Wednesday, July 30, 2008

Will the last medical dermatologist please turn off the lights? Access issues for dermatology patients

The trend of Dermatologists becoming more and more unavailable for actually treating dermatological conditions is in the news again in the front page of the New York Times. The article, "As Doctors Cater to Looks, Skin Patients Wait" discusses the discrepancy in how patients are catered to for cosmetic versus medical dermatologic conditions. I blogged about this same issue last September in "How Botox affects your access to a Dermatologist"

There's a few dermatologists quoted who really come off poorly in the language they use justifying their practice choices. You can bet they'd like a mulligan about now in their 'on the record' interview.

Peppered in the comments section to the article are the predictable griping like,

  • "Doctors should not get rich off their patients. Period. End of story. Society has greatly subsidized every doctor's education. If a doctor wants to supplement his or her income with cosmetic procedures, this should be strictly evenings and weekends."

  • "Why on earth should a 10-minute botox injection be worth $500?"

  • "...clinics will not take patients without referrals, and unless a matter is urgent, it can take 4 - 5 months to get an appointment (which they keep as short as possible). However, if a patient wants a cosmetic procedure, it takes only 1 - 2 weeks for an appointment. The dermatology profession needs to examine its ethics, or the lack thereof."

  • "The rest of the medical system will follow. Once health care becomes a one-payer system, there will be a second tier for the moneyed. This is how medicine works in Europe."

  • "This is a perfect example of market forces at work, and proof the market works perfectly. Money talks. In this case, however, market forces pervert the delivery of good health care. The solution is to reimburse doctors for actually taking care of patients, not doing procedures or ordering expensive tests. With a regime change in Washington on the horizon, we will hopefully have a complete overhaul of our decrepit and wasteful health care-industrial complex."

  • "Disgusting example of the growing scummy side of medicine. A terrific example of how the wrong people gain admission to medical school, sociopath sales persons, "I've always wanted to help people, blah, blah blah..." while only interested in the cash. We need a new health care system with salaried physicians"

  • "These comments are scary. Most are uniformed, ignorant and miss the point. Physicans can't meet their overhead and are responding to "managed care" in the only way they can. It is the root cause of most of the ills we see today. We will never able to administer quality healthcare in this type of system. How is it possible for a small practice to negotiate equitable reimbursements from a market giant such as Cigna?"

  • "The idea that patients with potential skin cancer have to literally beg to be seen by a doctor is absolutely horrifying. This is one area where civil suits can be an effective weapon. Drs. who refuse to deal with a skin cancer should be sued out of practice. And/or heavily regulated by the government or their own "Professional" organization (the AMA). Does this behavior actually conform to the AMA's code of conduct?"

  • "Any doctor who will not see a patient who suspects a mole cancerous, or has a chronic skin disease, for longer than 72 hours, should be sued and forced to explain his negligence in a court of law. "

  • Reading the comment sections of articles in "the nation's newspaper" is always really illustrative to me. There's alot of frustration and hostility about healthcare in the public which gets (mis)directed at physicians. (Don't forget poor Dr. Zenn who was sniped by the breast implant nutters in June.) It's really a systemic issue, but it's easier to blame "greedy" doctors then actually recognize the costs of administering and delivering healthcare is affecting this. Commenter's also usually fail to understand that this issue with dermatologists is actually going to get worse rather then better with whatever "universal healthcare" system we end up with. Unless you pay physicians market wages for their services, they're going to look for opportunities to realize it elsewhere.

    Reading this article I also kept thinking, why the hell would you feel like you absolutely have to go to a dermatologist (or Plastic Surgeon) to have a skin lesion or rash looked at? While I appreciate patient's opinion of our skills, evaluation and biopsy of lesions/rashes is simple enough that it logically should be largely the province of primary care providers or the nurse practitioners and physician assistants that affiliate with them in practice IMO. A lot of wound care clinics have such a set up, and I think wound care is much trickier then skin lesions!


Saturday, July 26, 2008

Plastic Surgery 101 officially endorses Index Funds. Bogleheads of the world unite!

There's been kind of a truism in contemporary Plastic Surgery practice that our business is kind of like "stocks and bonds". Cosmetic surgery has been more and more like "stocks" - high growth with lots of dividends, while reconstructive surgery has been more like a "bond" - steady, boring, and losing ground to inflation. Cosmetic surgery tends to have it's own cycle in that it's busy 3-4 months of the year (late winter - early spring), slows during the summer, and grinds to a halt in August/September when school is back in and women in school or with children can't take the time off to recover.

As we're teetering in the brink of a recession from the real-estate and credit bubbles, there's a lot of stories about how many predominately cosmetic surgery practices are feeling the pinch. A cosmetic practice is usually higher overhead and when things slow, they can get hit hard. Much like the DOW Jones index, these "stocks" are stagnant.

Common sense says, "it must be a good time to be a bond holder (or reconstructive surgeon in this instance)" which usually zig when stocks zag in terms of value.
Unfortunately this isn't true either. We've just narrowly avoided a showdown in Washington over an immediate 10% cut (and planned additional 5% next quarter) in Medicare reimbursement to physicians, which has the effect of actually reducing inflation adjusted compensation up to 30%(!). Private insurers, never one to leave money on the table, will quickly index their rates to the new Medicare scale and there will be significant disruptions potentially in access to care.

As I've been poised to assume custodianship of our office's 401K plan, I've tried to take it upon myself to learn more about investments. Since last October, the American stock exchange value is down something like 20% and has been hammered by fuel costs, the subprime mortgage meltdown, soaring costs of commodities, and a general lack of consumer confidence.

Recently I've been reading two books which have really been transformative in how I think about the stock market. William Bernstein's "The Four Pillars of Investing" & John Bogle's "The Little Book of Common Sense Investing". Both books advocate a strategy called Index Investing which is an extraordinarily boring but productive way to conduct your finances.

A few common concepts to this school of thought:

  • Trying to accurately time peaks and valleys of the market is impossible

  • Routinely beating the market return after expenses is (nearly) impossible

  • "Cost is King"- low overhead funds (like Index Funds) offer extraordinary advantage over time due to compounding interest versus actively managed mutual funds or hedge funds

  • Index funds and the related Exchange Traded Funds (ETF's) are increasingly the investment vehicle of choice for the multi billion dollar pension plans, large endowment vehicles, and investment industry professionals personal portfolios. (If their unlimited access to the best minds and research teams has driven them to indexing, don't you think you should consider it too?)

  • Whatever insight you may think you have into a mutual fund or stock's prospects, you're going to get crushed competing and trading against the resources and insight of large investment organizations. They already know and have responded to any information you have before you even have that information.

  • Consider carefully the added costs of advice (in fees) and beware of stars (as in, star mutual fund managers)

  • Do not overrate past fund performance. Bull markets mask underperformance of funds compared to benchmarks

  • Don’t own too many funds. Buy your fund portfolio – and hold it!

    • What's a "Boglehead"?
      "They are a bunch of diehard fans of John C Bogle, the founder of Vanguard, one of the most successful and largest mutual funds in the US. Started in 1975, the company is the pioneer of index funds. Its value proposition of low fees is well known to mutual fund investors all over.

      The low fees give Vanguard an edge when it comes to returns. According to a recent article in, Vanguard’s equity funds have returned 14.48% annualized over the last three years, compared to the company’s two closest rivals, American Funds (14.02%) and Fidelity (13.87%). The average equity fund in America returned 12.43%.

      Vanguard’s largest fund, the S&P 500 Index fund has an expense ratio of below 0.20% per annum
      . "


      Tuesday, July 15, 2008

      Copping a feel - now a civic virtue in Russian town of Bataisk

      The tiny town of Bataisk in southern Russia has established a hands on tradition on a new shrine to the female form.

      There is a new bas-relief silhouette of a woman's chest in the town square, on whose breasts a man’s hand is lying. It is being touted by locals that if a man touches this bust he is going to attain "family happiness".

      tacky de chez tacky!


      Sunday, July 13, 2008

      Plastic Surgery 101 welcomes Dr. Jason Jack to our sandbox. Roll Tide!

      I like to take this opportunity to welcome Dr. Jason Jack to my clinical practice and to Plastic Surgery 101. Jason is both a peer and friend of mine who was starting a new practice, and I was tickled to death to offer him a place in my office while he gets settled. Dr. Jack was a scholarship quarterback at the University of Alabama during their 1993 NCAA football championship before being an honors medical student and outstanding plastic surgery resident at the University of Kentucky.


      Saturday, July 12, 2008

      Breast implants and observed breast cancer rates. Could they actually be protective? Let's ask the rats.

      * Image at right spoofed from The Onion

      One of the most serious claims in the class action lawsuits against Dow Corning Corp. during the "silicone crisis" involving breast implants in the late 1980's was that silicone breast implants caused breast cancer and/or delays in diagnosis of breast cancer. Despite there being no evidence for it actually happening, these were reasonable questions to ask. Over the last 20 years, we've been flooded with data that has been reassuring on these issues.

      Implants do make conventional mammograms harder to interpret by their "shadow", but the increased ease of doing manual exams by having the implant to push against to feel lesions compensates a great degree. An MRI mammogram can be used to supplement mammograms when needed for better imaging for screening.

      One of the more interesting findings in several of the large series of women with implants was the observation of significantly lower (almost 40%) rates of breast cancer in the implant group versus a control population of women without implants. The intuitive reason for this has been that these women with implants were a self-selected (rather then "randomly selected") group who were likely to be healthier and have less breast tissue, which both should lowered their expected rates.

      To really sort out a true "expected rate" for breast cancer, you'd have to do some herculean effort of better characterizing the individual risks with a tool like one of the "Gail Model's" of the study participants, which is almost impossible in such large trials. The suggestion that the presence of implants themselves was protective wasn't really taken seriously. There could however, be something that makes us look at this issue a little closer.

      I came across a pre-publication in the journal Aesthetic Plastic Surgery entitled, "Breast Implants as a Preventive Factor" describing the differential temperature seen on thermography (a imaging technique that shows temperature) from experimental rats with silicone implants placed and the resultant affect that had on local circulating hormone levels and cellular abnormalities (both of which were decreased in the implant group). Now this was only an animal model mind you, but it immediately occurred to me that maybe part of that effect we were seeing was from this phenomena. Interesting stuff!

      Wednesday, July 09, 2008

      What's oncoplastic surgery?

      The Wall Street Journal profiled the concept of "Oncoplastic Breast Surgery". This is conceptually just lumpectomy or mastectomy done better. The concept uses rotating breast tissue to fill defects at the time of lumpectomy or larger "quadrantectomy" procedures. These are maneuvers we use with breast reduction and mastopexy procedures adapted to some of the cancer surgery procedures.

      It's a nice concept, but the rate-limiting step here is getting general surgeons to change how they think about breast surgery. Trying to coordinate someone else during the resection with a reconstruction is difficult, as they don't "think" like plastic surgeons do. I'm skeptical that short courses to surgeons can teach much beyond the most simple techniques. It's like putting someone in front of Guitar Hero on the Wii or Playstation and expecting them to play guitar professionally afterwards.

      I'm constantly evaluating blood supply, tension, and tissue quality in a way that you just don't get taught in other specialties. Weekend courses in this discipline just aren't the same as having doing hundreds of different possible reconstructive techniques all over the body and bringing that to bear on a given case. I had the pleasure of working with two of the leaders in this field during my breast surgery fellowship, in Plastic Surgeon Dr. Pat Maxwell and (an occasional basis) Breast Cancer Surgeon, Dr. Pat Whitworth in Nashville. I though I knew how to do mastectomies and whatnot before I saw these guys do their thing. They're incredible! Both do such anatomically sound breast procedures with no superfluous steps that it's really beautiful (for lack of a better word) to watch. Dr. Whitworth is quoted in the article BTW.