Friday, May 29, 2009

An aspirin a day may not keep the doctor away after all

Sudden shifts in medical advice can cause both patients and doctors confusion. In recent years the benefits of breast self exam for cancer, checking PSA (prostate specific antigen) levels for prostate cancer screening, vitamin supplements of any sort, and chest x-rays for lung cancer screening have all been reported to be ineffective and sometimes harmful to patients.

Add one more to the list - the routine use of low dose 81mg aspirin in the general population to decrease heart attack and stroke risk. This had been pushed such that most adults should consider taking a "baby" (81mg dose) aspirin a day. This seemingly harmless recommendation actually seems to be causing more problems then it's worth according to a new review of the literature.

Analysis of data from over 100,000 clinical trial participants found the risk of harm largely cancelled out the benefits of taking the drug. Use of aspirin in the lower-risk group was found to reduce non-fatal heart attacks by about 20%, with no difference in the risk of stroke or deaths from vascular causes. But it also increased the risk of internal bleeding by around 30%, a potentially life threatening complication. This is summarized here.

Only those who have already had a heart attack or stroke should be advised to take a daily aspirin is the new suggestion, at least for this week.

Click below to hear an audio summary:


Wednesday, May 13, 2009

Ireland and others on board with regulating cosmetic surgery providers - The end for Tom's Rhinoplasty, et. al?

The United States is not alone in trying to come up with a way to ensure quality and standards among providers of cosmetic surgery and related procedures. The Independent (UK) wrote about this problem in Ireland and the U.K. last fall (see here) saying,

"Once you have a basic medical degree you need no specialist qualification in order to perform plastic surgery. A GP could do a breast augmentation in the morning, even though he had never seen it done or performed one -- and that is perfectly legal. The International Association of Plastic Surgeons (IAPS) members are trained in plastic, reconstructive and aesthetic surgery. Other people carry out procedures despite having no formal qualifications." One major concern of the IAPS is that of surgeons being flown in from abroad by private clinics and simply flying home after performing a procedure. "You would expect any other surgeon to be resident in the country in which he is practising," says Mr David O'Donovan, Secretary of the IAPS.

"Yet private clinics are shipping in surgeons who are not around when the patient needs aftercare, or complications arise. Some say their doctors are specialists, but they don't say what they're specialists in. For instance, a doctor performing breast surgery could, in fact, be a bowel specialist."

Similar stories can can found around the world from the United States, Australia, and other western countries. It certainly seems likely to get worse here as reimbursements for physicians are poised to take a big hit with whatever happens with American health care reform. There will be even more pressure for many doctors to encroach outside of their areas of expertise and become self-styled "Cosmetic Surgeons" or "Aesthetic Medicine" specialists.

Catering to this trend is the ever proliferating alphabet of organizations seeking to give some fig leaf of authenticity for doctor's credentials who have little or no formal training in some of the services they're now offering. (WTF is laser "vaginal rejuvenation" by the way?). One of the "cosmetic surgery boards" here in the United States has even had the nerve to suggest that their members are more qualified then Plastic Surgeons to perform cosmetic procedures and has railed against hospital medical staffs who have (quite rightly) not granted their hodge podge of members surgical privileges outside the scope of their accredited training.

For a Gynecologist's take on some of his colleagues trying to peddle themselves off as reinvented cosmetic surgeons, read this great post at "David's waste of bandwidth".

"Cosmetic surgery can kill people. It can maim and disfigure people. Just as I think surgeons should respect the procedures we do as gynecologists, we should respect the things they do, and only do them when we really have the training and judgment to proceed. No weekend course on ”cosmetic gynecology“ (whatever the f that is) is going to provide skills and judgment comparable to someone who is boarded in cosmetic surgery and plastic/reconstructive surgery. As it is, the folks who are boarded in cosmetic surgery are rightfully pissed at those cosmetic surgeons who are doing this without board certification or a decent background in plastic and reconstructive surgery. Why are we adding to this nonsense?

As an example in terms of judgment, you're mentioning the possibility of doing ”gspot injections“ (sic). This is inappropriate and has no place in modern practice, cosmetic surgery, gynecology or otherwise.

To my point exactly. We have no business doing this crap. I sympathize with those who do, and understand their motivation in terms of a cash business. But we're surgeons and professionals, NOT car dealers trying to make a fast buck. Or are we?"

It's not so far fetched to imagine a proverbial "Tom's Rhinoplasty Clinic" (an olde school South Park season 1 reference) popping up every block stamped with the seal of approval by ____________. (fill in the blank with bogus board certification du jour)


Thursday, May 07, 2009

(smart) Skin Care for Dummies..... keep it simple stupid

There is an overwhelming amount of skin care products on the market, and it can get kind of confusing to patients and doctors about sorting out hype from substance. At the end of the day I think you've got to keep it simple and try to minimize the number of steps and products that people use.

At a basic level you need to consider 3 things to be essential
  • a gentle daily cleanser (which can be something cheap)
  • a restorative agent(s) to improve or maintain your skin
  • protection from the sun

There's a whole bunch of peripheral products addressing pigmentation (toners, hydroquinone products, etc...) that serve niche roles as well.

I've become a fan of the Neo Cutis line of products for two reasons
1. it's reasonably priced for medical grade skin products
2. you can do a lot with a very simplified regimen

The gimmick with NeoCutis is a substance called "PSP" which is a proprietary protein derivative of sorts derived from fetal skin cells. This PSP ingredient is common to their different product lines in different concentrations and with some other additives. For men, their gel-based, "Biogel"
is a very easy single product that men can use without overwhelming our simple brain or making us feel overly metrosexual. Highly recommended and one tube will last 3 months or so, pretty reasonable for $120-150 dollars. Neocutis makes a more concentrated PSP product eye cream which is also great. As I understand it, a lot of people just use it for their whole face. It seems to work well and be very tolerant to people even with sensitive skin.

I'm not here to pimp for that particular company, but I think they make a value-based product line that is very simple. If you combine one of their PSP products with an OTC gentle cleanser, Retin A (or another retinoid-like product), and some sunscreen you suddenly have a fairly formidable combination for less then $200-250.


Sunday, May 03, 2009

"Going Dutch" for ideas on healthcare reform

There's a real lovely article in the NY Times Sunday magazine about the Netherlands. The ostensible focus is on the social welfare network of the state, and contrasting an American expat's experience there. One of the issues discussed is health care, a very timely topic as it relates to the United States.

Since I started writing Plastic Surgery 101 in December 2004, I've periodically touched on medical economics as it's something that's fascinating both personally and professionally. It's been clear for several decades that we're creeping towards some type of state funded system ("Universal healthcare"), and the time table has sped up due to a couple of factors

  • the coming retirement of the bulk of the baby boomers. A demographic who has always been described as somewhat self-entitled. Their clout and collective zeitgeist are proving a potent voice in this.
  • the economic incentives of employers and unions coming into alignment on this. Someone wrote a few years ago that when Wal Mart decided it was time for universal health care, then discussions would happen in earnest.
  • a liberal president has a aggressively liberal congress and slight liberal majority senate
  • the real estate and stock market crisis have made not having both a job and health insurance a reality for a lot of middle, upper-middle, and white-collar classes.

  • I've been convinced that we're going to end up with a public-private system where basic care is covered and people with more money will be able to purchase higher levels of care or convenience to care. It's what actually exists in most of the world. There will still be moaning and gnashing of teeth about unequal access, quality, etc... but we'll be better off then we are on the whole.

    Anyway, there's a great descriptor of this in the article I was referring to, "Going Dutch"

    "The Dutch health care system was drastically revamped in 2006, and its new incarnation has come in for a lot of international scrutiny. “The previous system was actually introduced in 1944 by the Germans, while they were paying our country a visit,” said Hans Hoogervorst, the former minister of public health who developed and implemented the new system three years ago. The old system involved a vast patchwork of insurers and depended on heavy government regulation to keep costs down. Hoogervorst — a conservative economist and devout believer in the powers of the free market — wanted to streamline and privatize the system, to offer consumers their choice of insurers and plans but also to ensure that certain conditions were maintained via regulation and oversight. It is illegal in the current system for an insurance company to refuse to accept a client, or to charge more for a client based on age or health. Where in the United States insurance companies try to wriggle out of covering chronically ill patients, in the Dutch system the government oversees a fund from which insurers that take on more high-cost clients can be compensated. It seems to work. A study by the Commonwealth Fund found that 54 percent of chronically ill patients in the United States avoided some form of medical attention in 2008 because of costs, while only 7 percent of chronically ill people in the Netherlands did so for financial reasons.

    The Dutch are free-marketers, but they also have a keen sense of fairness. As Hoogervorst noted, “The average Dutch person finds it completely unacceptable that people with more money would get better health care.” The solution to balancing these opposing tendencies was to have one guaranteed base level of coverage in the new health scheme, to which people can add supplemental coverage that they pay extra for. Each insurance company offers its own packages of supplements.

    Nobody thinks the Dutch health care system is perfect. Many people complain that the new insurance costs more than the old. “That’s true, but that’s because the old system just didn’t charge enough, so society ended up paying for it in other ways,” said Anais Rubingh, who works as a general practitioner in Amsterdam. The complaint I hear from some expat Americans is that while the Dutch system covers everyone, and does a good job with broken bones and ruptured appendixes, it falls behind American care when it comes to conditions that involve complicated procedures. Hoogervorst acknowledged this — to a point. “There is no doubt the U.S. has the best medical care in the world — for those who can pay the top prices,” he said. “I’m sure the top 5 percent of hospitals there are better than the top 5 percent here. But with that exception, I would say overall quality is the same in the two countries.”

    While free associating on things Dutch, Sasha Cohen's Borat paid Amsterdam a visit a few years back. Good stuff!