Crazy Eyes: Adventures in Eye doctors doing breast surgery part deux

While it's hard to top the debacle I wrote about in Atlanta where an eye surgeon nearly boxed someone trying to do a breast augmentation surgery in his office, I came across this other article by another opthomolgist turned "breast expert". I don't know whether he's trying to be clever marketing a procedure or is just ignorant about breast surgery in general, but I came away from this article shaking my head.

The doctor is proposing a breast lift (mastopexy) surgery performed thru the armpit by suturing the breast to the pectoralis muscle and then placing an implant. He describes the surgery appropriate for women with little ptosis. Looking at his picture, you can see that whatever effect he's proposing is nonexistent as the patient doesn't even have ptosis (droop) of the breast. Any illusion of a "lift" is by placing an overly large implant for her frame and actually lowering her breast position to centralize the implant. There is clearly no "lift" going on whatsoever, but rather he's stretched out her lower breast.

I do not predict a good long-term result from this as that skin will frequently continue to stretch unless she develops hardening of her implant. I also would be reluctant to have suggested such a large implant for this patient as you had to violate her native breast boundaries to place it, again a poor strategy for long term results. These are elementary principles of modern breast augmentation.

It's been pretty well established thru collective world-wide experience among plastic surgeons that the maneuver of trying to sew the breast to a higher position to exaggerate the upper pole does not work, which has been demonstrated on a number of follow up studies when this has been attempted.

Rob

Plastic Surgery Specialists of Birmingham's new website is Live!

Our practice's totally redesigned website has gone live today! Check us out on the web at Plastic Surgery Specialists. We hope to more fully realize the technology available to communicate our practice to potential patients.

I'd like to thank the guys at Plastic Surgery Studios for working with this over the last few months on this project. It was a lot of sweat equity to get to the finished product and we're very happy.

Rob

Ways to (nearly) ruin your life 101 - Choosing an Atlanta eye doctor to do your breast augmentation surgery

This summer there was an awful instance of medical negligence in Georgia involving an eye-doctor (opthamologist) who had major complications while attempting to perform breast augmentation surgery in his office. You can hear a frantic 911 call from the doctor explaining that he has encountered uncontrollable bleeding he created while during her breast implant surgery and has no idea how to fix it. Since the patient was under only local anesthetic (with presumably mild oral or IV sedation) during the operation, she told reporters that she heard the call go out to 911 for help and then her doctor saying that he couldn’t stop her bleeding. Can you imagine how horrifying that must have been listening to that conversation?

You can view 2 video news clips on the story here & here.

This is a really frightening story as it highlights the proliferation of unqualified and untrained physicians attempting to practice cosmetic plastic surgery procedures. If you are not trained in plastic surgery you should not be performing these procedures PERIOD. The inability of this eye surgeon to handle routine issues during breast implant surgery and the patient safety issues it raises should cause state medical boards to get involved with scope of practice issues and office based surgery regulations.

Rob

Why is breast cancer reconstruction surgery with implants done in multiple stages? "Baby Steps"

From time to time you will get asked by breast cancer patients whether their reconstruction surgery can be done all in one stage at the time of mastectomy. The answer is you can, but there are a number of factors working against you for the best result, such that "baby steps" (planned sequential small procedures)

Typically, most implant reconstruction surgery involves placing a temporary implant called a "tissue expander" at the time of mastectomy that is later replaced by a permanent implant. As compared to a regular implant, a tissue expander is shaped different to maximize shape of the lower breast. It is decidedly more rigid and firm and then permanent devices, particular when silicone implants are later used. The advantage of such specialized devices is that they allow either 1) expansion of the skin by periodically adding fluid to them and 2) better resisting shrinkage of the skin following mastectomy.

Planned 2 stage surgery was popularized by Dr. Pat Maxwell (my mentor) and Dr. Scott Spears, and is well established as the most popular way to do breast reconstruction world wide. There has always been some interest in trying to skip the intermediate step, but doing it predictably is elusive. The big problem is tissue shrinkage of the skin, which as I mentioned is better resisted by the more rigid expander implant versus the softer permanent ones. The best candidates are those with smaller breasts who are having nipple-sparing procedures so that the native skin is 100% conserved. Even in that group, I find I'd be increasingly likely to go back and fat graft to camouflage the implant in a 2nd stage surgery. To my way of thinking, the benefit of single stage surgery just work enough to give up the benefit of the expander structural advantages.

Rob

Latisse (the eyelash drug) has been a raging clinical success

Quick thought of the day:

After dispensing Allergan's Latisse medication for enhancing eyelash growth for over a year now, I'm officially impressed. It is hand's down the single most reliable treatment we offer to patients, and I have not seen anyone who does not respond well with it. Part of it's popularity is also the relatively low price tag (~ $120-$130 for a 2 month supply).

The "off the record" advice I have for Latisse users is that I think you can actually use it less frequently then daily and maintain results. I advise patients that once they get to a good clinical result that they try every other or every third day for application. Rationing the medication like that can make a single box extend for 3-4 months instead of 2 without much diminishing results. A good cosmetic budgeting strategy in these times!

Rob

When is a medical record not a medical record? When the Obama adminstration get's PC with it

If the roll out of 21st century health care could have been more poorly handled, I'm not sure how. From a slow bleed over the spring involving an ill-conceived re-imagination of American health care delivery by the Democrats we are now presented with statements from President Obama's electronic medical record (EMR) czar that a medical record does not have to actually reflect what your medical history is.

Dr. David Blumenthal, the National Coordinator for Health Information Technology, said in an interview with CNS news (see here) that patients can choose to omit procedures such as abortions, positive HIV tests, or other perceived embarrassing information from their electronic health records (EHR).This is concerning in that a purported health record reporting a patient's comprehensive history could be edited so as to be politically correct. As a provider it would be important (for instance) to know that a patient had hepatitis or HIV before scheduling major elective procedures so as to protect oneself and operating room staff from unnecessary exposure or even advise patients to avoid some procedures altogether. Much as a physician has an informed consent with a patient, a provider must be aware of any and all material issues when delivering care.

Rob

What to look for for well done breast augmentation surgery -The inframammary fold

Sorry for the long break! We've been busy designing our practice's new web site. It's gonna POP! Stay Tuned.

This post is kind of an "inside baseball" topic about what surgeons look at when we judge our own or others work. One thing I fixate on more and more with cosmetic breast surgery is the position of the inframammary fold (IMF). The IMF (in layman's terms) is an anatomic landmark created by adherence of connective tissue to the chest wall. It defines the inferior border of the anatomic breast, and it's location makes it the most popular place for an incision to place breast implants via the "inframammary" approach.

One of the things I look for in someone I've operated on or whom comes in for revision surgery by another provider is where a prior inframammary scar is. If the scar is stable and in the position it was originally made in then I'm satisfied the surgical dissection was performed well. If the scar is now residing up on the skin of the lower breast, that suggests over release of the native IMF during prior surgery. Once violated, that anatomic border is hard to reliably recreate. Just a little extra attention during surgery can prevent a lot of issues down the road as it relates to this.

Rob

Use it or lose it: study shows consistant BOTOX use can allow longer results

Confirming what many Plastic Surgeons have noticed, a study just published suggests that patients who maintain their treatments with BOTOX for several years need fewer treatments to maintain their results.

On average, someone receiving treatment of their forehead or glabella (area between the eyebrow) requires retreatment every 3-4 months. The new study from the OHSU School of Medicine in Portland,OR shows that after 2 years of consistent treatments, the interval between treatment could be extended to 6 months with no difference in results.

Rob

Prophylactic Mastectomy - an ounce of prevention is worth 5% of cure

Sometimes things that are so obviously intuitive still have to be validated. After a number of years of controversy, an increasing utilized surgery to prevent breast cancer is now being shown to be quite effective in both risk reduction and cancer-related mortality. The study "A Population-Based Study of Contralateral Prophylactic Mastectomy and Survival Outcomes of Breast Cancer Patients" is published in the Journal of the National Cancer Institute and can be seen here.

Contralateral prophylactic mastectomy, (CPM), a preventive procedure to remove the unaffected breast in patients with disease in one breast, clearly appears to offer a survival benefit to breast cancer patients age 50 and younger, who have early-stage disease and are estrogen receptor (ER) negative. We've known for several decades that CPM reduced the risk of developing breast cancer, but it was always more elusive to show that it actually saved lives at the end of the day. The practice of CPM has expanded significantly, with >150% growth in the number of such surgeries since the late 1990's.

How effective is CPM? Those younger than age 50 with early stage cancer with ER negative disease had a survival benefit of almost 5% at five years.  For a therapeutic intervention for cancer, 5% is really substantial. You can take it to the bank that following these patients out even farther that we will show increased survival benefit with longer follow-up in the population. This is due to the fact that

1. the patient's likelihood of getting a second breast cancer in the non-removed breast increases with time
2. patients with prior breast cancer are among the highest risk group for developing breast cancer

Women older then 50 have a little more complicated decision. In cold, hard actuarial terms you are more likely to die from something else before a new breast cancer would kill you. On the other hand, steadily increasing lifespans of adult Americans has made some of these kind of statistical bets have to be reexamined. I would guess that the reported benefit of CPM gradually increases towards 60 years in future clinical guidelines.

Rob

Study confirms that breast implants do not affect breast cancer survival

A recent Canadian study long term follow-up (see here) confirms prior observations that women with breast implants who go on to develop breast cancer have similar outcomes as women without implants who develop cancer. This is more reassurance to our patients about this theoretical concern with implants (ie. that potential difficulty with mammograms would lead to delayed breast cancer diagnosis and worse outcomes). Along a similar vein, women with implants actually have a much lower (~ 40% lower I think) rate of breast cancer as compared to peer groups in the population.

Rob

Slick Deals from Allergan for Botox or Juvederm rebate

One of my favorite shopping websites is Slickdeals (www.slickdeals.net) which is a user driven collection of random shopping deals around the internet. You can find some fantastic bargains on all kinds of things, and the site is updated throughout the day by users reporting sales and promotional items.

In honor of this, I'd like to point out the "slick deal" Allergan is offering on it's products thru July. Allergan is the world's largest breast implant manufacturer, but they also make BOTOX, the dermal filler Juvederm, and the eyelash growing solution Lastisse. Thru July they are offering a $50 rebate coupon on either BOTOX or Juvederm purchases when you try Latisse. Details are available here.

Rob

FDA to mesotherapy - Put up or shut up! (but shut up first)

The FDA last week issued cease and desist orders for a number of clinics offering fat melting "mesotherapy" injections.  The drugs most regularly used in this process are phosphatidylcholine and deoxycholate. Other drugs or products such as vitamins, minerals, and herbal extracts are often mixed into the "gumbo", complicating any assessment of safety or efficacy. Phosphatidylcholine is not approved for injection into your body and has never been evaluated for that use in controlled settings. The new warning shot over the bow went out to six U.S clinics:

• Monarch Medspa in King of Prussia, Pa.
• Spa 35 in Boise, Idaho
• Medical Cosmetic Enhancements in Chevy Chase, Md.
• Innovative Directions in Health in Edina, Minn.
• PURE Med Spa in Boca Raton, Fla.
• All About You Med Spa in Madison, Ind

I would strongly advise people considering using these facilities to think again, as their disregard for patient safety with off label experimentation of these injectable concoctions should signal a general disregard for their patients. As alerts to this FDA warning went out on the ambulance chaser network of websites, expect to see ads shortly recruiting clients for lawsuits.

FYI If you are interested in reading about mesotherapy, I've written several entries about it since 2007 which can be seen here.

Rob

There's no escape from Magical Thinking on health care apparently

There's a good bit of magical thinking around the idea of preventive care. One of the most disingenuous aspects of this is the push for these measures as "free" as part of the health care reform debate. Nothing of value is free, and in health care the overhead propping up the system makes that even more true.

Now there are both cheap and expensive measures that included in what we call preventive care or cancer screening, but at the end of the day they do not save money (even if they may make us healthier). It's actually counterintuitive that some bad habits or diseases from them (smoking or diabetes) may actually save  money as they die younger and end up costing less over a lifetime. That's not a reason to not support early intervention, but it is something that has to be considered when making your countries health care budget.

The truth that the health care costs as a % of GDP are ignored by the bill passed is really scandalous. Facing those true costs was not something the  left was going to let get in the way of entrenching their goal of federal health care. A story about the effects of the health care reform bill I read (see here) seemed to forget that all costs matter until pointed out over and over by readers in the comments section. I thought this one was spot on,

Colonoscopies and mammograms are absolutely not “preventive” care, they are early detection. Having a mammography will not prevent breast cancer any more than owning an umbrella will prevent rain. It may stave off the full and most dire effects of a diagnosis of cancer by allowing early intervention, but that is far from prevention. You will have to pay for the surgery, the radiation, the medication, all the same. Talk about “magical thinking”.

The politics of  telling people NO is complicated and gets caught up in issue driven advocacy groups. A large study from Denmark touched on this obliquely by studying an area of screening efficacy (or lack thereof) when they found no evidence that screening women for breast cancer has any effect on death rates when applied to their countries women in well organized screening programs. For context, breast cancer is the most common cancer in women worldwide, accounting for around 16 percent of all female cancers and is attributed to almost 519,000 people globally each year.

How do other western countries with modern health care systems screen for breast cancer? In Denmark, women are screened every two years from age 50, while in Britain the policy is for women over 50 to be screened about every 3 years. Evidence now suggests that for every 2,000 women who are screened over 10 years, only one stands to have her life saved by the mammogram program, whereas the chance of getting an unnecessary breast cancer diagnosis is 10 times that.

If you'll remember in 2009, we had a hailstorm of controversy here in America when it was suggested that our current guidelines of starting screening mammograms at 40 was neither cost-effective nor evidence-based for affecting breast cancer mortality. There was a lot of ignorant political grandstanding on this as a woman's issue (step forward congresswoman Debbie Wasserman-Schultz D-FL) and Democrat's were furious that this kind of recommendation was coming out during their poorly-conceived sales job on health care reform. God forbid there be any notion that evidence based medicine might infringe upon you right to insist on your ______ (Mammogram, CT Scan, MRI, back surgery, etc....) without considering considering the cost or efficacy. It was a lie then and it's a lie now.

Rob

Growing Hacks in Cali...Cali - Underqualified cosmetic surgeons plague the Golden State

Nod to LL Cool J in the post title :)

California is an iconic part of the United States that sets many trends. Unfortunately one of these trends is the growth of under or untrained physicians performing cosmetic surgery procedures.

A snapshot of who is performing cosmetic procedures in California, published this month in the journal, Plastic and Reconstructive Surgery, examined 1,876 cosmetic practitioners from San Diego to Los Angeles. Only 495 of them were actually trained in plastic surgery. Primary care physicians with no surgical training to speak of made up the 4th group of liposuction providers following plastic surgeons, dermatologists and otolaryngologists.

Scary, Scary stuff! It seems obvious, but always look for a board certified Plastic Surgeon if you're considering plastic surgery.

Rob

Are your breast implants under warranty?

The New York Times had a story last week (see here) on how expensive orthopedic implants for knees and hips were to replace when they failed. As the cost of the devices themselves (without hospital or physician charges) can run north of $15,000, it can be more then $50K on the price tag when these patients require re-operation for premature failure. Highlighted in the story was the fact that the manufacturers did not expressly provide a warranty for replacement costs of their implants.

Much like these orthopedic devices, patients with breast implants can expect their devices to have to be replaced at some point in their life, either thru device failure or for aesthetic revision issues as their body changes. In contradistinction to the orthopedic companies, both Allergan and Mentor Corp. (whom combined sell 99% of all breast implants in the United States) have offered lifetime replacements on their failed devices for several years now. Allergan in particular has been admirable, as the parent company that makes the implants has been sold twice from it's roots as McGhan medical (later Inamed Corp.). As both Allergan and Johnson & Johnson (owner of Mentor Corp. since 2009) are huge multinationals, it would seem patients with these implants should have a good deal of security of their devices fail for replacement of their implants.

These implant companies do not however cover all other costs associated with the replacement of the devices, but have come up with a fairly generous standard program matched by both Mentor & Allergan

• 10 years of guaranteed financial assistance
• Up to $1200 in out-of-pocket expenses for surgical fees, operating room and anesthesia expenses not covered by insurance
• Silicone filled and saline filled breast implants are both covered
• Lifetime product replacement
• Automatic enrollment at the time of your original surgery

Now as a breast implant is relative expensive to design and test clinically, but inexpensive to manufacture by the unit, it's easy to see how these companies can absorb the cost. I don't know exactly their margin per device, but I think it's $600-700+ per silicone implant they sell.

Rob

Go Gators! An interesting use of "sovereign immunity" in Florida's medical malpractice reform

It's been an awful week or two for medical malpractice reform with state supreme courts in Georgia and Illinois striking down award caps on the vague category of "pain and suffering". (Missouri's supreme court reaffirmed that state's caps this same week ~ Rob)Such caps have been one of the most effective ways of discouraging frivolous or borderline lawsuits as it disincentives such proceedings unless the cases are truly egregious.

Florida has a bill being considered in it's legislature that would extend the concept of "sovereign immunity" to providers in the Emergency Room. Such status makes providers de facto ``agents of the state'', and consequently immune from medical malpractice lawsuits. In that setting the state would administer any successful claim, which would be subject to the sovereign immunity cap of $200,000. To recover more, victims would need to file a claims bill in the Florida Legislature. This turns the malpractice system into more of a no-fault worker's comp type of arrangement.

You can't help but think that would be a more efficient and fair way to administer such claims. Of course, trial lawyers are screaming bloody murder, but keeping them happy is low on society's to-do list (unless you are a Democrat politician accepting their bribes err... campaign contributions). If physicians are going to be involuntarily obligated by hospital credential committees or federal and state licensing issues to provide emergency services, they should at least enjoy some protection from these high risk (for malpractice exposure) duties. Kudos to Florida for experimenting with some real world solutions to tort reform!

Read more at the Miami Herald about this interesting idea.


Rob

New conflict of interest (COI) rules could decimate academic plastic surgery

The potential of conflicts (COI) for physicians who accept stipends or consulting fees has led some medical schools to formally prohibit their clinical faculty from accepting such compensation. This movement led to the resignation of a number of distinguished doctors who participate in industry sponsored research, consulting arrangements, and educational events. While not universal among medical schools at this point, this trend is likely to keep some of the best and brightest out of academics. Some consultants and speaks make tens or hundreds of thousands of dollars annually to supplement their clinical practice. As academic overhead tends to run high, this opportunity to make alternative income allowed some people to stay in academic surgery who might otherwise leave for pure private practice setups.

Stanford University has now (read here) taken the dramatic step of restricting even volunteer clinical or "adjunct" faculty from this as well. This type of restriction could have a potentially devastating effect on Plastic Surgery training as a number of the most prominent programs in plastic surgery (NYU, University of Texas-Southwestern, Emory, Johns Hopkins, Georgetown, Michigan, etc...) feature many active and adjunct surgeons whom recieve industry support or give educational seminars. The loss of access to these surgeons for training for real (or imagined) COI would be a big blow to the field. In January, the issue was highlighted in a when Boston doctor and well known Allergist-Immunologist, Dr. Lawrence DuBuske, resigned his Harvard medical school position rather than give up his speaking engagements. DuBuske got almost $99,000 from pharmaceutical giant GlaxoSmithKline in three months last year, more than any other doctor in the country.

While most speakers don't score that much in fees, it can add up to a substantial supplement to someone's clinical practice. COI have been managed in recent years by more stringent required disclosures by speakers at meetings and in our medical journals. The FDA has made efforts to remove panel members from hearings with any potential COI from drug and medical device hearings, including the hearings over silicone gel breast implants earlier this decade. The loggerheads with that idea is that many of the experts in these specialized fields inevitably have some COI from funding, speaking fees, stock holdings, or even intellectual property (shared or owned patents). Scott Spears (chief of plastic surgery at Georgetown University) is one of the world's experts on breast implants, but his testimony before the FDA during the hearings on silicone breast implants was attacked by activists trying to prevent the reintroduction of those devices by any means necessary because he is involved with dozens of companies in R&D, educational endeavours, and speaking sessions.

IMO, as long as clear disclosure by physicians is made these COI issues are manageable as long we always maintain some skepticism about what we are told and review data critically.

Rob

Plastic Surgery 101's "Mythbusters" on the health care debate

As a physician, I have a vested interest in following the debate on reinventing the American health care system. Listening to these discussions, I find there is a distinct lack of candor about where the costs are in the system and little insight into where true potential savings are.

• MYTH: Electronic medical records (EMR) will save money

FACT: No one can plausibly explain how any money will be saved. EMR does offer portablility of records, but does nothing to control cost in and of itself. The costs for physicans and hospitals to purchase equipment and pay ongoing subscription and IT costs will be a HUGE burden.
WINNERS: EMR vendors, IT companies, database miners and researchers
LOSERS: productivity of an office
OFF THE RECORD: Why should I be expected to subsidize a national EMR system through my office overhead when it's uncompensated and will surely be used down the road to squeeze providers?

• MYTH: Primary Care Providers (PCP) are the sacred cow in reform and hold the key to holding costs down

FACT: The PCP workforce is under and ill-equiped to treat a mass influx of patients into the system. It will take years to retool the training infrastructure to handle the volume of patients. Massachusetts experiment in universal care for it's citizens has been crippled by an insufficent number of participating PCP MD's.
WINNERS: PCP will be getting a small increase in fees for routine office visits per the federal government at the expense of some specialists (Cardiologists, Radioloists, & GI docs mostly)
LOSERS: specialists physicians
OFF THE RECORD: Medical students will continue to avoid primary care because they percieve it tedious and they realize that nurse practictioners can do 85%+ of what they do for 50 cents on the dollar. It's also intuitive that specialists who work more and have trained 2-3x as long would be expected to earn a good deal more then PCP's.

• MYTH: It's hard to find savings in healthcare!

FACT: There are some big savings in proceduras that could clearly be achieved with little affect on quality of care. Rigidly restricting (thru evidence based indications) the use of knee/shoulder arthroscopy and joint replacement surgery by orthopedists, upper/lower endoscopy by Gastroentreologists, coronary catheterization and stents by Cardiologists, lumbar spine surgery by Neurosurgeons, and the overuse of CT/MRI scans by all of us are the low hanging fruit in cost containment.
WINNERS: whoever's paying the bill (the feds or insurers)
LOSERS: whichever doctor's procedures are restricted and the idea (endorsed by my mother, wife, and many non-thoughtful doctors) that procedure or study "x" should be done "Just to be safe."
OFF THE RECORD: There's no way to make the numbers work without doing these kinds of restrictions. BTW I would not want to be a radiologist who expects to make big bucks in the next few years as they're about to get scalped.

One thing that makes me shake my head is the disconnect in the popular press when they talk about how individual doctor's practices are coping or planning to cope with whatever's coming. My favorite is the young PCP who is featured just out of residency boldly proclaiming things about how they're going to reinvent the doctor patient relationship by their use of technology.


http://www.businessweek.com/magazine/content/09_27/b4138034173005.htm


rob

Breast Implant bombs - Can you weaponize an implant? Unfortunately yes.

I saw a story today which touched on something I'd been thinking about for years. Apparently Islamic terrorists have been working on a way of turning a breast implant into a way to smuggle explosive liquids onto airliners. While that may sound like a joke headline from The Onion, it's really a scarry idea.

From relatively simple and innocuous ingredients, a highly explosive liquid can be produced.

This link to a BBC story demonstrates the devastating effect on a plane fuselage that such a liquid explosive could have:
http://news.bbc.co.uk/2/hi/uk_news/7536167.stm

I'm not exactly sure how you would trigger it, but presumable you could stab into the implant with a wire or pin and wire it to a celphone or battery (this type of liquid material can be ingnited with an electic charge)

Denied insurance claims- the bane of patients AND doctors

I started this post 2 weeks ago and got inspired by yesterday's goofy "health summit" between President Obama and Congress. Excuse the juxtaposition of the two subjects, but I think in the end they are related.

The issue of health insurance denying authorization for surgery or denying claims for procedures already performed is one of the most frustrating parts of being in practice. The New York Times featured a story on this entitiled , "Fighting Denied Claims Requires Perseverance" as it related to a patient fighting her insurer for coverage of an arthroscopic hip surgery.

To me the article is less about a hip operation, but rather represents the collisions of four forces


1. Insurers trying to control their cost and make money by limiting care
2. The people who pay for employee's health care trying to control their expenses by restricting unlimited utilization
3. Patients who want what they want, when they want it (but are removed from the actual costs of these procedures)
4. Physicians who are interested in advanced techniques and technology for procedures (who are slightly less, but still somewhat removed from the costs of these procedures)

As a society, America has not learned to reconcile our desire for expensive (and often futile) treatments with the fact that someone has to pay for all this. The congressional healthcare "summit" yesterday was a grotesque kabuki theater filled with political spin and lip service to the tough choices that have to be made to make the health care system sustainable. In summary: Democrats reflexively refuse to offend unions and ambulance chasers while afraid to limit or trim entitlement growth, while Republicans offer tepid (but useful) reform at the margins and refuse to budge on likely required tax increases.

The article about some advanced new orthopedic technique parallels the series the Times ran this week on an advanced melanoma treatment which described (what I presume) what was a very expensive palliative treatment which offered no cure and "worked" such that lifespan was extended for short periods of time. This kind of treatment is not sustainable for our health system, and focusing on it adds little value for considering "bending the curve" of costs. Ultimately, we'll have to decide whether we want society to pay for such exotic medical care, or expect patients to finance their own surgeries and treatments that go above and beyond approved evidence-based medicine (EBM) treatments.

Rob

Related letter to the editor on Mayo Clinic model and Medicare

In January, I wrote about the Mayo Clinic's satellite in Arizona dropping Medicare patients claiming it was financially unsustainable. (see "The Mayo Clinic decision signals the health care bill is "One Big Ass Mistake, America"). Besides being embarrassing for the Obama administration as he'd held it up as his model health delivery vehicle, it produced a lot of teeth gnashing. For many people, they always assumed nearly all doctors accepted Medicare, and certainly an institution like the Mayo Clinic would accept Medicare rates (no questions asked).

Mayo exists as a really weird historical quick of American Medicine. It established a reputation for excellence generations ago and managed to make that name a "franchise" for medical care. While Mayo has some fine clinicians, it's kind of well known among most surgeons that a place like Mayo has had a hard time keeping the talent happy in terms of compensation and selling rural Minnesota as a destination to live. It takes a certain kind of personality to accept the trade-offs of that clinic system, but security of such a protected & salaried position is certainly going to become more common.

Exactly how Mayo operates as to your insurance has always been confusing to many people, and the Medicare announcement had a lot of people looking for answers. I found a great letter to the Editor in a Boston Globe article that is the most succinct summary to date

I am a surgeon practicing in Phoenix, Arizona. I also grew up in Rochester, MN where my father was a physician at Mayo for 35+ years. It's time to set the record straight on the misconceptions of the Mayo Clinic as a model for efficiency.

1)Mayo does not take Medicare, as outlined in the article.
2)Mayo does not take Medicare supplements for new patients.
3)Mayo has never emphasized primary care and in fact closed their family practice program here in Phoenix at a time of acute shortage in our state, citing costs. Primary care is labor intensive
4)Mayo refuses to provide care to citizens of Phoenix, the city in which they reside, in need of specialty care in situations where their specialists have availability and where there are acute shortages in the community. Their decisions for taking patients is made by administrators, not doctors, based solely on insurance. Doctor to doctor requests are frequently denied.

5)The Dartmouth Study, touted by many as the proof of efficiency of the Model compared Medicare expenditures county by county, throughout the country. Mayo Rochester resides in a rural farming community, where Medicare usage would be expected to be low. But since Mayo does cares for virtually none of these Medicare patients, extrapolating the cost efficiency of Mayo is simply wrong.
6) Mayo's model is very much a boutique model, catering to the wealthy, those willing to pay extra or out of pocket for their care or those with very good indemnity insurance coverage. Mayo is not in network for virtually every HMO and PPO plan, based simply on the high reimbursements demanded by Mayo. Mayo quotes 2-4 times the cost for surgical procedures that those in the community at large get paid.
7)Mayo relies heavily on the$ 200-300M/year in endowment money each year, to supplement their payrolls, build their buildings, fund research, and fund their pension plan. The cost structure of the Mayo Clinic is prohibitive without this additional funding. In this recession, Mayo is having considerable difficulty because it has been having appealing to those who used to come out of pocket for perceived more individualized care.
7) Community physicians in Jacksonville and Phoenix/Scottsdale assume virtually all the care for those in need, regardless of ability to pay.

I have always been of the belief that Mayo has the perfect right to practice Medicine the way in which they believe. Their doctors are dedicated to their mission and contribute each and everyday to the growth of medical knowledge.

Please, however be honest about what the Mayo model is: exclusive medical care for those with means and those willing to pay considerably more for their services.

Cheers!

Rob

Horrible radiation injuries in NYC - One more reason Plastic Surgeons do not like radiation therapy

The bane of existence for plastic surgeons who treat breast cancer is the deliverence of external beam radiation (XRT) after surgery. It creates a hostile environment in the tissue exacerbating stiffening of the skin and scar formation. Above all else, it is the most disruptive factor for getting good results from breast reconstruction surgery.

The negative experiences of plastic surgeons with XRT in this setting has produced the interesting survey results among us, that we would overwhelmingly suggest our spouse (or self in the case of women plastic surgeons) get a mastectomy instead of lumpectomy and XRT.  Most women recieving mastectomy would not be suggested XRT except in rare instance involving more aggressive tumors, innvolvement of the chest wall, or extensive spread to the armpit (axillary) lymph nodes. In contrast, European physicians are much more likely to perscribe XRT to the chest and axillae. The practice patterns have to do with how the different countries interpret the same literature regarding this practice. IMO, the rationale Europeans emply to justify XRT is pretty sketchy and is hard to show much difference in outcomes.

On the front page of the New York Times today (click here) is an absolutely horrifying story on the frequent misdosing of patients recieving XRT in the NYC metro area entitled, "Radiation Offers New Cures, and Ways to Do Harm ". Some of the stories are jaw-dropping in how the series of events led to serious adverse events. It is absolutely incovievable that the delivery of XRT, a largely computer driven process, should be doing this. The number of radiation therapists, nurses, and techs who had to drop the ball or ignore clear warnings for these events to happen is staggering. Heads will roll in the Big Apple hospitals for this!

Rob

The Mayo Clinic decision signals the health care bill is "One Big Ass Mistake, America"

I've been on a little hiatus but hope to get back to semi regular output here on PS 101.

Since I last wrote, the Senate voted their version of the health care reform bill to consensus conference with the house. Even for Washington, the "sausage making" of this bill was pretty ugly. The naked bribes required to get Sen. Ben Nelson (D-NE) & Mary Landrieu's (D-LA) votes were particularly offensive, and quite possibly illegal (see here).

One story that is very symbolic but did not get much play in the media was the announcement that one of the Mayo Clinic satellites in Arizona would no longer see Medicare patients. Mayo is doing this because it lost $840 million last year on Medicare patients, and specifically it's Arizona hospital and four primary-care clinics lost over $120 million. No matter how efficient you are, that is unsustainable. It must be particularly embarrassing to Pres. Obama to see his "model" franchise for health care telling him to his face that he does not understand the effects of the legislation both he and his party are foisting on America.

To doctors in practice, it was always amusing to see the Mayo clinic proposed as a replicable model for our health care system. For starters they operate in a coccon on a largely wealthy, educated, and homogenous patient group. Even more ironic is the fact that the Mayo clinic doesn't even really take Medicare, but exists as a "non participant (non-par)" where they reserve the right to balance bill the patient for what they think their services are worth. From the Mayo website

"Mayo Clinic is a non-participating provider in the Medicare Program. We do not accept assignment on claims submitted to Part B Medicare except:

•where the law requires us to;
•in the case of documented financial hardship;
•when the supplemental insurance is a contract payer;
•when the patient resides in the state of Minnesota.
When claims are sent to Medicare on a non-assigned basis, the benefits for the services are sent directly to the patient. Mayo Clinic is entitled to bill the patient for the difference between our billed amount and Medicare's approved amount. We do not have to accept Medicare's approved amount as payment in full. Mayo Clinic limits its charges according to the limits set forth by HCFA for the Medicare program. Mayo hospital claims are sent assigned."

Expect to see real push back from providers at other places who treat these patients.

Rob