well-nourished patients are successful, with uncomplicated healing responses, even if nutritional intake is absent or curtailed for 7 to 10 days.”   It’s the patient with trauma, cancer, chronic illnesses, mal-absorption issues where this is most important.

First and foremost, the nutritional assessment should begin with a complete history and physical.  The authors reference the second article below for this statistic:

This alone has been found to be 80 to 90 percent accurate in evaluating patient nutritional status, and the addition of multiple or complex biochemical, immune, or anthropometric measurements does not increase greatly the accuracy of nutritional assessment.

Malnutrition should be considered if the history reveals unintentional weight loss (20% weight loss is indicative of severe malnutrition), if the patient appears cachectic with obvious muscle wasting, or if the patient has a history of or reason for alimentary malabsorption.  It must also be remembered that Obese Patients are at High Risk for Malnutrition in the Hospitalized Setting.

If the patient is found to be malnourished prior to an elective surgery, this should be corrected.  As the authors point out:

Determining who would truly benefit from nutritional supplementation is still a matter of some debate, but there is evidence that preoperative nutritional support reduces infectious complications and anastomotic breakdown in severely malnourished patients undergoing major elective surgery.

Postoperative nutritional support should be considered in patients expected to be unable to eat for a period of at least 2 weeks.

Other key points from the article:

• Enteral feeding is superior to parenteral feeding when possible.
• Fish oil supplements (omega-3 fatty acids) adversely impacts the healing response.
• Vitamin C deficiency, in addition to impairing wound healing, has also been associated with an increased susceptibility to wound infection.  Burn victims require as much as 1 to 2 g/day to restore urine and tissue levels to normal.
• Vitamin A deficiency impairs wound healing.  Vitamin A, administered either topically or systemically, reverses the antiinflammatory effects of corticosteroids on wound healing.
• The antiinflammatory properties of vitamin E are similar to those of steroids. Vitamin A can reverse the wound-healing impairment induced by vitamin E. Vitamin E has also been shown to affect various host immune functions, often in a negative fashion.
• Zinc deficiency impairs the critical roles each of these processes play in wound healing. Zinc levels less than 100 μg/dl have been associated with decreased fibroblast proliferation and collagen synthesis.

 

Related posts:
Nutritional Deficiency of Post-Bariatric Surgery Body Contouring Patients: What Every Plastic Surgeon Should Know -- An Article Review (September 3, 2008)
Herbal Supplements and Surgery Reviewed (April 30, 2009)
Local Wound Care for Malignant and Palliative Wounds – an Article Review (September 13, 2010)



REFERENCE

Nutrition and Wound Healing: An Update; Kavalukas, Sandra L.; Barbul, Adrian; Plastic & Reconstructive Surgery. 127():38S-43S, January 2011; doi: 10.1097/PRS.0b013e318201256c

Assessment of nutritional status; Jeejeebhoy KN, Detsky AS, Baker JP.;  JPEN J Parenter Enteral Nutr. 1990;14:193S–196S.

BDD Patients Can Get Better

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

The Science Daily article, Body dysmorphic disorder patients who loathe appearance often get better, but it could take years, discusses the The Journal of Nervous and Mental Disease (JNMD) article (full reference below, abstract available for free).  

The JNMD article reports the results of the longest-term study so far to track people with body dysmorphic disorder.  The study was conducted by researchers at Brown University and Rhode Island Hospital.

The good news:  the researcher “found high rates of recovery, although recovery can take more than five years.”

This is a small study with only 15 BDD patients who were followed over an eight-year span.

After statistical adjustments, the recovery rate for sufferers in the study over eight years was 76 percent and the recurrence rate was 14 percent. While a few sufferers recovered within two years, only about half had recovered after five years.

The subjects were a small group diagnosed with the disorder out of hundreds of people participating in the Harvard/Brown Anxiety Research Project (HARP). Study co-author Martin Keller, professor of psychiatry and human behavior and principal investigator of the HARP research program which has been ongoing for more than 20 years, said that because the BDD sufferers were identified through this broader anxiety study, rather than being recruited specifically because they had been diagnosed with BDD, they generally had more subtle cases of the disorder than people in other BDD studies. In comparing the HARP study with the prior longitudinal study of BDD, it is possible that the high recovery rate in the HARP study is due to participants having less severe BDD on average.

Body Dysmorphic Disorder

• In its simplest definition, it is an obsessive preoccupation with a slight, imperceptible, or actually nonexistent anatomic irregularity to the degree that it interferes with normal adjustment within society.
  
• This disorder may be present in varying degrees. It is the most common aberrant personality characteristic seen by the plastic surgeon.
  
• When postoperative dissatisfaction occurs (and in most cases, it will), it almost always is based on what the patient understood rather than what was actually said.
  

….
Related posts
Suitability (January 3, 2008)
The Barbie Syndrome  (March 25, 2010)
….

REFERENCE

The Clinical Course of Body Dysmorphic Disorder in the Harvard/Brown Anxiety Research Project (HARP); Andri S. Bjornsson, Ingrid Dyck, Ethan Moitra, Robert L. Stout, Risa B. Weisberg, Martin B. Keller, Katharine A. Phillips;  The Journal of Nervous and Mental Disease, 2011; 199 (1): 55 DOI: 10.1097/NMD.0b013e31820448f7

Body Dysmorphic Disorder; eMedicine Article, September 3, 2010; Iqbal Ahmed, MBBS and Lawrence Genen, MD, MBA

Factitious Disorder?

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

Have you ever seen a case of factitious disorder?  Ever had a patient who’s wound just wouldn’t heal in spite of all the good care you gave them, all the blood work you checked (ie nutrition, infection, etc)?  Ever wondered if perhaps this nice patient was doing something to themselves?

This recent case report in the December issue of the Journal of Plastic, Reconstructive & Aesthetic Surgery prompted me to look up the diagnosis of “factitious disorder.”  Here is the abstract summary (full reference below):

This case report presents the history of a 43-year-old man who sustained a relatively minor burn to his face but who subsequently suffered significant morbidity. Although the wound was grafted on a number of occasions, it failed to heal. Multiple investigations were carried out to determine the cause of recurrent wound breakdown. It had been suspected that the patient was interfering with the wound but this could not be proven initially. He was eventually diagnosed with factitious disorder and it was only when this was managed in the multi-disciplinary setting that his wound finally healed.

I don’t have access to the full article, but what I found when I looked up factitious disorder makes me wonder
The Cleveland Clinic has a nice overview of factitious disorder aka Ganser Syndrome aka Munchausen Syndrome (bold emphasis is mine).

Factitious disorders are mental disorders in which a person acts as if he or she has a physical or mental illness when, in fact, he or she has consciously created his or her symptoms. (The name factitious comes from the Latin word for "artificial.")

People with factitious disorders deliberately create or exaggerate symptoms of an illness in several ways.

The Cleveland Clinic website list the possible warning signs of factitious disorders include the following:

• Dramatic but inconsistent medical history
• Unclear symptoms that are not controllable, become more severe, or change once treatment has begun
• Predictable relapses following improvement in the condition
• Extensive knowledge of hospitals and/or medical terminology, as well as the textbook descriptions of illness
• Presence of many surgical scars
• Appearance of new or additional symptoms following negative test results
• Presence of symptoms only when the patient is alone or not being observed
• Willingness or eagerness to have medical tests, operations, or other procedures
• History of seeking treatment at many hospitals, clinics, and doctors’ offices, possibly even in different cities
• Reluctance by the patient to allow health care professionals to meet with or talk to family members, friends, and prior health care provider

I’ll pick on myself here.  In fact that is exactly why a small area in my left eyebrow has failed to heal as quickly as it should.  I keep picking at it, picking off the scab before it’s ready to fall off.  I don’t do it to create or exaggerate the problem.  It’s a nervous tick.  I’ve always been a scab picker (and, yes, I tell my patients not to pick at theirs).  It’s a trait that comes in handy as a surgeon who gets to debride wounds.

Don’t forget that some patients are simply like me.  Don’t forget that some may have a issue like this (Trigeminal Trophic Syndrome).  All these other possibilities must be ruled out before giving the patient the diagnosis of factitious disorder.

REFERENCE

Factitious Disorder as a differential diagnosis for recurrent skin graft failure; D.M. Seoighe, M. Dempsey, C. Lawlor, A.M. O’Dwyer;  
Journal of Plastic, Reconstructive & Aesthetic Surgery - 27 December 2010 (10.1016/j.bjps.2010.11.004)

Factitious Disorder; eMedicine Article, October 22, 2009; Todd S Elwyn, MD and Iqbal Ahmed, MBBS

Weight Lifting, Breast Cancer, and Lymphedema

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.

Last August, Kathryn Schmitz, PhD, MPH and colleagues published the results of their study Weight Lifting in Women with Breast-Cancer–Related Lymphedema in the New England Journal of Medicine.  They have now published a similar study in the Archives of Internal Medicine (see full reference below).

While the NEJM article focused on breast cancer survivors with lymphedema, the Archives article focuses on breast cancer survivors without lymphedema.

The new study adds weight for the need to change historic dogma which cautions breast cancer patients to avoid weight training after a mastectomy and or axillary dissection.

As noted by Schmitz, etc (bold emphasis is mine):

Breast cancer survivors at risk for lymphedema alter activity, limit activity, or both from fear and uncertainty about their personal risk level, and upon guidance advising them to avoid lifting children, heavy bags, or other objects with the at-risk arm.

Such guidance is often interpreted in a manner that deconditions the arm, increasing the potential for injury, overuse, and, ironically, lymphedema onset.

Adherence to these precautions may limit physical …. Furthermore, activity avoidance may deter survivors from performing regular exercise, which may prevent cancer recurrence and improve survival.

The randomized controlled equivalence trial (Physical Activity and Lymphedema trial) enrolled 154 breast cancer survivors (only 134 completed the study)  1 to 5 years post-unilateral breast cancer with at least 2 lymph nodes removed and without clinical signs of lymphedema.  Recruitment took place between October 1, 2005, and February 2007, with data collection ending in August 2008.

Participants in the weight lifting intervention group (n = 72)received a 1-year membership to a community fitness center near their homes. For the first 13 weeks, women were instructed twice weekly during 90 minute sessions on safe performance of exercises in groups of 2 to 6 survivors.

Upper body exercises (seated row, supine dumbbell press, lateral or front raises, bicep curls, and triceps pushdowns) were performed with dumbbells or variable resistance machines. Lower body exercises (leg press, back extension, leg extension, and leg curl) were performed with variable resistance machines. Three sets of each exercise were performed at each session, 10 repetitions per set.

After 13 weeks, participants continued twice weekly unsupervised exercise to 1 year. Weight was increased for each exercise by the smallest possible increment after 2 sessions of completing 3 sets of 10 repetitions with no change in arm symptoms.

Participants in the control group (n = 75) were asked to not change baseline level of exercise during study participation and were offered a 1-year fitness center membership with 13 weeks of supervised instruction following study completion.

Fewer women experienced incident BCRL onset in the weight lifting intervention group (11%, 8 of 72) compared to the control group (17%, 13 of 75).

The difference was even greater among women with 5 or more lymph nodes removed:  7% (3 of 45) in the weight lifting intervention group and 22% (11 of 49) in the control group.

Once again, this is a small group, but I lean more and more towards allowing motivated patients to begin weight-lifting with a slow, progressive program.   They should learn proper technique.  They should wear their custom-fit compression garment during all exercise sessions.

Weight-lifting has been shown to decrease bone loss which is important in these women as in all women.  Having more strength can also aid in everyday activities like carrying bags of groceries or carrying children/grandchildren.

 

 

REFERENCE

Weight Lifting for Women at Risk for Breast Cancer–Related Lymphedema: A Randomized Trial; Kathryn H. Schmitz, Rehana L. Ahmed, Andrea B. Troxel, Andrea Cheville, Lorita Lewis-Grant, Rebecca Smith, Cathy J. Bryan, Catherine T. Williams-Smith, Jesse Chittams; JAMA. Published online December 8, 2010. doi:10.1001/jama.2010.1837

Weight Lifting in Women with Breast-Cancer–Related Lymphedema; New England Journal Medicine, Vol 361 (7):664-673, August 13, 2009; Kathryn H. Schmitz, Ph.D., M.P.H., Rehana L. Ahmed, M.D., Ph.D., Andrea Troxel, Sc.D., Andrea Cheville, M.D., Rebecca Smith, M.D., Lorita Lewis-Grant, M.P.H., M.S.W., Cathy J. Bryan, M.Ed., Catherine T. Williams-Smith, B.S., and Quincy P. Greene

…….

Related Posts

Lymphedema (December 5, 2007)

ARM Technique (October 15, 2008)

Weight Lifting Good for Breast Cancer Patients  (August 19, 2009)

Drug Abuse in Plastic Surgery Patients

The article (full reference below) is a reminder of drug abuse in our patients.  Many of which can create issue peri-operatively.  The article begins:

In 1957, Dr. George Crikelair detailed the impact of drug abuse on the practice of plastic and reconstructive surgery.   Five decades later, the subject remains salient: surveys administered by the White House Office of National Drug Control Policy (ONDCP) state that 41.7% of the U.S. population older than 12 has taken an illicit drug in their lifetime.  12.6% reported illicit drug use in the past year. 

….. This article seeks to impart clinical savvy regarding verbal and non-verbal cues of the seven most commonly abused drugs by detailing their pharmacology, clinical manifestations, screening and management, thus enabling plastic surgeons to provide prompt and appropriate treatment when encountering complications related to these
drugs.

I would recommend this article be read by more than just plastic surgeons.  It will either educate you or simply be a good review.  I’m not as good at picking drug abuse up as say Gruntdoc or Movin Meat or White Coat, so I found it worth my time.

To begin:

The typical urine drug screen (UDS) is based upon federal guidelines established by the Substance Abuse and Mental health Services Administration, or SAMHSA. This drug screen is referred to as the “SAMHSA-5” (and previously as the “NIDA-5”) because it detects only the five drugs required by federal workplace testing. These include cocaine, opiates, amphetamines, cannabinoids, and phencyclidine (PCP).

Synthetic opioids, such as oxycontin and hydrocodone, will not be noted on these routine screens.

The seven drugs the article reviews are:

Cocaine -- Common names: coke, blow, crack, snow, nose candy

Marijuana  -- Common names: pot, weed, grass, mary jane

Benzodiazepines  -- Common names: benzos, bars, tranks, normies, sleepers and xanies

Opioids  --  Common names: Heroin (H, smack, horse, brown/black tar), Prescription pain medication (oxy, roxy, vike, patches)

Amphetamines -- Common names: speed, uppers, dexies for amphetamine, and meth, crank, crystal, ice for methamphetamine

Gamma hydroxybutyrate --Common names: GHB, liguid Ex, G

Ecstasy  -- Common names: E, Adam, XTC, X, love drug

 

Each drug review includes pharmacology, clinical manifestations, screening, and management sections.   If you don’t have access to the journal, get your medical library to get it for you and READ the article.

 

REFERENCE

Drug Abuse in Plastic Surgery Patients: Optimizing Detection and Minimizing Complications; Cone, J.D., Harrington, M.A., Kelley, S.S., Prince, M.D., Payne, W.G., Smith, D.J.; Plast & Reconstr Surgery: POST ACCEPTANCE, 23 September 2010; doi: 10.1097/PRS.0b013e3181fad5ac

Suture Material and Skin Irritation

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

I have written about Suture Allergy vs Suture Reactivity so was very interested in this new article accepted for publication in the journal of Plastic and Reconstructive Surgery (online ahead of publication). 

The article comes from researchers in Greece who chose to use digital image analysis to evaluate the erythema  associated with tissue reaction to suture material. 

The sutures evaluated were polydioxanone (PDS II(R), Ethicon, Sint-Stevens-Woluwe, Belgium), polypropylene blue (Polypropylene(R), Assut Sutures, Ascheberg-Herbern, Germany), polyamide 6 (Ethilon(R), Ethicon, Neuchatel, Switzerland), metallic clips (APPOSETM, ULC Tyco, Hampshire, UK), and polyglactin (Vicryl Rapid(R), Ethicon, Norderstedt, Germany).

Digital photos of 100 patients(70 females, 30 males; all Caucasian) were compared by software, evaluating red color superiority (mean value of red color) in the region surrounding the wound.  Most of the patients were Fitzpatrick skin type II and III (46 and 47 respectfully).  Mean age was 42 years old, ranging from 15 to 86 years. Each underwent the excision of cutaneous and subcutaneous lesions.

Surgical wounds included those after excision of skin or subcutaneous lesions on the face (68%), neck (14%), abdominal wall (12%), axilla (1%) and back (5%). All other anatomical areas were excluded from this study in order to produce sample homogeny as concerns the healing of skin wounds in different body areas.

The researchers excluded wounds which could not be primarily closed without tension or were located over a bony prominence to minimize other confounding factors as were wounds with any kind of post-operative complications, e.g. hematoma, dehiscence or infection for the same reason.

The researchers used two different suture materials in each patient to improve comparison between suture material and skin type.  This was done by dividing each surgical wound into two halves.  Each half was sutured with two different suture materials for each wound. The same number of sutures were used on each half of the wound.  The patients were randomly assigned a pair of suture materials by the means of a sealed envelope method.

The pairing of five different kinds of suture material yielded ten pairs (PDS II- Polypropylene, PDS II - Ethilon, PDS II -metallic clips, PDS II – Vicryl Rapid, Polypropylene - Ethilon,  Polypropylene-metallic clips, Polypropylene-Vicryl Rapid, Ethilon - metallic clips, Ethilon – Vicryl Rapid, metallic clips-Vicryl Rapid).

Each pair was tested on ten patients.  Sutures were removed on the 10th post-operative day.

According to the aforementioned comparisons polydioxanone was found to have the best performance, followed by polyglactin, polyamide, polypropylene and metallic clips. All the above mentioned differences between suture materials were statistically significant (p<0.05).

Their conclusions:

The absorbable sutures used for skin closure in our study were removed after the period of time which is indicated for non-absorbable suture material and respective to the site of the wound. Less skin erythema was observed after the use of absorbable materials (polydioxanone and polyglactin) than with the three nonabsorbable materials (polypropylene, polyamide and metallic clips).

This leads to the conclusion that, when used in skin closure and removed after 10 days, absorbable materials produce less tissue reaction in the form of erythema than non-absorbable sutures do.

So their small study would indicate that PDS II created the least skin redness at 10 days, followed by Vicryl Rapid, Polypropylene, Ethilon, and metallic clips.

REFERENCE

Significant differences in skin irritation of common suture materials assessed by a comparative computerized objective method; Plastic & Reconstructive Surgery: POST ACCEPTANCE, 17 November 2010; doi: 10.1097/PRS.0b013e3182043aa6; Original Article: PDF Only

P.O.U.R.

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.

A patient with postoperative urinary retention forced me to review the topic, conducting my private M&M conference.

Without giving away too much on my patient – female, less than 50 yo, general anesthesia used, length of surgery 4 hrs, ambulatory/outpatient, foley used intraoperatively, fluids used judicially (though I do not know the exact amount given by anesthesia), pain meds (Toradol, fentanyl, and sent home with script for Percocet).

From the first reference article below

I made my usual call to the patient the evening of surgery, asked how she was, “how’s the pain?”, “any concerns?”, “any nausea?”, “are you eating and drinking?”. I don’t recall specifically asking about whether she had peed or not, but I do recall her saying she needed to end the call so she could go to the bathroom.

I received a call from her the next afternoon. “Dr. Bates, I can’t pee. I keep trying and all I can do is dribble.”

The surgery center graciously agreed to catheterize her. I received a call from them immediately afterwards, “Dr. Bates, her residual volume is 1000+ cc.”

The patient graciously agreed to have the foley left in place for the next 24 hrs. I called her later the same evening and we agreed on a time for her to come into my office for the removal of the foley the next day (and yes, I gave thought into leaving it for a second day).

The surgery center’s action kept my patient from having to check in through the emergency department, incurring a wait time and additional cost.

The patient’s agreement allowed me to treat her as an outpatient, helped me reduce the need for a second catheterization, and keep her from incurring more expense.

It was fortunate that the patient had weaned herself from the pain medicine by this time and was mostly taking only Tylenol. Her P.O.U.R quickly resolved.

I did not see this complication coming for this patient. Perhaps the foley could have been left in and removed in recovery. Perhaps anesthesia could have restricted fluids more (though they were careful).

I can think of no reason she might need a urology follow up. Am I missing anything? Where is KeaGirl when you need her?

REFERENCES

Predictive Factors of Early Postoperative Urinary Retention in the Postanesthesia Care Unit; Anesthesia & Analgesia, August 2005 Vol. 101 No. 2 592-596; doi: 10.1213/​01.ANE.0000159165.90094.40

Postoperative Urinary Retention; Anesthesiology Clinics, Volume 27, Issue 3, Pages 465-484 (September 2009)

Patient Safety in the Office-Based Setting; Horton, J Bauer; Reece, Edward M.; Broughton, George II; Janis, Jeffrey E.; Thornton, James F.; Rohrich, Rod J.; Plastic & Reconstructive Surgery. 117(4):61e-80e, April 1, 2006; doi: 10.1097/01.prs.0000204796.65812.68

Urinary Retention in Adults: Diagnosis and Initial Management; Brian A. Selius, DO, Rajesh Subedi, MD; Am Fam Physician, 2008 Mar 1;77(5):643-650.

Families and Plastic Surgery

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

I read this article by Colin Stewart , Spouses often are jerks about plastic surgery (link removed 3/2017), a few weeks ago.  Since then I have been thinking about not just the husbands but families in general I see in my practice.  Remember I practice in Little Rock, Arkansas not Hollywood but I still find this to be true and not just of husbands.

Husbands of plastic surgery fans have a sensitive role to play.

It’s a challenge that most of them fail. Instead of communicating effectively and caringly with their wives about plastic surgery, husbands tend to act like jerks or wimps.

I think often the patient may also fail in communicating effectively to her spouse, significant other, family, and friends why she feels the need to have cosmetic/plastic surgery.  In defense of the spouse and others, it can be a mind-field.  After all, you don’t want to suggest your loved one is less than perfect with her small breasts or her saddle bags or the bat wings or her father’s nose or …..

It is easier for me to ask the question “why do you want to have ____?” in my office.  There’s less judging, not the same emotional baggage.  The individual is less likely to feel rejection from me if I suggest she re-examine her reasons or discuss them more fully with me.

I want the individual to be the one who initiated the visit to my office.  I certainly don’t want a pageant mom to bring in her daughter for liposuction or breast augmentation anymore than I want a husband to push his wife into having larger breasts.

The article mentions

The wimpy approach.

“You look wonderful, dear,” they say. “You don’t need any work done, but if it makes you happy, go ahead.”

The in-control approach.

Many other husbands go to the other extreme and become dictators. They demand their own way, whether it’s pro- or anti-plastic surgery.

It’s much nicer for all involve when the patient and her/his family discuss the options with respect for each other.  Some family members are anti-surgery because of fear of losing the person when they change themselves.  Some are anti-surgery because of the fear of losing the loved one to a complication of anesthesia or the surgery itself.

When those fears are voiced, the individuals can address the emotions.  Marriage counseling is often a better solution than surgery.  Bigger breasts won’t necessarily keep the husband from leaving for the younger woman.  And, yes, some women pre-plan their cosmetic surgery before the divorce.

Certainly a family member’s fear of losing the loved one to a death related to potential risks of surgery/anesthesia need to be addressed.  Complications happen.  Deaths happen, fortunately rarely, but they do happen.

The desired improvements must be weighed against those risks.  The patient (and her family) must be realistic regarding expectations. 

The article describes a successful discussion between a patient and husband.  She gave voice to specific reasons for desiring the surgery.  He voiced his concern.  They both listened to each other.  She won him over.

When Rinna began considering lip-reduction surgery to remove the scar tissue, she expected Hamlin to object, and she was right.

Plastic surgery is “never a good thing, in my opinion,” he told People magazine. “Plastic surgery is just an extension of that whole ‘let’s stay fresh and young’ vibe.”

She said, “I knew Harry would say, ‘Don’t touch it, don’t mess with it.’ He was like, ‘Maybe you should just leave it alone.’ He loves me the way I am.”

But she told him how important the operation was to her and what it was like to be the butt of never-ending snarky comments about her lips.

Family discussions can help the patient to be honest with herself regarding her reasons and expectations.

Shout Outs

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

Mother Jones RN, Nurse Ratched's Place,  is the host for this week’s Grand Rounds! You can read this week’s Veteran’s Day edition here (photo credit).

Welcome to the Veterans Day edition of Grand Rounds. Elvis and I are delighted that you dropped by. The King is very excited today because we are saluting celebrities that have served in the Armed Forces. Elvis said that his days in the army were memorable. I imagine having Life Magazine take your picture while you’re sitting in your underwear would be a memorable experience. My co-host and I want to thank everyone for their submissions, and we especially want to thank Dr. Nick Genes for allowing us to hold Grand Rounds at Nurse Ratched’s Place. ….

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Really patient-centered! via Paul Levy (Running a Hospital):  Here comes the bride - at Anne Arundel Medical Center by Wendi Winters (Capital Gazette)

The bride wore an elegant strapless gown and a radiant smile. The nervous groom was impeccable in his spotless Air Force dress uniform and a TV-sized heart monitor.  …….

"The wedding must go on," senior nursing director Ann Marie Pessagno said as she arranged the chairs for the ceremony that almost wasn't.  ………

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Dr Margaret Polaneczky updates us on HRT and breast cancer in her post:  HRT and Breast Cancer Deaths – Just in Case You Weren’t Listening the First Time…

…………….While the breast cancer risks associated with HRT use appear to be quite real, for a individual woman, they are not that large. Here’s how I explain the risks to my patients ……………..

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From tweeter  @IVLINE “For all your fracture naming needs http://bit.ly/98agy2 with pictures included.”  The link is to LITFL’s Eponymous Fractures.  Here’s an example of the great information you will see there:

Barton’s fracture
John Rhea Barton
1794-1871, American surgeon
Description/ Mechanism of injury:
Fall on outstretched hand

Intra-articular fracture of the distal radius with dislocation of the radiocarpal joint. Fractures may be displaced volar or dorsal direction

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From twitter: @docgrumpy: “The iPhone/iPod app "Nerve Whiz" is awesome for peripheral nerve help- and it's free (I wasn't paid for this, FYI)”

Nerve Whiz is an app designed by a neuromuscular neurologist at the University of Michigan.

Nerve Whiz is a free application for medical professionals interested in learning the complex anatomy of nerve roots, plexuses, and peripheral nerves. Select which muscles are weak, or point to areas of sensory loss, and the application can provide you with distinguishing features and detailed information, complete with relevant pictures and detailed information, complete with relevant pictures and diagrams.

NOTE: Nerve Whiz is intended to be an educational tool only. Nerve distributions vary between patients, and central or multifocal processes can mimic focal peripheral lesions. As such, this application should not be relied upon to make clinical decisions.

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The Alliance for American Quilts received 118 quilts for it’s “New from Old Quilt Contest Contest.” You can see all the quilts here. My entry was “Label Me.” The quilts are now being auctioned off.

Click on an auction week below to view or download an auction guide for that week.

Week One: Monday, Oct. 25-Monday, Nov. 1

Week Two: Monday, Nov.8-Monday, Nov. 15

Week Three: Monday,Nov. 15-Monday, Nov. 22

Week Four: Monday, Nov. 29-Monday, Dec. 6

The bidding for each quilt will start at $50 and each 7-day auction week starts and ends at 9:00 pm Eastern. No Daylight Savings Time changes this year to contend with--DST changes on November 7.

All proceeds will support the AAQ and its projects.

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There does not seem to be any Dr Anonymous’ show scheduled for this week. 

You may want to listen to the shows in his Archives. Here are some to get you started:

GruntDoc, Sid Schwab, Dr. Val, Kevin MD, Rural Doctoring, Emergiblog, Crzegrl, Dr. Wes, TBTAM, Gwenn O'Keeffe, Bongi, Paul Levy, John Halamka, and ScanMan

I Need to Reschedule You

Over the past 20 years, there have been very few times I have asked patients to reschedule.  Even though I tell patients they have nothing to apologize for when they then to cancel, I always apologize.   This is especially true when it comes to asking them to reschedule surgery.

Yes, I know you have asked for time of work.  Yes, I know you have arranged for someone to help care for you, for your children, etc.  Yes, I realize you may have airline tickets to come into town to stay with family here while recovering.

Yes, I keep all that in mind, so if I ask you to reschedule it truly will be a handful of good reasons:

I am sick or need surgery myself.  I had to ask a patient to reschedule her breast reduction early in my solo career.  I had an acute herniated disc (C6-C7) which left me with numbness in my left  index and long fingers and loss of triceps function, not to mention the pain.  I had to explain to her that it was not safe for me to do her surgery until after my own.  [She did reschedule.]

A family member is sick or dying.   I had to ask a patient last May to reschedule after my mother had her stroke during her CABA.  After we made the decision to AND (allow natural death), we did not know how long it would be.  I did not want to be in surgery when it happened.  I thought it was reasonable.  [She never rescheduled.]

I have a funeral to attend.  I have not canceled or rescheduled a surgery for this (yet), but have rescheduled a few office visits.  As I and my friends get older, I can see this happening more frequently in the future.  I will try to be considerate of both my friend/family and my patients.

Usually, when I ask a patient to reschedule it will be a last minute thing.  I regret this, but as you can see from the reasons I allow myself to make this request it will always be last minute.  Some things are tough to plan.

Believe me when I say I am sorry to have to ask you to reschedule.  I truly mean it.

No Need to Apologize

Patients sometimes to need to cancel elective surgery. When they do, I don’t feel they need to apologize.

There are many reasons to cancel an elective surgery. All are valid to the patient. Not all would be to everyone else, but that does not matter (in my humble opinion).

So whey you call me or my office to cancel a scheduled elective surgery, do not feel you have to offer an apology. By all means, do call though. If you don’t I will worry about you, e

“My Office’s Cancellation Policy” for an elective surgery is simple: You have the right to cancel at any time prior to being actually put under anesthesia. My office doesn’t not charge a cancellation fee.

More seriously, it is nice from the business side if you let me/my office know at least a week in advance, sooner if any special garments or implants need to be ordered. First, this way the office doesn’t loose money on the returns of goods that can’t be used for another patient.

Second, it allows my office the opportunity to schedule another patient in your canceled OR time slot. If no other patient in my practice wishes to fill the time slot, the surgery center may have another surgeon who can use the time.

So there is really no need to apologize. You may wish to give me a reason, but there is no need.

Over the years I have been given many reasons (fear, couldn’t get the time off from work, money didn’t come through or had to be re-allocated, family member died or had emergency surgery).

Please, let me know. If I show up the day of surgery and you don’t (even after I just talked to you two days ago), then I may assume the worse. Several years ago this scenario played out. When I finally reached someone at my patient’s home I was told she had totaled her vehicle the evening before the surgery date. She ended up being okay, a few minor injuries that kept her in her hometown hospital for a couple of days. She didn’t (nor should she) think to call me. But I now worry when people don’t show up.

It is okay to cancel elective surgery, but please have the courtesy to call with as much notice as possible.

Palpable Implant Valve

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

I received a call recently from a patient who is one month postop from an augmentation mammoplasty. She and her family physician had found a “lump” in her left breast on a wellness exam. The patient who loves her new implants was worried she something was wrong and she would have to have the implants removed.

I asked her to come in and allow me to do an exam. She happily agreed.

My first thought was not breast cancer. All her mammograms prior to surgery had been normal. Her breast exam prior to surgery had not revealed any abnormal lumps.

My first thought was a palpable implant valve.

Fortunately, I was right.

This patient is thin, has little breast tissue, submuscular saline implants. She did not want silicone implants. While the valve is flat and non-projecting on the surface of the implant, in women such as this patient the valve can sometimes be felt.

In reassuring the patient, she and her husband were educated. I reminded them of the muscle anatomy. The border of the pectoralis just misses covering the implant valve. I pulled out a saline implant for them to see and feel the valve.

Even though the surface is smooth, the valve is 2-3 mm thick.

She will learn through self-exam her new “normal.” She will be encouraged to come back to my office yearly for a breast exam. She has been educated to continue to get her yearly mammograms.

REFERENCES

Breast Implants and Breast Cancer Screening: Implants and Breast Cancer Screening; Medscape article, 11/14/2003; Stacy M. Smalley, CNM, MSN

Saline-Filled Breast Implant Surgery: Making an Informed Decision, Updated January 2004 (pdf); FDA.gov

An Unusual Case of Itching in a Surgery Patient

Patients who are in the early postoperative period (first 2 days) will sometimes complain of itching. I hear this either during the call I make the evening of surgery or when the patient calls the next day. I follow up this complaint up with a few questions:
How severe is it?
Where do you itch?
Is there any rash?
When did it start?
Most often the itching is a minor irritation. Often they or a family member will immediately think they have to be allergic to one of the medications they are taking. Most often this is not the case.

If the itching is localized to the area of the surgery, then most often it is due to the surgical scrubs not being cleaned off well enough (almost impossible to fully do). This itching goes away quickly when the patient takes their shower and can fully cleanse the soaps away.

I worry more about an allergic reaction if the itching is generalized, includes a rash, and has gotten worse after the second or third dose of some medication. When told this I review medications they are taking and stop the most likely offending one.

Regardless of the cause, if it bothers the patient enough I will tell them to try taking Benadryl to ease the irritation of the itch.

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There was an unusual case of itching I encountered once in a postoperative patient. The patient was a 27 yo nurse who developed an elevated temperature (no increased pain, no redness or added tenderness in the surgical area, no pain on urination) and flu like symptoms on the second day after surgery. The rash broke out on the third day after surgery.

Her rash consisted of vesicles located initially on the chest, neck, and later her face and arms.

My initial thought was chicken pox. She initially insisted there was no way it could be, but agreed to see her internist. Turned out I was right.

She was miserable while she recovered, having to deal with the surgery issues AND the chicken pox.

Dealing with Unhappy Patients

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

There is a nice article in the May issue of  Plastic Surgery Practice which discusses how to deal with unhappy or difficult patients.  No matter the area of medicine or surgery, you are bound to have one or two of these patients over the years.  It never hurts to learn or review tips in dealing with them.

In the article Rima Bedevian interviews Julie Ann Woodward, MD who is chief of the oculoplastic and reconstructive surgery service at Duke University

how to successfully deal with them – with compassion and humanity without allowing them to “run you over” or manipulate a difficult situation into a potentially litigious one.

 

Here is Dr. Woodward’s Checklist:

We all have them – not even the very best physician can deny this…. I learned many of the tips described below from observation during my fellowship, from talking with colleagues, and from personal experiences.

PREOPERATIVE STAGE

1)  Slightly downplay expectations – eg, “Laser skin resurfacing will not get rid of every wrinkle.  You may still need some fillers.”

2)  Talk in numbers and give percentages whenever possible – eg, “Twenty percent of patients may need an adjustment with this procedure.”

3)  Stress the time required to heal.

4)  Beware of a patient who abuses your staff’s time.  If so, tell her, “I’m sorry, the staff and I can’t meet your expectations.” 

5)  If a patient seems uneasy and difficult, encourage them not to do the surgery.  The money you collect from a difficult patient will not be worth your time.

POSTOPERATIVE STAGE

1)  never disagree with what a patient sees is wrong, even if you do not see it at all.

2)  Remind the patient that healing can take from 6 months to a year.

3)  Take action – If the patient does not like the look of their scar, inject a small amount of steroid or make an appointment 4 to 6 month out for a touch-up.  In my experience, most patients will be happy by then and will not even want the touch-up.

4_  See the patient with increased frequency and show that you care.  Call them frequently.  Don’t be afraid to gently touch the patient’s arm in a calming way.  The worst thing a physician can do is to send the patient away for a month and hope that they will cool down.  Even if it is stressful for you, ensure the patient will return frequently.

5)  A happy patient will tell two friends, and an unhappy patient will tell everyone on the planet via the internet.  As unethical and inaccurate as we know these Web sites can be, they are here to stay.  If a disgruntled patient posts a negative comment on a Web site, contact five of your happy patients and encourage them to post positive comments to push the negative comment down on the Web page.

6)  Consider doing touch-ups either for free or for a nominal fee – but set limits.  Do not give free Botox/Dysport touch-ups.  These patients will want free touch-ups every time.  They will “doctor shop” the entire medical community to locate the practices willing to give freebies.

7)  Maintain positive interactions with your colleagues so that you can refer patients for second opinions.  Ask them in some cases to see patients with worrisome outcomes.

DEALING WITH ANOTHER PHYSICIAN’S UNHAPPY PATIENT

1)  never say anything bad about another physician.  The patient will naturally seek the physician with a higher level of self-confidence and who does not speak poorly about colleagues.  Negative comments about colleagues will usually come back to bite you.

2)  Disgruntled patients who come to you from other practices will probably be unhappy with whoever treats them, even if you dramatically improve their situation.  You may want to encourage that patient to return to the physician who did the original surgery.

3)  Consider giving a friendly call to the physician who did the original surgery to let them know you have seen the patient.  mention that you supported that physician’s original work.  you might establish a new referral source from this call.

4)  never return a patient’s money.  Most lawyers will say that patients will view this as an admission of guild, and it usually is an excuse for them to just go out and complain to more people.

Julie Ann Woodward, MD

 

 

 

REFERENCES

How to Deal with Unhappy or Difficult Patients; Rima Bedevian; Plastic Surgery Practice, May 2010, pp 26-29.

Consultations

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

Recently Dr. Debra Benzil (Women Neurosurgeons: Hearts and Hands) wrote a post suggesting doctors are often their own worst enemies.  As I continue to read through Dr. Robert Goldwyn  essays, “The Operative Note: Collected Editorials” (published in August 1992), I came across this one which suggest the same. 

I contend that his essay could apply to consultations for many different medical and surgical issues in how we physicians treat our patient and each other.  The bold emphasis is mine.

 

Consultation for Breast Reconstruction

The woman who has just heard that she has breast cancer faces not only the prospect of deformity and death, but also the quandary of having to decide among various treatments:  mastectomy – radical, simple, or segmental; node dissection; chemotherapy; or irradiation – alone or in combination.  Should this patient later want breast reconstruction, she must sort through another set of alternatives.  A few years ago, the choice for patient and plastic surgeon was relatively easy – an implant or nothing.  The advent of musculocutaneous flaps has allowed more latitude and, in may instances, superior results.  Even the implants have changed and now exist in a bewildering array:  saline- or gel-filled, in various sizes, shapes, and thicknesses, as well as the expander type.  My purpose here is not to list the indications, advantages, and disadvantages of each or to advocate one over another.  Numerous articles in this Journal have already done so.  This editorial is to make two pleas:  for each of us to take the time to explain to the patient the different methods for rebuilding the breast and the reasons for our specific recommendation, and for each of us not to denigrate the plan or person of another plastic surgeon who may have suggested something different to that patient. Results, though improving, are still not ideal and should not foster dogmatism.  The fact that the number of plastic surgeons has increased makes it easier for patients to obtain additional opinions.  In my own practice, I have heard such statements as “Dr.  ____ says that the flap from the abdomen is the only way to do it.”  Or “Dr.  ___ said that implants should never be used if you can avoid it.”  and “Dr. ___ told me and my husband that it is rarely necessary to use a flap because an implant can do the same thing more easily.”  One wonders whether that surgeon knows  how to do a latissimus dorsi or rectus abdominis flap.

I realize, of course, that patients misquote doctors; nevertheless, I am sure that much depends on what door a patient enters.  One surgeon may be in hsi Radovan expander phase; another in the flush of his first rectus flap; or a different surgeon may be fossilized, unwilling to try anything other than an implant.

Advising a patient about breast reconstruction involves the same principles as counseling in other areas of medicine.  What are the objectives and what methods are available for attaining them?  Am I capable of providing that treatment?  If so, should I proceed?  If not, I should refer.  In all these deliberations, the patient must be an informed participant.  Involving the patient and helping her choose a course of action is not the same as making the patient decide on her own.  The doctor who lists the serval ways of reconstructing the breast as a waiter would recite the entrees for the evening abrogates his or her responsibility.  The patient did not come to the surgeon to flounder in the sea of indecision while the surgeon sits comfortably in a nearby lifeboat.

Since reality is seldom perceived beforehand, photographs of average results of breast reconstruction, showing scars in the recipient and donor sites (if a flap is to be used), are helpful.  So is having the patient speak to or perhaps, see another patient who has already been through the ordeal.  One has to make clear in the record and to the patient that this does not imply guaranteeing a similar result.  In fact, on occasion, I have referred a patient to someone who is unhappy with the result if I sensed the new patient was screening out information about what could go wrong. 

Breast reconstruction is a challenging aspect of our specialty.  With several thousand plastic surgeons working in the world, ingenious developments will be forthcoming.  Tolerating ambiguity is necessary if we are to advance.  Is there unanimity in how to repair a cleft palate or how to treat cancer of the tongue or breast?  Breast reconstruction has come of age; there are now several ways of doing it.  Despite this variety, I expect that surgeons of the next generation will do better for patients than we can now.  Perhaps the need for breast building will have disappeared if an alternative to mastectomy proves effective and safe.  In the meantime, we must remain sympathetic to the patient, who bears the greatest burden. We should not make her lot more difficult by behavior that is unprofessional toward colleagues and damaging to those whom we are supposed to serve.

The Plastic Surgeon Knows Best?

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

I tend to agree with what Dr. Robert Goldwyn had to say in this essay from his book “The Operative Note: Collected Editorials” (published in August 1992). 

The Plastic Surgeon Knows Best: 

A Hazardous Assumption

Two incidents, within four hours, seemingly disparate, were instructive nevertheless.  The first was in the barber shop, where I paid a long overdue visit.  The hair stylist – there are no more barbers left in the world – was a woman, whom I had not seen before.  She was one-half my age and a hundred times as attractive.  She was sitting in her own chair, brushing Lady Godiva length hair muttering that her friend – another “stylist” – had “ruined” her.

“She cut too much off,”  she said.

My fantasy was that her hair previously must have trailed like a bridal train.

This is a good sign, I told myself.  She will not prune me excessively, something that is easier to do with each year.  To my request for a “light trim,” she replied, “Don’t worry.  I’ll take care of it.  You’ll like the result.”

That last statement triggered an iota of apprehension but I gave myself over to her obvious charm and flying fiingers.  I must have dozed and awoke to a World War II soldier staring back at me from the mirror.  I look like an old recruit, perhaps a General Schwarzkopf but without his girth or tanks.

Then a more primal fear seized me.  Maybe my modern hair stylist was really an incarnated Delilah.  That thought sent my strength ebbing as I went to my car and then to the office – for the second incident.

This was a new patient, a twenty-eight year old writer, who was displeased with the outcome of her rhinoplasty done elsewhere.

“I told him that I wanted surgery only on the tip,” she said.  “I even wrote him a note to that effect and also specified it on the operative permit.  I couldn’t believe what I looked like when he took off the splint.  He had given me a total nose job.  When I protested and asked him what he had done to me during the operation, he got very angry and practically yelled, ‘It’s none of your business.  I was the surgeon and I know what is best for you.’ ”

Her plastic surgeon and my barber have forgotten that my hair and her nose belonged to each of us respectively and not to anyone else.  They also shared the same deficiency:  not listening.  But there is more involved:  namely, arrogance.  After they have finished with their work, we are left holding the result.  Of course, I do not equate my Marine hair cut with her new nose.  With God’s grace, in a few weeks I will regain what I had but she will not.

I believe it was Osler who advised us to listen to the patient because he or she will tell us what is wrong and if we listen longer, the patient will tell us what to do.  I am afraid that each of us occasionally ignores or forgets that verity.  The patient becomes somehow incidental to our treatment which we impose without proper regard for that person’s sensibilities and desires.

This phenomenon of not taking into meaningful account what the patient wants I have observed more among older practitioners.  Perhaps they feel that they are beyond the restrictions that usually apply to other plastic surgeons.  This kind of megalomania is not without possible severe repercussions  -- the kind that take place in a court room.

In our specialty, more crimes are of commission than omission.  fewer problems result from doing less than from attempting more.  One would think that the older plastic surgeon would appreciate doing less in order to conserve his or her strength.  Maybe the issue is one of routine:  performing “the operation” instead of the right operation.  The patient who receives more than he or she requested is about as grateful as the diner who was served Beef Wellington when he wanted a green salad.

 

When breast augmentation and reduction patients ask me what size they should “go for.”  I tell them my opinion, but also tell them they should decide “what they want.” 

I have been known to use the example of me making them a dress in a lovely green silk.  The dress fits perfectly, the color suits their skin/hair/eye coloring, BUT I find out too late they hate the color green.

So while it is my duty to listen, my patients must tell me what they want.  Then we can have a discussion about whether it is possible, etc.

When Healers Need Healing

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 my office mail this morning I found my medical school classmate, Janet Cathey, looking back at me from the front of the last issue of the Journal of the Arkansas Medical Society. Her photo was linked to an article entitled “When Healers Need Healing: Physicians’ Experiences on the Receiving End of Medicine.”

I knew that Janet had been injured in a car accident last summer. I have tried reaching out to her with notes, etc. She had “closed” herself off from me and many others trying to reach out, so it was nice to see the report on her.  Janet had a busy Gynecology practice prior the accident. I have hear that she had since retired due to the back injury sustained in the accident.

“Things were happening at lightning speed,” she recalled of the scene at Baptist. “I had a burst fracture of L-1 and needed spine surgery….They were moving me, cutting off my clothes. I was scared and still screaming in pain and frustration,” she said. “At that moment, ER doctor Wendel Phals, MD, was at the head of my bed. He held my face and calmly and quietly said, ‘Janet, you’re going to be alright. We’re going to take care of you.’ For the first time since I’d hit the culvert, I felt calm, secure.”

The article also includes comments from Columbia University psychiatrist Robert Klitzman, MD who has written a book “When Doctors Become Patients”

After his own recovery, Klitzman wanted to understand the rare, dual perspective of physicians who have confronted serious disease. His interviews revealed first and foremost that many physicians resist, at least initially, the idea of beiing “sick” or being “the patient.” Furthermore, many physicians most resist “not” being the doctor…..

The article includes another Arkansas physician, orthopedic surgeon Frank Griffin, MD who found himself a patient when he was diagnosed with a chondrosarcoma.

Griffin found both emotional and practical aspects of being a patient surprised him. “I was surprised at the size of my bills,” said Griffin, adding that he understands now the number of medical bankruptcies. ….

Also surprising to him was his embarrassment to ask for pain medicine. “I was afraid someone would think I was becoming addicted,” he said. “……..I imagine there are many more patients suffering from pain than are abusing pain meds.”

Janet is quoted making these observations

“As a physician, you never know what little thing a patient is going to latch onto…be impacted from,” she said, remembering that night eight months ago, in the Baptist ER. “As a patient, I felt my recovery began when amidst the chaos of the night, Dr. Pahls took a few moments to look at me and reassure me.”

All of that medical knowledge can be a blessing and a curse, especially when physicians suffer from something serious or debilitating, Cathey implied. “For me to have a devastating injury, it really hit hard. Being a physician takes away some of the hope that you’d have if you didn’t know your limitations,” she said.

All of us will be patients at some time during our lives. It is important for us to keep this in mind as we care for others. I wish I could link you to the entire above article, but it is not up online yet.

There is a post on the same topic over at Mothers in Medicine: Lessons learned on the wrong side of the stethoscope

I was walking down the hall at work on a very ordinary day in December. I had sudden onset of excruciating right shoulder, neck, and upper arm pain. For the first time in my life, the "...if 10 is the worst pain you can imagine" finally had meaning. ……. The next 48 hrs were a whirlwind: emails, calls, and pages to my internist (I am usually a once a year-ish whether I need it or not patient), a possible diagnosis of multiple sclerosis, MRIs of my brain, spinal cord, shoulder, appts with ortho, neuro, and ultimately neuromuscular, including the test that provided a diagnosis: an EMG/NCS. The diagnosis was something rare called Parsonage-Turner Syndrome. I had never heard of it before (which is a very bad feeling as a doctor).

So, what have I learned from this experience of being on the wrong side of the stethoscope? A lot that I am still struggling to put into words and a lot worth sharing.