Wednesday, December 26, 2007

PORTAL and your Surgeon - The Cake is a Lie.

In October I wrote about spatial perception and the concept of being left or right brained as it applied to your surgeon. While generalities about artistic taste or surgical ability being associated with left/right dominant brained people and the like as it applies to individuals is a silly idea, I definitely think the ability to understand and intuit spatial relations is important.

Much like a pool hustler understands the geometry and physics of a bank shot without getting a compass and calculating force vectors, surgeons process symmetry, proportion, and volumetric relationships. With laparoscopic surgical techniques utilizing small cameras and long, remote instruments there are several studies suggesting that people who are good at video games tend to be better at laparoscopy. Researchers found that surgeons who spent at least three hours a week playing video games made about 37 percent fewer mistakes in laparoscopic surgery and performed the task 27 percent faster than their counterparts who did not play video games.

I think I've discovered a great video-game proxy for Surgery. Valve Software published the title PORTAL this Fall as a under-publicized throw-in for their blockbuster video game, Half-Life 2. Portal is a unique puzzle game that is a real mind-bender in the way you have to understand spatial relations, momentum, physics, and inertia. It is also a really, really creepy experience in artificial intelligence (AI) paranoia. The phrase in the title of this post, "The cake is a lie....", is a critical plot device in the story. You can read plot spoilers on Wikipedia's Portal Page.

So next time you go to surgery, forget those questions about their experience, training, or board certification. Rather, find out how good they are at Portal :)

Portal's trailer is visible below via YouTube.


Saturday, December 22, 2007

More detail for those interested in the Tucson patient who had trouble finding care for her leg wound

There's an article in the Arizona Daily Star (click here) which goes into more detail on the events surrounding the patient in the MSNBC story I referred to in my last post, who could not find a Plastic Surgeon in the city of Tucson (pop. 946,362+) to take care of her leg injury.

The patient in this instance, Mary Jo McClure chronicled her experience with this episode on the web by starting a website "My Severe". You can actually see photos of the wound during her treatment which required two surgeries to treat.


Friday, December 21, 2007

Emergency Room coverage by surgical specialties continues to worsen

Last summer I wrote a post "What's going to happen when you need a plastic surgeon in the E.R.?" about the worsening crisis in E.R. coverage among many specialists including Plastic Surgeons.

As we end the year, I've been seeing a number of articles referring to this come up again in our professional journals and on the news wires. MSNBC today highlights this again in a story "Emergency rooms find on-call specialists rare: Seriously ill suffer as relationship between physician and hospital unravels." Surveys of Emergency Room around the country have reported that as many as 75% have had issues about coverage for services like Orthopedics, Neurosurgery, Obstetrics, Hand Surgery, Oral Surgery, and Plastic Surgery.

In the MSNBC story, they profiled a patient who had trouble finding treatment from a plastic surgeon

Retiree Mary Jo McClure, 74, experienced the problem firsthand one Friday afternoon in January when she fell down some concrete steps, tearing large chunks of flesh from one leg. The plastic surgeon on call for Tucson Medical Center refused to leave her private-practice patients to come to the emergency department to treat McClure, who has health insurance. The doctor said instead she would see the injured woman in her office the next Monday.

But over the weekend, the specialist telephoned the family to say that she could not treat McClure after all because she performs only cosmetic procedures and is not trained to handle severe wounds, McClure said.

I can remember seeing this scenario multiple times during residency, and in this instance it is B.S.. This doctor may not want to or like to treat wounds but she is certainly over-qualified to. After examining it, she may determine that the extent of it requires surgical techniques she is no longer proficient in (eg. microsurgical techniques). This particular doctor is going to have to decide if staying on staff at that hospital is worth it to her for exposure to these issues from the ER. She may choose not to, but it looks real bad to behave like she did in this instance. Now for patients who present with hand issues, complex facial fractures, and mangled extremities I do feel it is more appropriate to defer treating if you don't do those types of procedures as the skill sets for treatment are more advanced and the resources required for their global care do not always exist at all hospitals.

I, for example, do not do any hand surgery (beyond smaller burns and occasional peripheral nerve procedures) in my elective practice and I do not take ER call for hand. Out of the nearly 40 Plastic Surgeons in my city, maybe 5 do any amount of hand surgery with most of those working at the University-affiliated level I trauma center. Outside the University, you may be SOL if you're trying to find a plastic surgeon doing hand injuries. As many orthopedic surgeons are following plastic surgeons out of the hand business, we're reaching critical mass for coverage of that specialty.

Traditionally, many specialists agreed to pull on-call duty in exchange for admitting privileges and use of a general hospital's facilities to perform operations and other procedures as part of their regular practice, O'Malley said. But the rise of physician-owned specialty hospitals and outpatient surgical centers over the past 15 years has reduced doctors' reliance on the general hospital.

"The historic relationship between physicians and hospitals is unraveling," O'Malley said.

I think that last sentence says it all. Surgeons en mass have reached a breaking point about being bullied by hospitals and insurers and now have some opportunities to walk away from uncompensated and unreasonable demands for ER coverage. In years past, the ER was a reliable practice builder for many plastic surgeons but in many instances it's now a reservoir of uninsured patients and offers less then cost reimbursement on insured patients with significant exposure of malpractice liability. What's not to like?

Much like I suggested when talking about specialty hospitals, the relationships between doctors and hospital ER's is going to have to be renegotiated. It's clear that hospitals will be having to pay stipends for ER coverage (which is perfectly reasonable to me) and that there will have to be increased medical malpractice tort reform for ER coverage to halt (if not reverse) this trend.


Friday, December 14, 2007

St. Louis Mesotherapy clinic chain (FIG) filing for bankruptcy

The first major casualty in the American experience with mesotherapy has arrived with reports that FIG, the first franchised mesotherapy clinic company, is closing it's doors in the wake of hundreds of complaints from unhappy clients.

FIG had operated over a dozen clinics in seven states that promoted a package of mesotherapy injections, costing almost $2,000 per body part, to reduce fatty deposits on the thighs, abdomen, buttock, and neck. Its clinics reportedly performed over 100,000 mesotherapy-style treatments across the nation.

Now all this doesn't mean that mesotherapy can't or doesn't work, but it clearly shows what happens when you put the cart in front of the horse with new technology or techniques. It's to the credit of the Plastic Surgery Education Foundation that they've taken the lead in trying to study the safety and efficacy of standardized regimens for these injection lipolysis treatments. The inaction of other medical groups who have dabbled in this is disturbing.

Hopefully this will temper the enthusiasm for people experimenting with these kinds of injections until we have more information. Remember that the active components of all these treatments are cyto-toxic medications being used in a way far from their accepted indications.

Wednesday, December 12, 2007

Physician-owned hospitals - an unavoidable trend IMO

The issue of whether or not hospitals run better when the doctor's who work there own all or part of it has been a contentious issue. A provision ram-rodded into a 2006 deficit-reduction bill was a mandate that could put a moratorium on hospitals that are partly owned and run by doctors by denying eligibility for medicare/medicaid reimbursement for services (a condition that makes running a hospital impossible). There's compelling arguments on both sides of this.There are almost 130 physician owned hospitals in the United States versus approx. 5000 plus general hospitals.

"General Hospitals", who offer wide ranges of service and exist as either not-for-profit or for-profit hospitals, claim that doctor's face conflicts of interest over patient referral and will "cherry pick" healthier patients in higher-profit areas of medicine (usually cardiac medicine/surgery and orthopedic surgery) while eschewing medicaid patients and money losing endeavors (like emergency room services).

Physician investors in hospitals meanwhile argue that existing hospital corporations fear competition, and that they've built highly efficient facilities which have a tendency to have more nurses on patient floors, invest more in high-technology, and provides amenities and levels of service not available at general hospitals.

There's data from the feds which actually show both arguments to be true simultaneously.

My personal take is that physician ownership is both necessary and will become increasingly common unless prohibited by congress (as the hospital lobby has worked towards in Washington). As the margins of the economics of organized medicine become tighter, hospital-based physicians are going to demand a "piece of the action" to offset the savaging of their income by medicare and corporate medicine reimbursement. Hospital-Physician partnerships will be necessary for institutions to attract and maintain their medical staff in some profitable specialties. When doctors have a stake and more input into operating decisions, I can't help but think we'll all be better off at the end of the day.

Will this affect Plastic Surgery much? Not really I suspect. Our specialty has been marginalized for years by hospitals as we don't generate near as much revenue as other surgical specialties like orthopedics, cardiac surgery, or transplant surgery. With outpatient cosmetic surgery now the horse pulling the cart for the public face of our specialty, I think more and more Plastic Surgeons will feel like they don't have much of a stake in that fight. That may be kind of myopic and narrow-minded, but it's true. Except for outpatient surgery centers, I don't think there's a lot of doctor's going to be lining up to throw money at the full-service hospital business.

There's a great blog on WebMD, "Mad About Medicine" which has a number of related articles on the economics of medicine. Good stuff!


Saturday, December 08, 2007

The "Squidworth's Nose" deformity : Does breast feeding make your breasts sag?

A study was presented at our major Plastic Surgery meeting in Baltimore which came to the conclusion that breast-feeding did not cause ptosis (drooping) of the breasts.

While I haven't seen the published manuscript yet, I find this conclusion somewhat implausible clinically and flawed based on the thumbnail descriptions of the methods of study used.

The researchers interviewed 132 women who consulted for a breast lift or breast augmentation. The women were, on average, 39 years old; 93 percent had had at least one pregnancy, and most of the mothers--58 percent-- had breastfed at least one child. Also evaluated were the patients' medical history, body mass index, pre-pregnancy bra cup size, and smoking status.

The results suggested no difference in the degree of breast ptosis (the medical term for sagging of the breast) for those women who breastfed and those who didn't. However, researchers found that several other factors did affect breast sagging, including age, the number of pregnancies, and whether the patient smoked.

Quantifying something as subjective as this is hard to do under most circumstances (and I give the doctor's credit for writing something interesting), but unless you study these women prospectively (rather then retrospective as was done here) and get better characterization of their baseline breasts size/shape, skin quality, body weight, and breast tissue tone (ie. firm vs fatty) then you really can make no valid conclusions about their hypothesis.

You get breasts that hang for a number of reasons including:

  • gravity (no explanation needed!)

  • thinning of the skin with age

  • attenuation of the internal soft tissue support of breast tissue (aka Cooper's Ligaments)

  • "tissue expansion" phenomena from weight gain or engorgement during lactation

Now in re. to ptosis and lactation, the tissue expansion effect is what I'd say predominates. Now as a lactating breast will be swollen for a longer time, it's pretty intuitive and obvious that it's going to affect the breast shape more. I'm skeptical from this intuitive POV plus an (occupational) observational basis on this idea that there's no difference after breast feeding.

One of the more common sub-groups in the breast augmentation or breast lift group are women in their early or mid 30's who present with "involutional ptosis" (our fancy words for saggy breasts after pregnancy). During my residency at the University of Louisville (KY), I can remember spending time with one of my favorite surgeons, Dr. Marc Salzman, who was kind enough to let me accompany him during his cosmetic surgery consults. There was a pretty girl ~ 33 years old who came in, and when describing what she did not like about her breast declared, "Dr. Salzman, after having my babies, my breasts now look like Squidworth's nose!". He was kind of puzzled by her comment, but I burst out laughing aware (due to having small children) that Squidworth is Sponge Bob Squarepant's boss on the popular cartoon show.

Pictured below is Squidworth. And you know what? Her breast looked exactly like Squidworth's nose. :)