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Monday, June 23, 2014
By Anu Bajaj, MD
 
After seeing the proposed TOC for the June issue of PRS, I was intrigued by the title of Lopez, et al.’s   “the Impact of Conflicts of Interest in Plastic Surgery:  An analysis of Acellular Dermal Matrix, Implant-Based Breast Reconstruction”.  I have always wondered whether certain biases influence our decision-making in medicine.  Most of us will deny that we are influenced by external factors and the potential for financial gain when we treat our patients.  But I’m not sure that this is always true.  And it can be far more complicated than we realize because there may be many more subtle conflicts of interest in our everyday lives.
 
"While it is tempting to say that the financial rewards we obtain from either patients or industry are our “treats”, I don’t believe that it is so simple."
 
Last year, I adopted a second lab, Scout.  Scout and I have been taking additional obedience training classes – mainly because he is my problem child.  For those of you who don’t have dogs, most of the training involves rewards (treats) for good behavior.  If he looks at me when I ask, he gets a treat; if he doesn’t growl at my neighbor, he gets a treat; if he sits and stays, he gets a treat.  While it is tempting to say that the financial rewards we obtain from either patients or industry are our “treats”, I don’t believe that it is so simple. 
 
Lopez’s article defines a medical conflict of interest as, “a set of conditions in which professional judgment concerning a primary interest (such as a patient’s welfare or the validity of research) tends to be unduly influenced by a secondary interest (such as financial gain).”  In the article, conflicts of interest can take many forms -- recipient of grants, royalties, stock options, member of speaker’s bureau or advisory board, and employee or consultant status; according to the article, most reported conflicts of interest were being a consultant or members of a speaker’s bureau.
 
Over the past few years, I have incorporated the use of ADMs into my breast reconstruction practice.  However, I have always had concerns about the complication rates in my patients and in the literature.  I do believe that in the right patient and under the right circumstances, their use provides a huge benefit.  Nevertheless, I have always been suspect of the studies that many of the different sales representatives have shown me about the use of ADMs; invariably, these studies report low or comparable complication rates when an ADM is used and when no ADM is used. 
 
"While this article discusses one type of conflict of interest, I started to consider the other types of conflicts of interest that each of us grapples with on a daily basis."
 
My concerns were validated after reading this article.  In Lopez et al.’s analysis, they found that there was a lower complication rate with the use of an ADM if a conflict of interest was reported; however, when no ADM was used, studies with and without conflicts of interests reported similar complication rates.  This finding correlates with the author’s initial hypothesis that industry funding of research is more likely to be associated with pro-industry findings.
 
While this article discusses one type of conflict of interest, I started to consider the other types of conflicts of interest that each of us grapples with on a daily basis.  One example would be the young surgeon who chooses to operate on a borderline surgical candidate – a woman, who is a poor surgical candidate, is referred for breast reconstruction from a general surgeon whose last patient you saw was also not a surgical candidate.  You may choose to offer this patient surgery where as two weeks ago you may not have offered her surgery because you don’t want to lose this general surgeon as a referral source or because it is a “slow” week.
 
"The reality is that we have potential conflicts of interest every day in our lives – both personal and professional."
 
Another type of conflict of interest is at the heart of our specialty.  We routinely perform elective surgical procedures for money, and on the most basic level, every cosmetic patient is a potential conflict of interest.  Once again, not all patients will be ideal surgical candidates.  For example, several weeks ago, I was supposed to perform an abdominoplasty on a woman whose past medical history was only significant for gestational diabetes.  On her pre-operative bloodwork, I discovered that her blood sugar was over 350.  She argued with me to go ahead and proceed with surgery; I chose to cancel her surgery, refunded her money, and referred her to a primary physician to work-up and treat this new diagnosis.  I had counseled her that we could perform her elective surgery once her medical issues were well-controlled and that I was trying to do what was in her best interest; however, I have to admit that as she cried and begged, it was tempting to say “ok, let’s do surgery.”
 
The reality is that we have potential conflicts of interest every day in our lives – both personal and professional.  As surgeons who strive to care for our patients and use evidence-based medicine to help our clinical decision-making, we have to be aware of these conflicts so that we can appropriately interpret the data.  We will never be able to completely eliminate these conflicts of interest.  Rather, we have to be aware of them and do our best to analyze our motives if there is ever any doubt.
 
 

 

Monday, June 16, 2014

By Anu Bajaj, MD

 

On this Fathers Day, I’ve had the opportunity to reflect on the past seven years of working with my father.  In 2007, I joined my father in private practice in Oklahoma City.  Many have assumed that I pursued a career in plastic surgery to follow in my father’s footsteps.

 

"Almost in defiance of these assumptions, I pursued a fellowship and then joined an academic practice in a different city."

 

The actual story is that while as a young girl I had dreamed of becoming a surgeon, that dream turned to one of becoming a writer while I was in college – my father believed that journalism was an unstable career choice, so I was told to pursue an alternative.  Then, when I did decide on pursuing plastic surgery, my father actually discouraged me from a surgical career. 

 

The same assumptions repeated themselves after I completed my plastic surgery residency.  Many of my surgical attendings and fellow residents assumed that I would join my father in private practice in Oklahoma City.  Almost in defiance of these assumptions, I pursued a fellowship and then joined an academic practice in a different city. 

 

"My patients and others always ask me about what it is like working with my dad."

 

After a few years, I did move back to my hometown, and I did join my father in private practice.  Initially, I worked under his direction – he had fallen on the ice during the winter and broken his wrist, making him unable to operate for three months.  All of his patients (who were already scheduled for surgery) were given the choice of a referral to another plastic surgeon in the community or me.  Then, in the early years, we worked together on many of the larger surgeries in plastic surgery -- breast reductions, breast reconstructions, abdominoplasties, etc.  As time wore on, he stopped performing those larger, more tedious surgeries and now limits his practice to primarily hand and face.  And we stopped working together for most surgeries.  However, he still assists me on all of my free flaps, which are primarily DIEP flaps.  During this time, I have been able to share with him the new microsurgical techniques that I had learned during my fellowship.

 

"The good part of working with your father is you always have a support system"

 

My patients and others always ask me about what it is like working with my dad.  I’ve always said that it is both good and bad.  I remember the first free flap he and I did together in 2007.  He tried to assist me under the microscope.  Both of us became frustrated with one another because each of us wanted to be in charge.  After that experience, he does not assist me under the microscope anymore.  We had a similar degree of mutual frustration with the first free fibula that we did together too.

 

The good part of working with your father is you always have a support system – he has told me that he worries for me and becomes just as stressed as I do about having a successful outcome when I perform complicated microsurgical cases.  The bad part is that while I am also a surgeon, I am his daughter – like many fathers, he believes that his way is right, and this sometimes applies in the operating room as well.  As surgeons, we have come to believe that we are the leaders in the operating room, and while it takes an entire team to perform a surgery, there is ultimately one person with the primary responsibility – the surgeon.  As a daughter, I have to listen to my father; as a surgeon, I may not want to.

 

"I had a really good time working with him last week on this surgery. Part of the joy came from the excitement in the preparation for the surgery"

 

Now that we have worked together for seven years, we have an established routine, and we rarely have father-daughter conflicts.  He primarily will assist me on my DIEP flaps only, unless I ask him to work with me on other surgeries.  Recently, I did ask him to assist me on a closed rhinoplasty because he has a great deal more experience with this procedure.  My father particularly loves this operation, and I think that he was excited that I asked him to help me.

 

I had a really good time working with him last week on this surgery.  Part of the joy came from the excitement in the preparation for the surgery – reviewing photos, ensuring that we had all of the necessary instruments in our new surgical facility, and discussing the surgical goals.  The actual surgery was fun too – I think that I’ve learned that I have to allow my father to be my father, even when we are working together, and I don’t have to be the daughter who has something to prove.


 


Monday, April 21, 2014
 
by Ash Patel, MD
 
The Health Insurance Portability and Accountability Act (HIPAA) of 1996 like most legislation affecting healthcare is extremely complicated. Electronic information identifying patients is protected by HIPAA as well as provisions in the Health Information Technology for Economic and Clinical Health (HITECH) Act. On September 23 2013 the HIPAA Omnibus final rule) http://www.hhs.gov/ocr/privacy/hipaa/administrative/omnibus/) became effective, which extended HIPAA requirements to Business Associates (BA) of Covered Entities (http://www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/index.html) . These changes to HIPAA mean that service providers are required to follow HIPAA regulations to legally handle PHI. One of the many challenges facing the modern plastic surgeon is how to insure that the vast array of digital patient information remains confidential, and protected from unauthorized access.
 
Like many of our colleagues, on a daily basis I take photographs with my digital camera, send text messages to residents about patients (which also may contain photos), send emails about patients, and access the electronic medical record.

At my institution we use a HIPAA compliant smartphone app for messaging, and this got me thinking about whether other technologies in common use are HIPAA compliant.
 
Apple Facetime
 
A letter in PRS (March 2012 - Volume 129 - Issue 3 - p 562e-563e<http://journals.lww.com/plasreconsurg/toc/2012/03000>) highlighted the use of Facetime as a mode of video consultation. Whilst Apple states that Facetime calls are encrypted (https://www.apple.com/iphone/business/it/security.html), this encryption does not satisfy HIPAA requirements because Apple hold the encryption key, and the data is transmitted through their servers. Under the regulations, Apple is classified as a 3rd party with access to EPHI, and therefore would have to sign a Business Associate Agreement (BAA) to meet compliance. As Apple do not sign BAAs for this purpose, Facetime cannot be considered HIPAA compliant.

Dropbox
 
Dropbox is not HIPAA compliant. As part of the HIPAA security rule technical controls, the ability to audit who has accessed electronic protected health information (ePHI) is required. Dropbox does not have any audit controls in place to allow a review of who accessed information that is stored on Dropbox.  Without auditing, it is not possible to determine which individuals accessed ePHI. Additionally, file metadata (http://en.wikipedia.org/wiki/Metadata) is visible to Dropbox, which doesn't meet HIPAA requirements.
 
Google Apps for Business

In February 2014, Google announced that their cloud based platform (Gmail, calendar, Drive) would be HIPAA friendly, and that they would support BAAs. However, it's important to remember that the BAA refers only to the business version of these commonly used services. The free individual user versions do not offer the same audit and security capabilities.
 
So why is this important? HIPAA violations, including losing a smartphone, camera or flash drive can be a costly mistake, even if inadvertent. (http://www.ama-assn.org//ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/hipaahealth-insurance-portability-accountability-act/hipaa-violations-enforcement.page).
 

Monday, April 07, 2014
 
At least twice a month, PRSonally Speaking posts full abstracts of interesting or potentially controversial articles from a future issue. This 'sneak preview' of a hot article is meant to give you some food for thought and provide you with topic for conversation among colleagues.
 
When the article is published in print with the May issue, it will be FREE for a period of Two Months, to help the conversation continue in the PRS community and beyond. So read the abstract, join the conversation and spread the word.
 
This week we present the introduction to "Effects of Hypotensive Anesthesia on Blood Transfusion Rates in Craniosynostosis Corrections." by Fearon et al.


Abstract
Purpose: Hypotensive anesthesia is routinely utilized during craniosynostosis corrections to reduce blood loss. Utilizing Near-Infrared Spectroscopy, we noted cerebral oxygenation levels often fell below recommended levels. Intrigued by these observations we sought to measure the effects of hypotensive
versus standard anesthesia on blood transfusion rates.
 
Methods: 100 children undergoing craniosynostosis corrections were prospectively randomized into two groups: a target mean arterial pressure of either 50 mmHg, or 60 mmHg. Caregivers were blinded (aside from anesthesiologists) and strict transfusion criteria were followed. Multiple variables were
analyzed and appropriate statistical testing was performed.
 
Results: The hypotensive and standard groups appeared similar without statistically significant differences in: mean age (46.5 vs. 46.5 months), weight (19.25 vs. 19.49 kgs.), procedure (anterior remodeling (34 vs. 31) vs. posterior (19 vs. 16)), and preoperative hemoglobin levels (13 vs. 12.9gm/dl.). Intraoperative mean arterial pressures differed significantly (56 vs. 66 mmHg, p<0.001). The captured
cell saver amount was lower in the hypotensive group (163 vs. 204 cc., P = 0.02), yet no significant differences were noted in postoperative hemoglobin levels (8.8 vs. 9.3 gm. /dl.). Fifteen of 100 patients (15%) received allogenic transfusions, but no statistically significant differences were noted in transfusion rates between the hypotensive (9/53, 17.0%) and standard anesthesia (6/47, 13%) groups (P = 0.056).
 
Conclusions: We were unable to find any significant difference in transfusion requirements between hypotensive and standard anesthesia during craniosynostosis corrections. Considering potential benefits of improved cerebral blood flow and total body perfusion, surgeons might consider performing craniosynostosis corrections without hypotension.

 
The full article will be published with the May 2014 issue of PRS, and will be free online for non-subscribers. Until then, we hope this "sneak peek" will pique your interests and start a healthy, meaningful conversation.

Thursday, April 03, 2014

By Henry Hsia, MD

 

It had been two weeks now. Her implant was gone and she was looking at me from where she sat on the exam table.  Even though she had known it could happen, had signed the consent form indicating I’d told her that this could happen, I could tell from the look she was giving me that she never expected it would actually happen.

 

I knew better, but I admit I hadn’t expected it would happen either, especially to her and now.  Several months had passed since the implant was placed.  She didn’t smoke, never had radiation for her breast cancer, and had done everything I asked.  She’d been doing well and at her last routine visit a month ago I’d congratulated her on making it through the reconstruction gauntlet.  Back then, she had sat on that exam table looking at me with a smile of relief and gratitude.

 

But that was then.  Some time after that visit I got the call she had redness and some drainage.  During the ensuing flurry of evaluation and discussion, I had her focus on making sure the infection didn’t get worse and threaten her health.  And with that in mind, we decided the implant couldn’t be salvaged and had to come out.  The explantation had gone smoothly and she completed her antibiotics.  She was doing well, except….

 

“So what’s next?”  That’s what her look now seemed to ask me.  At her initial consultation, she’d been adamantly not interested in autologous reconstruction.  She didn’t want the added scars, the possible donor site morbidity, etc.  And the last few weeks hadn’t changed her mind about that.  But she also wasn’t willing to accept a bra prosthesis as a long-term solution.  She wanted to try the implant again.  I didn’t think that was a good idea without better tissue coverage.  We were at an impasse.

In the end pressed for time, I punted the question to a future visit, telling her we had to wait a few months anyway.  I’m sure it wasn’t the most satisfying answer for her and the lack of a clear plan left me in a frustrated mood.  I was still feeling that sour mood when a few days later I found myself at the Plastic Surgery Research Council meeting in New York City.  

 

"Having the opportunity to speak face-to-face with the surgeon and pick his brain about the flap made me feel a lot less sour about missing time with my family"

 

Even though I’ve always enjoyed going to these and other plastic surgery meetings, it’s been getting harder and harder each year to go, what with the squeeze of ever increasing expectations for clinical productivity and family commitments.  As I wandered among the scientific sessions, my phone was a constant distraction as it buzzed with photos of my young daughters that my loving wife was sending from their weekend trip away along with text messages like “Check out what you’re missing!”

 

Then, looking up from my wife’s latest salvo of guilt-laden cuteness, I saw a poster entitled “The Lateral Intercostal Artery Perforator (LICAP) Flap for Outpatient Total Breast Reconstruction”.  Forgetting my family (for just a moment), I immediately thought of my patient and went up and started chatting with the authors who were standing there.  This flap wasn’t something I’d thought of during my patient’s visit earlier that week, and it was wonderfully fortuitous and timely to come across this particular poster.  Having the opportunity to speak face-to-face with the surgeon and pick his brain about the flap made me feel a lot less sour about missing time with my family. 

We had a great discussion and I left the poster looking forward to seeing my patient again.  Even though I couldn’t be sure, at least I had a feasible option to offer that I thought she just might be willing to accept.  Whatever frustrations and qualms I had about coming to the meeting had melted away.  I stood there among the poster presentations and all the exciting and innovating work around me and felt a reinvigorated sense of optimism.  Now this is why I go to meetings like the PSRC! 

 

I took a selfie among the posters and shot it back to my bemused wife with the message “Hey, check out what YOU are missing!”

About the Blog

Plastic and Reconstructive Surgery

PRSonally Speaking is the official blog of Plastic and Reconstructive Surgery, the journal of the American Society of Plastic Surgeons. Visit our blog for exclusive previews of and discussions on hot topics in plastic surgery as well as insider-tips on open access content. PRSonally Speaking is now powered by frequent contributions from the American Society of Plastic Surgeons’ Young Plastic Surgeons Forum (YPS); these practicing plastic surgeons provide the personal side of the plastic surgery story, from daily challenges to unique insights. PRSonally Speaking is home to lively, civil debate on hot topics and great discussions pertaining to our field. So, bookmark us, subscribe to the RSS feed and join in the on-going conversation with Plastic and Reconstructive Surgery. This is your Journal; have fun, be respectful, get engaged and interact with the PRS community.

The views and recommendations of guest contributors do not necessarily indicate official endorsements or opinions of the Journal, PRS, or the ASPS. All views are those of the authors and the authors alone.

Contributors

Anureet K. Bajaj, MD is a practicing plastic surgeon in Oklahoma City. She completed residency and fellowship in 2004, had a brief stint in academia at the University of Cincinnati, and then chose to join her father (Paramjit Bajaj MD, also a practicing plastic surgeon) in private practice in OKC, where she focuses on breast reconstruction and general cosmetic surgeries.

Devra B. Becker, MD, FACS, is an Assistant Professor of Plastic Surgery in the Department of Plastic Surgery at University Hospitals/Case Western Reserve University School of Medicine in Cleveland, Ohio. She completed Plastic Surgery residency at Washington University School of Medicine in St. Louis, and completed fellowships with Daniel Marchac and with Bahman Guyuron. She currently has a primarily reconstructive practice.

Henry C. Hsia, MD, FACS is at Robert Wood Johnson Medical School of Rutgers University in New Brunswick, New Jersey and also holds an appointment at Princeton University.  When he’s not working hard trying to be a good father and husband, he runs a practice focused on reconstructive surgery and wound care as well as a research lab focused on wound biology and regenerative medicine.

Stephanie K. Rowen, MD is a senior physician at The Permanente Medical Group in San Jose, California.  She joined TPMG upon finishing residency and a hand surgery fellowship in 2005.  She has a primarily reconstructive practice, about 50% hand surgery.  Outside of work she enjoys participating in triathlons and spending time with her family.

Jon Ver Halen, MD is currently an Assistant Professor in the Department of Plastic Surgeryat the University of Tennessee Health Science Center, in Memphis. He also acts as Program Director for the plastic surgery residency. His practice focuses on oncologic reconstruction.

Tech Talk Bloggers

Adrian Murphy is a plastic surgery trainee in London, England. He studied medicine in Dublin, Ireland and has trained in Ireland, Boston, MA and the United Kingdom. He is a self-confessed geek and gadget aficionado.

Ash Patel, MD is Assistant Professor of Plastic Surgery and Associate Program Director at Albany Medical College, in Albany NY. His practice is primarily reconstructive.