Archive for the ‘Featured’ Category

Tell me your cosmetic secrets

I live and work in Los Angeles, one of the plastic surgery capitals of the world. Quite a few of my patients have “had a little work done” — the blandly euphemistic term you’ll hear for plastic surgery makeovers of all kinds. That’s fine. Plastic surgeons have children to feed too.

The problem is this: many of my patients want to convince everyone that their “look” is entirely natural. They don’t want to admit that they’ve had a tummy tuck, an eyelid lift, or breast implants. One patient tried to tell me that the perfectly matched scars behind her ears were the result of a car accident, not a face lift. In front of family members, patients will even deny having dentures. That’s understandable, but unwise from a medical point of view.

The fact is that plastic surgery has implications for future medical care. Your anesthesiologist needs to know about it, and your surgeon does too. It may be cosmetic, but it’s still a bigger deal than getting your eyebrows waxed.

Here’s why we need to know the cosmetic secrets our patients may NOT want to tell us.

Why does a tummy tuck matter?

One of the worst complications I’ve seen after plastic surgery happened to a lovely patient who, years before, had an abdominoplasty, popularly known as a “tummy tuck”, with a very good cosmetic result. Many women request this procedure once they’ve finished having children, to tighten up the skin and smooth out the appearance of the abdomen. The incision is similar to the one for a cesarean section, across the lower abdomen, though it extends further to each side. Once it’s well healed, it may barely be visible.

Years later, the patient needed major surgery on her liver, and the surgeon made an incision known as a “chevron” or “rooftop” – an incision across the upper abdomen, just below the ribcage. The surgical team didn’t realize she’d had a prior abdominoplasty, and the patient never thought to mention it.

The blood supply to her abdominal wall had been interrupted from below by the abdominoplasty incision, and now was interrupted from above by the chevron incision. The skin and soft tissue of the patient’s whole abdominal wall essentially died and turned black from lack of blood flow and oxygen, a condition called tissue necrosis. The patient needed extensive skin grafting and several surgical procedures for reconstruction.

What about breast implants?

For the most part, breast implants don’t matter much in terms of subsequent surgery – unless you need an operation that involves your chest. Surgery on the lungs or esophagus often is done today with a minimally invasive technique called video-assisted thoracoscopy, where the surgeon inserts slender instruments and a tiny camera through small incisions in the chest wall. It would be easy to rupture a breast implant unless the surgeon knows it’s there and can work around it.

Chin enhancement?

Chin enhancement surgery, or genioplasty, may involve inserting a small plastic implant to improve the appearance of a receding or “weak” chin. It may seem like a trivial procedure, and the tiny scar beneath the chin may be hard to spot. But please tell your anesthesiologist if you have a chin implant! A receding chin is a facial feature that can alert the anesthesiologist to possible trouble inserting a breathing tube. It’s important for us to know if a patient’s chin didn’t always look the way it does today.

(As an aside, it’s not uncommon for men to grow beards as a cheaper, easier way to conceal a receding chin. An experienced anesthesiologist knows to look for this feature when evaluating the patient’s airway prior to surgery.)

Eyelid lifts? False eyelashes?

Eyelid lift, or blepharoplasty, is done to remove excess or sagging skin from the eyelids. It’s also popular among East Asian patients (both men and women) who want to alter the shape of their eyelids for a more “western” look.

After a blepharoplasty, the eyes may not close completely if a patient is sedated or unconscious during another operation. If the eyes aren’t fully shut, they may dry out because the patient isn’t blinking normally. The delicate corneas may develop micro-cracks, which cause pain when the patient wakes up just like any other corneal scratch or injury. Oxygen from a face mask blowing past partially open eyes may also cause the corneas to dry out and become red and painful. If we know that you’ve had a blepharoplasty, we can take extra precautions to protect your eyes and keep them moisturized.

False eyelashes or eyelash extensions can easily be damaged during surgery. This is because the anesthesiologist usually protects the patient’s eyes from corneal scratches by putting tape or a transparent dressing over the eyelids. When the tape comes off at the end of surgery, the eyelashes can come with it. If you’ve just paid $150 or more for a full set of lashes, I can understand why you’d be upset. If you mention that you have them on, we can use goggles to protect your eyes and leave the eyelashes undisturbed.

We promise not to tell

The take-home message to patients? Please tell us your cosmetic secrets. Send your family members off to get coffee before you talk to us if you don’t want them to know. But what we – your anesthesiologist and your surgeon – DON’T know about your cosmetic history, unfortunately, can hurt you. We promise not to tell.

Do you think I went too far in my last blog post, calling out some journalists as “pontificating parasites” who love nothing more than to slam physicians and blame us for the cost of healthcare?

If you do, then you must not have read Elisabeth Rosenthal’s latest salvo in the Feb. 16 New York Times, where she says physicians are in “a three-way competition for your money” with hospitals and insurers, as if we’re all equally well-funded players at a craps table.

Even National Public Radio, often no friend to physicians, acknowledges that physician pay adds up to a mere eight percent of total US healthcare costs.

What stings even more, hearing that kind of accusation from Ms. Rosenthal, is that she used to be a physician herself before she quit emergency medicine to edit Kaiser Health News. I’m sure it’s a better gig: no nights, no weekends, no holidays. But, as Julius Caesar noted, it’s always worse when the stab in the back comes from someone you thought of as a colleague, if not a friend.

Surprise medical bills

The topic of Ms. Rosenthal’s one-sided op-ed is out-of-network billing, also known as “surprise” billing. Emergency physicians (along with anesthesiologists) may be the doctors most often accused of not being “in-network” with insurance companies and sending patients large “surprise” bills after the fact.

However, the American College of Emergency Physicians (ACEP), which represents Ms. Rosenthal’s former colleagues, is no happier than anyone else about out-of-network bills. “Much of this conflict over surprise billing is playing out in the media,” ACEP notes, “and insurers have been trying their hardest to paint emergency physicians in a bad light.”

ACEP is right. The facts about out-of-network bills, and the history behind them, differ from what Ms. Rosenthal would have the public believe.

What is a narrow network?

Read the Full Article

If physicians are “muggers” and co-conspirators in “taking money away from the rest of us”, then journalists and economists are pontificating parasites who produce no goods or services of any real value.

I don’t think either is true, but the recent attacks on physicians by economists Anne Case and Angus Deaton, and “media professional” Cynthia Weber Cascio, deserve to be called out. You could make a case for consigning them permanently, along with the anti-vaccination zealots, to a healthcare-free planet supplied with essential oils, mustard poultices, and leeches.

My real quarrel with them — and with the Washington Post, which published their comments — is that they have the courage of the non-combatants: the people who criticize but have no idea what it’s like to do a physician’s work. More about that in a moment.

Ms. Cascio was enraged by the bill from her general surgeon, who wasn’t in her insurance network at the time she needed an emergency appendectomy. She doesn’t care — and why would she? — that insurance companies increasingly won’t negotiate fair contracts, and it isn’t the surgeon’s fault that Maryland hasn’t passed a rational out-of-network payment law like New York’s, which should be the model for national legislation. She doesn’t care that Maryland’s malpractice insurance rates are high compared with other states, averaging more than $50,000 per year for general surgeons. She just wants to portray her surgeon as a villain.

The two economists are indignant that American physicians make more money than our European colleagues, though they don’t share our student loan debt burden or our huge administrative overhead for dealing with insurance companies. They resent that some American physicians are in the enviable “1%” of income earners. But do they have any real idea what physicians do every day?

Read the Full Article

The Hahnemann Disaster

Though the news at first stayed local in Philadelphia and the northeast, it’s gaining traction nationwide. ZDoggMD is on it. Bernie Sanders held a rally.

What happened? The venerable Hahnemann University Hospital, the main teaching hospital for Drexel University College of Medicine in Philadelphia, is bankrupt and will soon close its doors after more than 170 years as a safety-net hospital serving inner city patients.

Why should we care? After all, there are other teaching hospitals in the immediate area with capacity to absorb the patients, and they had several months’ warning to prepare.

We should care for many reasons, but I’ll start with the plight of the 570 residents and fellows who are being displaced from their jobs. Getting a residency position in the first place is a perilous process – there aren’t enough spots for all the graduating medical students who want them. Only 79% of the more than 38,000 applicants in 2019 snagged a first-year or internship position in a residency program.

So the Hahnemann residents – the “Orphans from HUH”, as they’ve started to call themselves – are scrambling on their own to find new jobs at a time when most residents are thankfully settling in to the new academic year. There’s no organized program to help them.

Even for the residents who’ve already found new positions, there are other boulders in the road. To begin with, they haven’t been released yet. They can’t start their new jobs and the Medicare funding for their positions is still tied up in bankruptcy court.

They’re still at work, wandering around a nearly empty Hahnemann with only a handful of patients left. The ER isn’t admitting any new patients and will shut down completely on August 16. The labor-and-delivery ward has closed. The new interns aren’t gaining any real experience and will be lagging behind their peers wherever they go.

“Doctors have been writing notes to update plans of care and people have come in as part of the liquidation to take away their computers,” a third-year internal medicine resident named Tom Sibert, MD, told Medscape reporter Marcia Frelick last week.

Tom Sibert? Any relation? Why yes; he’s my son. You can understand, I’m sure, why I went into full-blown mama lion fury when the Hahnemann situation blew up, and why I was beside myself with worry until he locked in an acceptance to an excellent program where he’ll finish his training.

Read the Full Article

When adjectives obfuscate

A few years ago, at the misguided recommendation of a public relations consultant, many of us in America started referring to ourselves as “physician anesthesiologists”. That was a silly move. The term is cumbersome and does not flow trippingly on the tongue. It is also redundant. You don’t hear our colleagues referring to themselves as “physician cardiologists” or “physician urologists”.

There was never any need of an adjective to modify “anesthesiologist”.

Anesthesiology is a medical specialty, practiced by physicians who have completed residency training in anesthesiology. To become board-certified, we undergo a rigorous examination program conducted by the American Board of Anesthesiology.

In England, comparably trained physicians are called “anaesthetists”. In England, they also refer to their subway system as “the underground”, and to the hood of the car as the “bonnet”. It’s confusing, but we muddle through.

The term “nurse anesthesiologist” is an oxymoron.

I’m all done with the term “physician anesthesiologist”. I am the immediate past president of the California Society of Anesthesiologists, and a 30+ year member of the American Society of Anesthesiologists. I am a physician who is immensely proud to practice anesthesiology. My patients know I am a physician because I make it clear to them when I introduce myself and give them my business card.

Dr. Virginia Apgar was an anesthesiologist. It is an honor to follow in her footsteps, even if most of us will never match her achievements. That is all.

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