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PRSonally Speaking
Wednesday, November 12, 2014

by John Ver Halen, MD

Instead of waiting for the next technological “quantum leap” to improve patient care, what can we do better with the tools at hand? Fayezizadeh, et al, describe their impressive (but unsurprising) results using a multimodality pain control program in patients undergoing transversalis abdominis release, and find that time to resumption of oral diet was significantly shorter (versus historical controls)(1). In contrast, when pain management is viewed as a simple direct feedback system (i.e., patients are administered narcotics according to a linear pain scale), the incidence of postoperative nausea and vomiting, ileus, and length of stay goes up considerably.

As we are all aware, patients (and thus, medicine) are far from simple, and require a complex approach. Modern management strategies (e.g., Lean, six-sigma, PDSA cycles) advise us to make small, incremental changes, measure our results, and change accordingly. To quote Winston Churchill (and Frank Underwood): “To improve is to change; to perfect is to change often.” Numerous small changes have resulted in the end product of decreased length of stay, decreased narcotic use, and accelerated recovery in patients in enhanced recovery after surgery (ERAS) protocols. The authors’ results are representative of the global experience with these protocols.

Since my hospital system has initiated an ERAS protocol for abdominal surgery, we have noted a similar decrease in the utilization of narcotics, incidence of postoperative ileus, and hospital length of stay. This has been in the absence of an increase in readmissions, or added morbidity. We have subsequently started using it for our complex abdominal wall reconstruction (hernias, fistulas, component separation) with similar results. We have also changed our mesh repair technique from an inlay, to an onlay technique fixated with fibrin glue to remove trans-fascial suture pain. Like so many hospital systems, mine is undergoing a transition from “quantity” to “quality”. Some of our measures are objective, while others are patient-centered (e.g., Press-Ganey scores). Undoubtedly, instituting an ERAS system is initially more resource-intensive, and requires significant provider training … but how much does it save? And what are the gains, from a patient perspective? Will these changes be requisite, in the future, for providers and hospitals to survive in the changing environment? Finally, in an era of widespread narcotic abuse, is there a positive impact on society at large?

The immediate challenge to improving the quality of surgical care is not discovering new knowledge, but rather how to integrate what we already know into practice. Once again, this will be a situation where we will be either “flying ahead of the plane”, or “behind the plane” (to borrow project management jargon). Many plastic surgeons are already using Exparel with abdominoplasty and breast augmenation patients, with convincing results in most cases. But I feel as though we are still behind other specialties in utilizing these techniques. My orthopedic colleagues are using complex pre-surgical, intraoperative, and postoperative cocktails that have permitted outpatient knee arthroplasties for years. What will it take, and what will be the result, when we apply these protocols to our patients?

1. Enhanced Recover After Surgery Pathway for Abdominal Wall Reconstruction: Pilot Study and Preliminary Outcomes.
Plast Reconstr Surg. 134:151S, 2014.

Thursday, October 09, 2014
by Henry C. Hsia, MD, FACS
With Breast Reconstruction Awareness Day ( approaching this month, a timely article appears in the October 2014 issue entitled “Helping Patients Make Choices about Breast Reconstruction: A Decision Analysis Approach” by Sun et al.  The authors adapt techniques which originated in business management, and which have been increasingly applied in medical decision making, to the purpose of helping a breast cancer patient decide whether and how to undergo reconstruction.
"... a Google maps-like personalized reconstruction decision guide would be returned..."
In my practice, the initial patient visit (IPV) for a patient contemplating breast reconstruction is by far the most time-consuming type of patient encounter, often extending an hour or longer.  And with the inexorable pressure to cram more patients into my office hours, I have long sought the “holy grail” of time management solutions to make these visits somehow happen more efficiently through brochures, websites, adjunct counseling by staff members… you name it.  And while these measures are helpful in educating patients about breast reconstruction, in the end they haven’t significantly reduced the amount of time I spend talking to a patient, and my office staff knows never to schedule a “breast reconstruction IPV” for only 15 minutes.
Perhaps the approach offered by Sun et al will change that.  Although the authors never explicitly state this, their approach, with its need for computation-intensive analysis of probabilistic outcomes and use of equations with values weighted based on individual circumstances and preferences, does lay the basic groundwork for a future computerized application where patient-specific information could be entered and a Google maps-like personalized reconstruction decision guide would be returned, telling patient and surgeon the best way to get from the present office visit to the future goal of a restored breast with a minimum of complication.
"...the initial consultation is to help the patient understand my role in her recovery and to get her to see me as not only a surgeon but also a guide for her healing process. "
Yet I spend much of the visit time not in outlining probabilities but in reassuring patients, an especially difficult task given that these patients often come in already scared and anxious, still in the process of coming to terms with the reality of their recent diagnosis.  And as we go over the various alternatives for reconstruction and the potential pitfalls, it can take a great deal of effort and time to help my patient keep her anxiety level in check, while also being forthright about potential complications and managing her expectations appropriately.  It’s a delicate balance, and I often find that the information I say matters much less than the manner in which I say it, as well as the patience with which I listen, often at length, to my patient’s fears and concerns.
I’ve learned over time that the most productive use of the initial consultation is to help the patient understand my role in her recovery and to get her to see me as not only a surgeon but also a guide for her healing process.  I try to get her to understand that proper healing requires not just my technical proficiency but also her cooperative efforts (and that of her support network) to help her body to heal well.  That my technical skills as a surgeon cannot “make” her body heal and become whole again any more than a gardener can “make” a plant grow and bloom or bear fruit.  Restoring a garden ravaged by disease and drought requires not just the gardener’s technical expertise but also an effort, often collaborative, to get the environment and conditions just right to promote the proper growth.  To restore a women’s body requires not just my skill but also substantial efforts on her part.  And I find that getting a patient to understand and buy in to this, especially if she is already afraid and anxious, takes time.  And so while I welcome efforts like Sun et al, I don’t think I’ll be telling my office staff any time soon that I will be squeezing my breast reconstruction IPV’s into a crisp 15-minute encounter.

Wednesday, September 24, 2014
by Anu Bajaj, MD
Recently, I’ve had the opportunity to consider this question since I’ve experienced both personal and professional injuries.  Physicians usually apply different standards to themselves than they apply to their patients.  Everyone else I know, if they are sick or injured takes time off of work – my nurse, my scrub, my husband.  But because our job is to care for others, as physicians, we believe ourselves to be invincible.
everyone had his or her own tale of working at all costs – throwing up in the call-room bathroom, working with a high fever, or asking the nurse to start an IV on oneself.
As a resident, regardless of how bad I felt, I always dragged myself into work.  When I spoke with my fellow residents or former residents, everyone had his or her own tale of working at all costs – throwing up in the call-room bathroom, working with a high fever, or asking the nurse to start an IV on oneself.  During my training, I can recall only one instance when I left the hospital early  -- as a fourth-year medical student, I came down with Rotavirus while on my pediatrics rotation and remember having both nausea/vomiting and diarrhea.  After spending the entire morning in the bathroom, my chief resident finally sent me home.  Similarly, I can recall stories of my father (who is also a surgeon) needing to get breathing treatments between OR cases for his asthma.
In fact I started working with my father when he was injured – he had slipped on the ice and had broken his wrist.  He was in a cast for 3 months and was unable to operate during this time.  When I joined his practice, I was instantaneously busy since he was unable to work.  A year later, I broke my elbow while riding my bike -- I had a non-displaced radial head fracture.  My practice was still young so when my orthopedic surgeon advised that I keep my elbow immobilized for 10 days, I reluctantly complied for a week.  After further discussion, he conceded that I could do gentle range of motion and start operating on SMALL cases; he even specified, no breast reductions or abdominoplasties or weight bearing for 6 weeks.  I did return to work (and followed his instructions).
We were able to find the pieces in the midst of the zucchini, and my father – the hand surgeon – was able to secure them as grafts to my fingertips.
Then three months ago, as I was making zucchini spaghetti on my fancy kitchen mandolin, I sliced off the tips of my thumb and long finger (as a surgeon, I was grateful that it was the radial side of my thumb and my long finger knowing that these areas are less critical for my operating skills).  We were able to find the pieces in the midst of the zucchini, and my father – the hand surgeon – was able to secure them as grafts to my fingertips.  A typical hand patient would have been told to keep the dressing clean and dry and to elevate the hand; I was not a typical hand patient.  Since I didn’t follow instructions, I did have a little graft loss (all eventually healed well).  My father told me that I wouldn’t have lost any of the graft if I hadn’t used my hand while it was healing.  How does one do that?  I’m used to washing my hands umpteen times in a single day.
In the past, I have treated my running and athletic endeavors the same way that I have treated surgery – I have always learned to run through the pain whether it was plantar fasciitis, a strained muscle, or hip pain.  I was able to get away with this approach until a few years ago when I had my first stress fracture.  At that point, there was no way for me to continue to run through the pain, and I had to take time off from running – 4 weeks after the first stress fracture 6 weeks after the second.   I was forced to take time off again following a recent hamstring injury.  I injured my hamstring while running – the pain was so severe that initially I had difficulty walking.  Nevertheless, as soon as I started to feel better, I started running again – probably too soon and promptly reinjured it.  This time, I dutifully rehabbed the injury – took time off from running, then after the pain had disappeared started gentle stretching and cross-training with swimming.  I followed instructions so well that I didn’t run for five weeks despite having an upcoming relay race (Hood to Coast in Oregon). 
As caregivers, it is difficult to acknowledge our vulnerability – not only for ourselves but also for our patients.
So, why do I have this compulsion to keep working or running despite the effects to my well-being?  When we watch professional athletes, many of them will take time off because of an injury – OKC Thunder player Russell Westbrook was sidelined during NBA playoffs for example.  Similarly, as a physician, when I discuss upcoming procedures with patients, I routinely advise them how much time they may need to take off of work, how long before they can work out, and how long they may require someone to help them at home.  And as they recover from surgery, when they ask about resuming activities, I always urge them to listen to their bodies.  They can gradually start to increases activities but should pay attention if “something doesn’t feel right, ” and “listen to your body.”  While it may be easy for me to give advice, it is far more difficult for me to follow this advice.
The easy answer is that we are the caregivers.  As caregivers, it is difficult to acknowledge our vulnerability – not only for ourselves but also for our patients.  Telling a patient that you have to cancel surgery – even if it is because the surgeon is sick or injured still results in disappointment and frustration for the patient.  When I broke my elbow many years ago, I had to cancel a bilateral DIEP flap – despite the excellent reason for needing to reschedule, my patient’s initial response was negative.  So, I have had it ingrained in me that I don’t cancel patients, ever. 
... we are human and not invincible.
The other part of the equation is the guilt I feel for having to cancel on any commitment – whether it’s to myself or to others.  With running, I beat myself up if I skip a day – saying that I’m lazy; and I take the same approach if I have to change my work schedule for a personal reason.  I have had asthma since childhood.  Typically, when I have a severe episode, it will rapidly progress to bronchitis.  After having a particularly bad weekend, I spoke to my father on Sunday evening about our DIEP flap for the next day.  My dad said, “are you sure that you’re ok for tomorrow?”  I responded, “ Of course I am, I’ve never cancelled a surgery before for an asthma attack.”  He said, “maybe you should consider it, you don’t have to work if you’re not feeling well.”  At that point I realized that I had never had permission to think of myself and how I felt.  Now, I had permission to acknowledge that I may not be 100% upto a task. 
Usually, when I’ve had an athletic injury severe enough to keep from running, I have been told not to run; when I have a personal illness, as physicians, we rarely obtain “permission” not to work – even on days off, patients still have needs and will still call.  Struggling to take care of our patients and ourselves is a balancing act that many of us are still trying to navigate.  Nevertheless, we must all admit that we are human and not invincible.


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.


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.


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 Chief of plastic surgery, Baptist Cancer Center; Research member, Vanderbilt- Ingram Cancer Center; Adjunct clinical faculty, St. Jude Children's Research Hospital. He also acts as Program Director for the plastic surgery microvascular surgery fellowship. 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.