Shout Outs

Updated 3/2017--photos and all links removed as many no longer active. 

Paul Ware, Life with Huntington's, is (suppose to be) the host for this week’s Grand Rounds. You can read this week’s edition here.

Next week’s host is Dr. Rob (@doc_rob): What’s Grand and Round and Comes in an RSS Feed?

……To submit your GR post for next week’s GR, fill out the attached submission form. I must have submissions in before Sunday, March 4th at 6 PM EST……

………………………………….

H/T to @jilltomlinson who asks.

Was this 27yo man's life lost in ill-conceived race to perform "World 1st" surgery? bit.ly/x2bGEJ #retrospectoscope

The link is to this Mai lOnline article: Man, 27, who had world's first quadruple limb transplant dies days after operation.

A 27-year-old Turkish man who underwent the world's first would-be quadruple limb transplant died yesterday, hours after the limbs were removed due to metabolic failure, the hospital said…….

I thought it was too risky when I first heard about the transplant prior to them having to later remove the limbs. We are certainly pushing the limits with transplants these days with double hand, face, multiple organ, etc.

………………………………………..

From Letters of Notes a letter that gives a glimpse of breast Cancer in 1855. This woman had surgery with no pain meds: 'Deep Sickness Seized Me"

In September of 1855, Lucy Thurston — a 60-year-old missionary who had been living in Hawaii with her husband since 1820 — underwent a mastectomy after being diagnosed with breast cancer. Incredibly, she somehow endured the operation wide-awake, without any form of anaesthetic. She wrote the following letter to her daughter a month later and described the unimaginably harrowing experience.

The procedure was a success. Lucy Thurston lived for another 21 years………………

…………………………………….

From @Skepticscalpel comes a post with his take on the survey in the Archives of Surgery: Surgeons and alcohol abuse.

“Prevalence of alcohol use disorders among American surgeons” appeared in the February, 2012 issue of Archives of Surgery.

A survey of 7197 surgeons, all members of the American College of Surgeons [ACS], had a 28.7% response rate and revealed that 15.4% had scores on an alcohol use assessment test that indicated abuse of or dependence on alcohol. This is consistent with the rate of such alcohol problems in the general public…………….

………………………………………

VIDEO: Kyle Dyer, 9NEWS anchor, interviews with the Denver Post

Channel 9 news morning anchor Kyle Dyer talked to the Denver Post on Wednesday, February 23, 2012, about the injuries she sustained from a dog bite and her road to recovery.……. Video by Mahala Gaylord

……………………………..

H/T to @impactednurse ‏for this tweet:  “Very cool. Federico Carbajal's anatomical sculptures made with galvanized wire: bit.ly/yRSvFk”

More Surgeon’s Caps

These are caps I made between just before Christmas and the first part of January. 

The first ones went to @doctorwes after he made his request for photos of Christmas themed clothing seen at work. 

I then decided I needed to use some of this lovely fabric from Africa given to me by an old high school friend to make @Bongi1  and @globalsurgeon surgeon’s caps.  I gave bongi his choice and he chose the colorful ones.  No photo of him wearing his, but received this nice tweet.

@globalsurgeon did share a photo of @ReinouGroen via twitter wearing one of his (theirs):   yfrog.com/kk54exnj

These two went to @bramzo after he made an innocent comment in regards to @Bongi1 receiving his.


I have shared my pattern via google docs (pdf file).
Related Posts:
Surgeon’s Caps  (April 18, 2009)
Razorback Surgeon's Caps for a Colleague (Oct 17, 2010)

Make Sure Your Surgeon is Trained for Your Procedure

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

Don’t simply look for a surgeon who is board certified.  Make sure they are trained to do the procedure you are having.  Yes, board certification is important, but the training is more so (in my humble opinion).

If you are having a breast augmentation, you don’t want a board certified maxillofacial surgeon or Ob-Gyn or neurosurgeon.  You want someone trained in plastic surgery.  It is a bonus if they are board certified.  By the same token, if you need brain surgery you don’t want a board certified plastic surgeon you want someone trained in neurosurgery. 

This rant was prompted by the USA Today article written by Jayne O’Donnell:  Lack of training can be deadly in cosmetic surgery

……….Sant Antonio is one of a soaring number of doctors who trained in other medical specialties, such as vision or obstetrics, but have branched into the more lucrative field of cosmetic surgery. Because state laws governing office-based surgeries often are lax, levels of training vary so widely that some doctors are performing cosmetic procedures after only a weekend observing other doctors. Sant Antonio himself has offered three-day liposuction training at his office for the last few years, according to interviews with doctors who have trained under him.

Some dentists trained in oral surgery now do breast implants; OB/GYNs perform tummy tucks, and radiologists are doing liposuction. The results can be disastrous, according to interviews with scores of victims, plaintiffs' lawyers and plastic surgeons, and a review of lawsuits. ………….

Role Playing to Learn Communication

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

I was alerted to this Archives of Surgery article (full reference below) by MedPage Today:  Role Playing Boosts Surgical Residents' Bedside Manner.

I find it intriguing.  Role playing gives you a chance for a “do-over” when you make a social or communication faux pas. 

So much of medicine is communication.  Those of us who have been at it for years, deliver bad news differently (learned the hard way) now than we did previously.  You choose your words more carefully (though I still occasionally screw up).  Some words are more emotionally charged than others.  Some patients want more information than others. 

The University of Connecticut Health Center conducted a prospective study  of a pilot projected designed to  teach surgical residents patient-centered communication skills.

The study offered 44 general surgery residents the opportunity to participate in the three-part patient communication curriculum: A pre-test, training, and a post-test.  Only 30 completed all three parts.

The pre-test assessed general communication skills awareness of the resident while he/she delivered a new diagnosis of either breast or rectal cancer to a patient. The evaluation was done by a standardized patient instructor.

The training portion required residents to attend a 90-minute workshop that involved a lecture from a professor of surgery and formal instruction from the director of the center's clinical skills program, followed by a 30-minute role-playing session.

The post-test assessment re-evaluated the residents by the standardized patient in a crossover fashion (those who previously participated in a breast cancer diagnosis now participated in a rectal cancer diagnosis and vice versa).

The study authors concluded:

Residents' assessment of their patient communication skills indicates that there is an immediate need for a formal educational curriculum. Our results show that case-specific improvements seem more amenable to measurable improvement than general communications skills, at least with the limited short-term training that we used. Such skills can be assessed over a longer period, perhaps by incorporating this model and assessments from year to year.

Surgical and nonsurgical residency programs will benefit by helping residents incorporate patient needs and opinions into the care team's decision-making process. Principles such as emotional support, transition and continuity of care, provision of information and education, involvement of family and friends, and respect for patient values and preferences will form the basis of our educational series.

REFERENCE

Pretraining and Posttraining Assessment of Residents' Performance in the Fourth Accreditation Council for Graduate Medical Education Competency: Patient Communication Skills; Rajiv Y. Chandawarkar; Kimberly A. Ruscher; Aleksandra Krajewski; Manish Garg; Carol Pfeiffer; Rekha Singh; Walter E. Longo; Robert A. Kozol; Beth Lesnikoski; Prakash Nadkarni; Arch Surg. 2011;146(8):916-921.

Barbers of Civility

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

It seems to me this topic of surgeon and their lack of civility gets pulled out ever on a fairly regular basis.  This latest discussion in the news media is due to a short article in the current Archives of Surgery (full reference below).

Surgeons as a group have a reputation (which even nice ones have trouble overcoming) of arrogance and incivility. 

The authors, Klein and Forni, of this article state (bold emphasis is mine):

Uncivil behavior is so present in society at large that we should not be surprised to find it among health care workers. This article is meant to raise the awareness of the costs—both in dollars and in human misery—of incivility in the practice of medicine by looking in particular at the case of surgeons.

Uncivil behavior brings misery wherever it occurs.  If the individual tends to behave in an uncivil fashion prior to medical school and prior to residency, then that individual is likely to behave in an uncivil behavior in practice.  Medical school and residency aren’t “finishing schools” in that regard.

Medical schools seem to have become aware of this simple fact.  Recent news articles report some medical schools will begin interviewing for “people skills” in their applicants --  NY Times article by Gardiner Harris: New for Aspiring Doctors, the People Skills Test.

I applaud Klein and Forni for their suggestions that surgeons lead the civility imitative in health care: 

The surgical community has an incredible opportunity to lead a civility initiative in health care. The first step is to recognize the power that civility has to improve the surgical workplace, the patient outcomes, and the workers' quality of life. Organizations should commit to developing a universal code of conduct that is identical for surgeons, nurses, staff, administrators, and patients. This code must have clearly defined expectations as well as consequences for violations. More important, the code should be applied fairly and consistently, without modification or special allowances based on an individual's actual or perceived status in the group.  ………

“I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.”   --Maya Angelou
……….
My past article on the topic
Behavior of Surgeons  (July 24, 2008)
A Surgeon's Outburst  (August 13, 2008)
Consultations  (May 24, 2010)
Tips on Dealing with Difficult Colleagues (May 9, 2011)



REFERENCE
Barbers of Civility; Andrew S. Klein; Pier M. Forni; Arch Surg. 2011;146(7):774-777; doi:10.1001/archsurg.2011.150

Dr. Ralph Millard,

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

Dr. D. Ralph Millard (1919-2011) is known in the plastic surgery community for his contribution to improved surgical techniques for the correction of cleft palates.  He died Sunday, June 19, 2011. (photo credit)

PSNews tribute:  Plastic surgery pioneer D. Ralph Millard Jr., MD, dies at age 92
NBC Miami tribute:  Cleft Palate Pioneer Ralph Millard Laid to Rest

……He trained more than 180 young, and not so young, men and women in whom his legacy is entrusted.  The “Chief,” as he was known to his residents at the University of Miami, was an exacting task master, an elegant surgeon and a consummate teacher.  His surgical greatness cannot be denied, but his most profound legacy may be as a teacher of Plastic Surgery.  Through the gift of his text books and manuscripts he tried to pass on to all Plastic Surgeons his vision of our specialty.  ……

The Millard technique or the rotation-advancement cleft lip technique (photo credit)

Dr. Millard was a “giant” in plastic surgery who will be missed.  My condolences to his family.

REFERENCES to just a few of Millard’s articles (full bibliography)
1.  Millard DR Jr. Rotation-advancement versus Giraldes’ cleft lip technique. Plast Reconstr Surg Transplant Bull. 1961;28:595-7.
2.  Millard DR Jr. Refinements in rotation-advancement cleft lip technique. Plast Reconstr Surg. 1964;33:26-38.  (pdf file)
3.  Millard DR Jr. Rotation-advancement principle in cleft lip closure. Cleft Palate J. 1964;12:246-52.
4.  Millard DR Jr. The unilateral cleft lip nose. Plast Reconstr Surg. 1964;34:169-75.
5.  Millard DR Jr. Closure of bilateral cleft lip and elongation of columella by two operations. Plast Reconstr Surg. 1971;47(4):324-31

VIPS Guidelines for Providing Surgical Care

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

No this VIPS doesn’t stand for “very important person” or the famous (local or national) person you might care for in your practice.   I think it is best to try to treat everyone with the same standards of care.  Similar to the checklist that Atul Gawande has brought to the public eye, this keeps you from “missing” something or not providing some important aspect of care.  The Cleveland Clinic Journal of Medicine had a nice article by Dr. Jorge Guzman recently on this topic:   Caring for VIPs: Nine principles

…….

In this case, VIPS stands for “volunteers in plastic surgery.”  

The online site of the Journal of Plastic and Reconstructive surgery has an article discussing the guidelines for VIPS who provide surgical care for children in the less developed world.

The guidelines were developed by the Volunteers in Plastic Surgery (VIPS) Committee of the ASPS/PSEF  in conjunction with the Society for Pediatric Anesthesia (SPA).

This document is not intended to represent a standard that must be followed by everyone performing this work in developing countries.  Locations, circumstances, and needs may vary greatly depending on the site.  Rather it is intended to provide a framework for providers involved in the care of children in the less developed world.

The guidelines can also be found here as a pdf file:  Guidelines for the Care of Children in the Less Developed World. 

The VIPS program stresses working in conjunction with the local plastic surgeons by invitation and proper planning with a mission/purpose for the trip.  Adhere to high standards of quality of surgery, care, and teaching.  Be sensitive to host needs and customs.  Be a Good Guest!

 

 

 

 

REFERENCE

Volunteers in Plastic Surgery (VIPS) Guidelines for Providing Surgical Care for Children in the Less Developed World; Schneider, William J.; Politis, George D.; Gosain, Arun K.; Migliori, Mark R.; Cullington, James R.; Peterson, Elizabeth L.; Corlew, D. Scott; Wexler, Andrew M.; Flick, Randall; Van Beek, Allen L.; Plastic & Reconstructive Surgery., POST ACCEPTANCE, 8 February 2011; doi: 10.1097/PRS.0b013e3182131d2a

The Role of Humanitarian Missions in Modern Surgical Training; Campbell, Alex; Sherman, Randy; Magee, William P.; Plastic & Reconstructive Surgery. 126(1):295-302, July 2010; doi: 10.1097/PRS.0b013e3181dab618

Surgeons and Suicide Ideation

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

There is a new article on surgeons and the risk of suicide in the January issue of Archives of Surgery (full reference below).

The Kansas City Star’s new article on the study includes this from a colleague who was a plastic surgeon here in Little Rock when I went into practice.  He left his surgical practice a few years ago, retrained and is now in hospice care at the local VA. (photo credit)

Dr. Robert Lehmberg, 63, said it took prodding from close friends to finally get him to seek treatment for depression and suicidal thoughts several years ago. Though he feared losing his license and being stigmatized, neither happened, and he said medication and psychotherapy have greatly helped.

…….

The article notes suicidal ideation (SI) among individuals 45 years and older is 1.5 to 3.0 times more common among surgeons than the general population (P < .02).

This study was commissioned by the American College of Surgeons (ACS) Committee on Physician Competency and Health.  It used an anonymous cross-sectional survey in June 2008. The survey included questions regarding suicidal ideation (SI) and use of mental health resources, a validated depression screening tool, and standardized assessments of burnout and quality of life.

There was a response rate of only 31.7% which resulted in 7905 participating surgeons.  Of these, 501 (6.3%) reported SI during the previous 12 months.

 Only 26% (130/501) of the surgeons with recent SI had sought psychiatric or psychologic help.  More than half [301 (60.1%)] reported the same reluctant to seek help due to concern that it could affect their medical license as Dr. Lehmberg mentions above. 

Burnout with all 3 domains of burnout (emotional exhaustion, depersonalization, and low personal accomplishment), depression, and  report of a recent medical error were independently associated with SI even after controlling for personal and professional characteristics.

The authors conclude:

Although 1 of 16 surgeons reported SI in the previous year, few sought psychiatric or psychologic help. Recent SI among surgeons was strongly related to symptoms of depression and a surgeon's degree of burnout. Studies are needed to determine how to reduce SI among surgeons and how to eliminate barriers to their use of mental health resources.

Related posts:
Doctors with Depression (September 24, 2008)
Stress and Burnout Among Surgeons – an Article Review (April 22, 2009)
Doctors With Depression (September 24, 2009)

REFERENCE

Special Report: Suicidal Ideation Among American Surgeons; Tait D. Shanafelt; Charles M. Balch; Lotte Dyrbye; Gerald Bechamps; Tom Russell; Daniel Satele; Teresa Rummans; Karen Swartz; Paul J. Novotny; Jeff Sloan; Michael R. Oreskovich; Arch Surg. 2011;146(1):54-62.

Florida Liposuction Death?

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 was going to wait until the autopsy came back to comment on this news article, but there are points to be made even now.
First, it isn’t known if the death was due to liposuction. 
This December 30th Palm Beach Post article gives the basics and that is all:   South Florida woman, 35, dies getting plastic surgery (bold highlights are mine).

Lidvian Zelaya's New Year's resolution for 2011 was to "look good," so she went to Strax Rejuvenation Center in Lauderhill on Monday to have fat liposuctioned from her waist and added to her buttocks, her husband, Osvaldo Vargas, said.

Three hours later, Vargas said, his wife was rushed to emergency facilities at a nearby medical center. When he arrived there, he was told she had died. She was 35. 

Vargas and his attorney, Spencer Aronfeld of Coral Gables, said they were not sure what doctor performed the procedure nor whether the procedure had started when the medical problems began.

It troubles me that the husband isn’t sure who performed the procedure.  It wasn’t a training hospital, but a private clinic (Strax Rejuvenation Center).  Perhaps it is reports like this one  and this one which has caused a loss of trust in physician integrity.

It troubles me that the husband wasn’t sure the procedure had even started when the medical problems began.  As difficult as it would have been, didn’t Lidvian’s surgeon (reported elsewhere to have seen Dr. Roger L. Gordon in consultation)  sit down and talk with the family?

He may not have done anything wrong.  It may turn out she had an allergic reaction to a medication or malignant hyperthermia or ….

Or perhaps Dr. Gordon did talk to the family, but the grief stricken husband didn’t hear or process it.

This also troubles me, as I know it will Dino Doc who has written on clearing patients for surgery.

From the ABC News article on January 3, 2011:  Did Florida Woman's New Year's Resolution Costs Her Life?  Cosmetic Surgery Gone Wrong Has Family Wondering What Happened 

According to the family, Zelaya was in perfect medical condition, and the clinic cleared her through a pre-operative screening. Now, the family is urging anyone considering cosmetic surgery to undergo a second, pre-surgical health evaluation by an independent primary care physician.

"I think it's an inherent conflict of interest if you are getting screened by the surgeon who wants to do the procedure," said Aronfeld.

Dino Doc that says a lot about why you are increasing asked to do pre-surgery clearances.


Related posts:
Know Your Surgeon (November 3, 2010)
Liposuction – Shaping not Weight-loss  (February 8, 2010)
Liposuction Overview  (October 6, 2010)
Major and Lethal Complications of Liposuction -- An Article Review  (July 16, 2008)

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.

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.

Know Your Surgeon

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 would caution anyone who elects to have cosmetic or plastic surgery to go to a surgeon’s office.  Meet your surgeon.  Along with learning about the procedure, ask about their training.  If your procedure is to take place outside of a hospital (for example, in a surgery center), ask if your surgeon has privileges to do the procedure in a major hospital (the hospital should have checked their training when doing the credentialing).

Treat cosmetic/plastic surgery as surgery with all the benefits AND risks of non-elective surgery.

I stumbled across this article Owner of Cosmetic Surgery Clinic Sentenced in New York for Health Care Fraud.

Arthur Kissel,a/k/a "Arthur Froom," was sentenced October 25th in Manhattan federal court to 10 years in prison for healthcare fraud offenses.  Neither Kissel nor his wife Sonia LaFontaine are doctors, but they engaged in a series of fraudulent practices out of their Manhattan cosmetic surgery clinic.  (pdf file of press release from United States Attorney Southern District of New York)

LaFONTAINE and KISSEL, along with several coconspirators including doctors who worked at LRMA, engaged in four different types of fraud at the clinic:
•  LaFONTAINE performed procedures which were billed as if they had been performed by licensed physicians.
•  LRMA billed cosmetic procedures as medically necessary procedures so that health insurance companies would be duped into paying for them.
•  KISSEL and LaFONTAINE submitted claims to health insurance companies for procedures that were never performed.
•  KISSEL and LaFONTAINE exaggerated insurance claims by increasing the number and complexity of procedures.
KISSEL and LaFONTAINE were indicted in March 1998 with conspiracy to commit health care fraud. KISSEL was extradited from Canada in 2008 and pled guilty on September 4, 2009.

Kissel and LaFontaine’s practices actually led to the death of one patient:

In imposing the maximum sentence permitted by law,Judge CHIN rejected KISSEL's claims of "ignorance and dumbness"and found that he "acted out of greed." He also stated that his crimes "led directly to the death" of JOEL CUNNINGHAM, who died on January 8, 1998, while undergoing an outpatient abdominal liposuction procedure at LRMA. CUNNINGHAM had wanted to become a NYPD police officer, but was too heavy to meet the entrance standards. He decided to have a liposuction procedure at LRMA,which used extensive advertising claiming that it was operated and supervised by a "world renowned surgeon," when in fact it was operated and supervised by KISSEL and LaFONTAINE. Evidence presented at a subsequent wrongful death suit in state court indicated that Cunningham had died of complications from anesthesia, which had been administered by an LRMA anesthesiologist who was at the time on professional probation due to drug and alcohol abuse.

Shout Outs

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.

Medical Resident's Journey is the host for this week’s Grand Rounds!  You may recall his poem won Dr. Charles Poetry contest.  The theme this week is “uplifting moments in medicine.”  You can read this week’s edition here (photo credit).

Good morning! Thank you for all the submissions which have flooded my inbox over the past week. They kept me going through a stretch of countless overnight shifts in the emergency department, which seemed never-ending and darker than a moonless night. In the midst of stunning fall foliage this October, the vibrant colors of this week’s Grand Rounds reach towards the sky. Take a moment out of the day to live in the present. Listen to the sounds around you, whatever they may be – leaves rustling in the wind, blaring sirens, constant monitors. Sit back, relax, take a long, deep breath and a sip of your favorite morning drink. Take in the flying kites, subtle music, and silver linings of today’s indulgence: Uplifting Moments in Medicine.  ………….

……………………………………….

I hope you will all read Dr. Rich’s recent post:  Medical Ethics and the Amish Bus Driver Rule

Rachel Maddow, in a discussion related to the provision of abortion services, once proposed that we (society) should invoke the Amish Bus Driver Rule whenever medical professionals invoke their personal convictions in refusing to provide legal medical services.

The Amish Bus Driver Rule goes like this: If you’re Amish, and therefore have religious convictions against internal combustion engines, then you have disqualified yourself for employment as a bus driver.  …..

…………………………………….

From twitter:  @SusannahFox

#ACS2010 survey: Half of surgeons use FB; 20% use Twitter http://bit.ly/9XRBFt (PDF via @Sani2012)

Compare to @Pew_Internet survey: Half of all adults use FB, MySpace, LinkedIn; ~13% use Twitter http://pewrsr.ch/awb5wt

The first tweet links to this article: Time to Tweet: Session highlights importance of social networking for surgeons (page 1 and 3 of the PDF file)

………….According to Dr. Glick, 7% of the U.S. population is on Twitter, while 20% of ACS survey respondents (approximately 300 as of last week) are on Twitter. 41% of the U.S. population is on Facebook, compared with 64% of ACS survey respondents (see table, page 3). The more sobering results, according to Dr. Glick, are the number of ACS survey respondents who participate in online forums or read online health blogs – 34.5% – which is a comparatively low number.  ….

………………………….

Fellow physician, blogger, and twitterer  Jill of All Trades, MD has begun doing a podcast!  The podcast, Girlfriend M.D.,  is part of Quick and Dirty Tips family. She will be sharing the hosting duties:

Join Dr. Sanaz Majd and guest host Dr. Lissa Rankin as they answer the most common questions women have about their bodies and their health. This is a chance for you to learn about all those issues you were so curious about, but were too afraid or embarrassed to ask about. Girlfriend MD will show you that you are not alone, and that no topic is off-limits. After all, we are all girlfriends here.

…………………………..

From the #hcsm twitter chat this past Sunday evening – a very helpful tip sheet to use in searching for health information online:

@pfanderson T2 My tip sheet for patients using ehealth info w/docs http://www-personal.umich.edu/~pfa/mlaguide/free/quickgd.pdf #hcsm

It is a pdf file, but I encourage you to check it out. 

………………………………….

Dr Anonymous’ show will be about  DigPharm Mtg. The show begins at 9 pm EST.

Upcoming shows:
10/23 : Saturday Nite
10/28 : About FMEC Mtg
10/30 : On Location

“Women’s Health and Cancer Rights Act of 1998’’

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

Recently the New York signed into law requiring hospitals and doctors to discuss breast reconstruction options with the patient prior to her undergoing cancer surgery. 

It troubled me that this law was needed.  Is it not the duty of the physicians and surgeons to educate the patient on the options available? 

We need to make sure the patient and their family know of the treatment options which may vary depending on the diagnosis and stage.  Radiation.  Chemotherapy.  Surgery – lumpectomy, mastectomy, axillary dissection.  A combination of treatments.

Even if the patient and her physicians don’t chose to do immediate reconstruction, isn’t the discussion and information part of the discussion?  At least inform the patient of the option.

Do we physicians and surgeons need another law to ensure we do right by our patients?

Not all patient’s have health insurance so reconstruction may become unattainable due to finances.   Susan G. Komen has a nice resource page for financial assistance available for breast cancer patients.  I did not see any that would cover reconstruction.  Many will help will obtaining a prosthetic.

Patient’s that do have health insurance are afforded protection under the “Women’s Health and Cancer Rights Act of 1998.”   However, as I was reviewing and researching the WHCRC for this piece I learned that it’s not a blanket protection:

Generally, group health plans, as well as their insurance companies and HMOs, that provide coverage for medical and surgical benefits with respect to a mastectomy must comply with WHCRA.

However, if your coverage is provided by a "church plan" or "governmental plan", check with your plan administrator. Certain plans that are church plans or governmental plans may not be subject to this law.

Breast Reconstruction—Part I (October 2007)
Breast Reconstruction – Part II (October 2007)
Patient Satisfaction Following Breast Reconstruction Using Implants  (June 7, 2010)

REFERENCES

Before Breast Is Removed, a Discussion on Options; New York Times article, August 18, 2010; Anemona Hartocollis

“Women’s Health and Cancer Rights Act of 1998’’ Summary; American Society of Plastic and Reconstructive Surgeons website

Your Rights After A Mastectomy...Women's Health & Cancer Rights Act of 1998; Department of Labor

Dr. Goldwyn’s “Surgeon”

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

After learning about Dr. Robert Goldwyn’s death, I pulled out his book “The Operative Note:  Collected Editorials” to reread (published in August 1992).  I’d like to share a few with you over the next weeks/months.

The first is entitled “Surgeon”

On a recent trip to Hawaii, I learned that in the Polynesian dialect spoken there, the word for surgeon is kauka oki:  doctor (kauka) who cuts (oki).  While some of us surgeons might resent such a graphic, “cut and dry” definition, we cannot deny its verity.  No matter how we may slice it, a surgeon is a doctor who makes incisions.  In fact, the origin of the word surgery is Greek, from cheir, meaning “hand,” and ergon, meaning “work.”  That surgeons work with their hands did not always bring honor.  Centuries ago, one recalls that those who cut on others, with their permission, generally held a lower status than those who eschewed the knife.

At the bottom were the barbers, and slightly above them, the surgeons.  In England in 1462, the Guild of Barbers became the Company of Barbers, and under Henry VIII, the Barber Company was united with the smaller Guild of Surgeons to form the United Barber-Surgeon Company.  In commenting on Henry VIII’s role in this episode, Garrison cites the painting by the younger Holbein, the court painter:  “Henry VIII—huge, bluff, and disdainful—in the act of handing the statute to Vicary [Thomas Vicary, First Master of the United Barber-Surgeon Company], in company with fourteen other surgeons on their knees before the monarch, who does not condescend even to look at them.”1  Perhaps Henry was irate at having to leave his dinner table and his newest wife.

The metamorphosis from the lowly barber to the glamorized surgeon has been long.  I am sure that Henry VIII did not envision the consequences of his royal decree.  The seesaw of history is marvelous as long as you are on the upswing.  The rise of the surgeon did not erase the schism (in fact, it may have intensified it) between the so-called thinkers and the doers.  This enmity, although lamentable, is centuries old.  some, however, such as Lanfranchi of Milan (the first to describe concussion of the brain and to distinguish between cancer and hypertrophy of the female breast), did rise above the petty, professional fray.  In his Chirurgia Magna, completed in 1296, he wrote:

• Why, in God’s name, in our days, is there such a great difference between the physician and the surgeon?  The physicians have abandoned operative procedures to the laity, either, as some say, because they disdain to operate with their hands, or rather, as I think, because they do not know how to perform operations.  Indeed, this abuse is so inveterate that the common people look upon it as impossible for the same person to understand both surgery and medicine.  It ought, however, to be understood that no one can be a good physician who has no idea of surgical operations and that a surgeon is nothing if ignorant of medicine.  In a word, one must be familiar with both departments of Medicine. 2

We do accept the fact today that the best surgeon is one who knows not only how to operate, but when not to.  Harvey Cushing, about the time that he became the first Surgeon-In-Chief of the Peter Bent Brigham Hospital, Boston, said in his letter to his counterpart in medicine, Henry Christian:  “I would like to see the day when somebody would be appointed surgeon somewhere who had no hands, for the operative part is the least part of the work.” 3

Cushing, of course, did have hands, good ones, and more important, a superior brain, which he used prodigiously.  His remark was a hyperbole that reflected his correct view of surgery; it must grow from research and basic sciences and from its application to clinical problems.  Surgery, despite the awe it now has (for those who doubt this, see the afternoon “soaps”), represents a failure of nonoperative medicine.  Who would not want to take a pill rather than undergo an operation for cholecystitis, breast cancer, or benign prostatic hypertrophy if the results were the same?  Would not genetic engineering by medication to prevent facial clefts be preferable to repairing them, no matter how meticulous and innovative the surgeon?  The thought that a capsule could safely enlarge or reduce breasts or salve could eliminate Dupuytren’s contracture or a prominent dorsal hump may seem too fanciful even for the most imaginative, yet landing a man on the moon and retrieving him without mishap has long been a fait accompli.  However, since medical Shangri-La is many years hence, we heirs of Pare will be continuing our manual ministrations, our barbers’ burden.

References

1.  Garrison, F.H.  An Introduction into the History of Medicine with Medical Chronology.  Suggestions for Study and Bibliographic Data, 4th Ed.  Philadelphia: Saunders, 1929; reprinted in 1960. Pp. 238-240.

2.  Lanfranchi of Milan.  In M.B. Strauss (Ed.), Familiar Medical Quotations.  Boston: Little, Brown, 1968. P. 583.

3.  Fulton, J.F.  Harvey Cushing:  A Biography.  Springfield, Ill.:  Charles C. Thomas, 1946.  P. 352.

ACS’s Surgical Case Log for Haiti Workers

Updated 3/2017 -- links removed as many no longer active.

H/T to Dr. Val, Better Health and her post  The American College Of Surgeons Creates Case Log For Surgeries Performed In Haiti.  I’d like to help her get the word out on this web-based tool the ACS has created to help medical workers in Haiti keep track of surgical procedures.

The ACS has a case log system in place already for College members which they have expanded and opened to non-College members as well.

Non-ACS members can register here.  The system will automatically add Haiti as a location, and surgeons can start adding cases right away.

ACS members who have used the case log system before can log in here.  ACS members who have not registered to use the case log system can register at here.  Once ACS members are logged in, they can add “Haiti” as a location for cases associated with relief activities.

The system currently works with both Palm and Pocket PC phones.  The iPhone and Blackberry editions will be released in the next 1-2 weeks.

“Female Physicians Fill Halls of Medicine”

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

Interesting article in the November issue of the Journal of the Arkansas Medical Society regarding women in medicine -- Healing the Gap: Female Physicians Fill Halls of Medicine by Casey L Penn (pdf, pp 104-106)

Harriet Hunt was the first woman to apply to Harvard Medical School. The year was 1847, and Harvard rejected her – as it would all women for the next century. It was 1945 before the school would finally
admit women medical students.

Today, Hunt’s experiences seem like ancient history to students like UAMS senior medical student Sarabeth
Bailey, who decided at a young age to enter the medical field. Bailey, a small town girl from DeQueen, Arkansas, was the first in her family to pursue a higher education, and found the doors of UAMS wide open to her when she entered in 2006………….

Related post

Women in Medicine (April 24, 2008)

Women in Surgery (August 21, 2008)

Surgical Glove Perforation and the Risk of Surgical Site Infection – 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.

H/T to ACP Internist for bringing this article to my attention (see full reference below).

It's best not to get holes in one's surgical gloves in the middle of a procedure, as this leads to a higher risk of infection for the patient, the Archives of Surgery reports in a study about the effect of ripped gloves. …… Which is, perhaps, why the surgeons put on the gloves in the first place?

For me, I found nothing new in this article.  Yes, surgeons wear gloves to both protect the patient and him/herself.  Gloves are part of the universal precautions. 

It is well known that the risk of getting a hole in one’s glove increases with the length of the surgery (especially when over 2 hours) or when dealing with spiked bone fragments.  The authors of the article felt they had a new angle --

The frequency of glove perforation during surgery has been studied extensively and found to range from 8% to 50%.  The impact of glove perforation on the risk of surgical site infection (SSI), however, is unknown. The present study was conducted to test the hypothesis that clinically visible surgical glove perforation is associated with an increased SSI risk.

I think most surgeons change their gloves if the hole is visible.   It is intuitive that the patients who are not on antimicrobial prophylaxis would be at the greatest risk of surgical site infection when a defective glove is involved.  This holds true with the authors’ findings: 

In the presence of surgical antimicrobial prophylaxis, the rate of SSI (6.9% vs 4.3%) was higher in procedures involving perforated gloves compared with procedures with maintained intraoperative asepsis.  After adjusting for 6 confounders in multivariate logistic regression analysis, however, the odds of contracting SSI in the event of glove puncture were not significantly higher when compared with procedures with intact gloves.

In the absence of surgical antimicrobial prophylaxis, glove leakage was associated with an SSI rate of 12.7%, as opposed to 2.9% when asepsis was not breached.  This difference proved to be statistically significant.

Double gloving may decrease the risk of transfer of germs (either direction:  patient to surgeon or surgeon to patient), but it is not always the answer.  I have tried all the combinations:  both gloves the same size, the outer one a smaller size, the outer one a larger size.  In all cases, my hands go numb.  Numb hands is not a good thing in a surgeon.

Routine changing of one’s gloves might capture some of the “un-caught” glove perforations and therefore decrease the risk of SSI in patients.  The authors even suggest doing so every two hours.  It would be interesting to figure up the costs of all the glove changes compared to the SSI costs.  Would it be cost effective?

The use of surgical microbial prophylaxis for all cases is still controversial.  The risk of SSI with clean surgical procedures is considered too low to be worth the risk of “side effects” from the antibiotics or the possibility of contributing to “super bugs.”  As pointed out in the article, indications for prophylactic antimicrobials approved by the CDC are clean operations involving prosthetic material and any operation in which a potential SSI would pose catastrophic risk (ie all cardiac operations, most neurosurgical and major vascular operations, and some operations on the breast).

REFERENCE

Surgical Glove Perforation and the Risk of Surgical Site Infection; Arch Surg. 2009;144(6):553-558; Heidi Misteli, MD; Walter P. Weber, MD; Stefan Reck, MD; Rachel Rosenthal, MD; Marcel Zwahlen, PhD; Philipp Fueglistaler, MD; Martin K. Bolli, MD; Daniel Oertli, MD; Andreas F. Widmer, MD; Walter R. Marti, MD

Related post

Needle Sticks (January 2008)

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)

The Ethical Challenge and Surgical Innovation

 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 short articles referenced below make for thoughtful, interesting reading. I had a similar discussion once during an ethics CME course I took. Most there thought that any “change” in an operation was risky and maybe unethical as the surgeon was “not trained” for it. My view point as I tried to explain it, was that like dress-making or tailoring, surgery is based on good skills. If I know how to put in a zipper or do a collar or do button-holes well, then you can put all those together to do more than just make a dress. I should be able to put those skills together to make a suit coat. That simple example opened (didn’t necessarily change) up the minds of most there.

That example is way too simple and there do need to be ways to make sure that surgeons who left their residency PRIOR to learning a technique that came along ten years later (laproscopy is a great example) have properly learned the technique prior to being given hospital privileges. What is the learning curve? Who should oversee them while they do their first six or ten or twenty cases? What if they are the first in the community to learn the skill (went to the university and took a week long course)?

Here are some short bits to entice you. This is from Dr Clayman.

The challenge for the surgeon as a creative being is that unlike all other arts, the surgical medium is sensate. Every alteration in a tried-and-true technique
exposes both the surgeon and patient to censure and unknown complication, respectively…….

The question arises, at what point along the creative continuum does a minor variation on a theme become an innovation? When does the surgeon-scientist need to ask or request a panel of peers to review an idea or concept and judge it—seeking permission prior to performance? How well equipped is the average institutional review board (IRB) panel, all too often composed of a minority of surgeons, able to pass judgment? ………….

The surgeon today, through technology, seeks to accomplish a surgical cure while lessening surgical
morbidity, hence the advent of minimally invasive surgery. However, as the incision wanes, the technology waxes and thus the surgeon must now enter a realm unfamiliar, that of the medical industrial
complex. While the surgeon is thinking less pain, quicker convalescence, better cosmesis, the industrial
side of the partnership is evaluating potential profit/loss, marketability and expense of development. In this light, it is essential that the IRB stand between the innovator and the patient, just as the FDA now stands between industry and the patient….

In this regard the sage advice of Dr. Agich bears repeating: “We need a well-grounded set of criteria to differentiate at least three types of cases: routine or
normal variation; innovation that is beyond routine, not formal research, yet requires review; and innovation that involves research and so requires formal IRB review.”

However, as with most gradations, the extremes are obvious (one and three), it is the middle ground (two) that provides the greatest challenge and concern…….

Both articles are worth reading and discussing.
REFERENCES
Dialogue: The Ethical Challenge Posed by Surgical Innovation by Ralph V Clayman, MD with Response by George J Agich, PhD; Lahey Clinic Journal of Medical Ethics, Fall 2008, Vol 15, Issue 3, pp 6-7 (pdf file)
The Ethical Challenge Posed by Surgical Innovation by George J Agich, PhD; Lahey Clinic Journal of Medical Ethics, Spring 2008, Vol 15, Issue 2, pp 1-2 (pdf file)