MALPRACTICE CLAIMS

Malpractice Claims Consume Years
of a Physician’s Career

On average, each physician spends 50.7 months, or approximately 11 percent of an average 40-year career, on resolving medical malpractice cases—the majority of which end up with no indemnity payment. That’s the conclusion of a recent study¹ by the RAND Corporation based on data provided by The Doctors Company, the nation’s largest medical malpractice insurer. Researchers found that 70 percent of the time physicians spend on claims is spent defending claims that end in no payment to the plaintiff.
Key findings of the study include:

• Physicians experience additional stress, work, and reputational damage from the time spent defending claims.
• Fighting claims takes time away from practicing medicine and from the opportunity for the physician to learn from his or her medical errors.
• The lengthy time required to resolve claims also negatively impacts patients and their families.

The effect of malpractice claims on physicians’ careers is discussed further by Richard E. Anderson, MD, FACP, chairman and CEO of The Doctors Company, in two short videos that can be viewed at www.youtube.com/doctorscompany.

Plastic Surgeons in the U.S. average 1 malpractice claim every 2 years. The average cost of Malpractice coverage for plastic surgeons is $60,000 to $100,000 per year.

PLASTIC SURGEONS PARTICIPATE IN BOSTON'S TRAUMA INJURIES

BOSTON — For years, Dr. Michael J. Weaver, an orthopedic trauma surgeon, went to meetings of his professional society and heard surgeons from the military describe what they had learned treating blast injuries. Then he would return to his practice at Brigham and Women’s Hospital in Boston, where he mostly treated people injured in auto accidents or falls.

All that changed on Monday when victims of the bombings at the Boston Marathon arrived.

“We’ve seen similar injuries, but never of this magnitude,” Dr. Weaver said. “This is completely different.” The military experience, he added, “has been phenomenally helpful.”

But doctors said they had also prepared for a disaster, with regular drills. At Massachusetts General Hospital, for example, part of the emergency department’s disaster preparedness included bins of special wristbands to identify disaster patients. “We can’t sit there and write names of patients” on wristbands, said Dr. R. Malcolm Smith, chief of the medical center’s orthopedic trauma service. Instead, medical personnel in the emergency department slapped wristbands on patients that identified them with special disaster numbers. The bands said simply, Disaster Victim 001, Disaster Victim 002, and so on. Patients’ names were added later.       

It turns out to be an art — and a delicate balancing act — to treat people with blast injuries that can pulverize muscle and rip blood vessels, that can drive pieces of metal into soft flesh and shatter bones. Trauma surgeons call it damage control, and say the military experience showed how important it is. The idea is not to try to solve all of a patient’s medical problems at once, but instead to deal with the urgent and life-threatening ones immediately. Patients often have to return to the operating room again and again as their injuries are successively repaired. The first priority for those who were severely injured was to prevent them from dying, often from bleeding to death. Many had tourniquets on their legs when they arrived at the hospitals. But that was just a temporary measure to slow the bleeding. They needed immediate surgery to get their bleeding under control and prevent muscles and nerves from dying for lack of blood.  That requires a vascular surgeon to repair the torn blood vessels and restore blood to legs and feet that may no longer have a blood supply. To do those repairs, surgeons often sew in part of a vein from the other leg, if it is uninjured, or from an arm. Or they use a synthetic tube. Meanwhile, an orthopedic surgeon must stabilize a bone that might be flopping because it is fractured in several places. Surgeons do that with a temporary solution — they drill into the bone from outside the leg and attach pins that they screw into a metal bar also outside the leg. Plastic surgeons clean the wound. In this case, blast victims had BBs or nails or debris embedded in their legs and feet. Everything the surgeons took out of the wounds was placed in plastic bags for the F.B.I., said Dr. Samuel J. Lin, a plastic surgeon at Beth Israel Deaconess Medical Center who helped care for blast victims. “The crime scene extends to the hospital,” Dr. Lin said.       

Patients then are sent back to intensive care or their hospital rooms for the next few days while doctors wait to assess the damage to muscles and nerves and blood vessels. “With a blast injury in particular, we can’t always be sure how widespread the soft tissue injury is,” Dr. Smith said. Badly injured, dead tissue needs to be removed to avoid infection. And that may mean repeated visits to the operating room. But there are no other options. “If we leave dead tissue in place, it gets infected,” Dr. Smith said. And if the soft tissue dies, a leg might have to be amputated. The next priority is repairing soft tissue — muscle and nerves and skin. “Everything depends on soft tissue repair,” Dr. Smith said. “If you don’t have healthy soft tissue, bone will not survive.” That means that plastic surgeons have to close what may be gaping wounds.       

Wound healing has been revolutionized by a vacuum device, Dr. Lin said. Patients with large wounds used to just be bandaged and have their dressings changed several times a day. Now, doctors put a black sponge over the wound, cover it with a thin sheet of plastic wrap, and attach it to a vacuum hose. Wounds heal faster, and patients are in less pain.

A big advance, Dr. Weaver said, whose value was proved by the military, is taking tissue from smaller areas to close a large open wound. Surgeons used to take big chunks of muscle along with blood vessels from a person’s abdomen or back and move it to the wound to repair the injury.

Now, he said, they take much smaller pieces of tissue from places like the forearm or thigh. It means a smaller surgery and fewer complications.

But uncertainty about the fate of soft tissue surrounding a wound can remain for days after a repair. If it dies, and if further attempts to trim the dead tissue and repair the wound fail, patients face amputations.

When it comes time to repair shattered bones, orthopedists make use of stabilizing metal plates developed over the last decade or so that are vast improvements over earlier ones, Dr. Weaver said. They still have to attach the plates directly to the bone, where they will remain for the rest of the patient’s life. But the new plates are designed to fit exactly against the shape of the bone, making the bone more stable.

“To restore the function of a knee or ankle, you have to put the pieces of bone together like a jigsaw puzzle,” Dr. Weaver said.

The military also greatly improved reconstruction, prosthetics, and rehabilitation for those who need amputations. Of course an amputation is still devastating, but now, with the improved prosthetics, many patients can walk, run and enjoy essentially normal lives, Dr. Weaver said.

For many of the blast victims, the path to recovery will be long and arduous, with weeks in the hospital and rehabilitation lasting as long as a year. While bones can heal, patients may be left with stiffness from torn muscles, bad scars from the operations, and, if a joint was severely damaged, arthritis in it.

The victims, Dr. Smith said, were mostly younger people who were watching the race. The blasts went off behind them, ripping the backs of their legs.

Some know what they are facing in the months to come, Dr. Weaver said. But others, he added, do not. “Many who are critically ill in intensive care are still waking up,” he said.

OBESITY

We might think that everyone knows the facts about obesity and weight loss, but a recent article in the New England Journal of Medicine exposes a number of myths and misunderstandings that many still believe. The results may surprise you, from the real link between eating more produce and weight loss to the amount of calories burned during sexual activity.

Defined as a body mass index (BMI) of 30 or higher, obesity is an epidemic -- more than one-third of American adults are obese and obesity-related medical costs in 2008 totaled nearly $150 billion dollars.
Adding more fruits and vegetables to your diet will result in weight loss, right? Wrong. Adding any elements to your diet without making other behavioral or environmental changes will not change your body. "Healthy foods" can also be tricky -- you might be surprised to know that a can of grape soda contains fewer calories than a similarly-sized can of grape juice.
The conclusion the NEJM article draws is that there are so many unsupported beliefs about obesity in both scientific literature and the popular press that these misunderstandings are actually contributing to the epidemic.
Given the percentage of obesity in the population and the growth of the plastic surgery as an industry, plastic surgeons are seeing more and more overweight and obese patients. While we are discussing myths and presumptions, let's dispel the notion that body contouring is an effective treatment for obesity. Liposuction, for example, is best used to treat patients with isolated areas of fat; it is not a surgical technique for weight loss. Abdominoplasty and brachioplasty remove redundant skin from the abdomen and upper arms, respectively -- after the weight is lost.
A patient whose weight has been stable for years but is still having trouble with certain problem areas is a good candidate for liposuction -- not someone whose weight has been unstable and who is seeking full-body results. Obese patients should tread carefully when considering any surgical procedure and note that their physicians should make the following clear: Liposuction is not designed to remove tens of pounds from a body in a single day -- this is an extremely dangerous practice.
No matter the elective surgery, from facelifts to liposuction, the rule of thumb that many of my colleagues and I follow is to request that any potential patient get their body weight to below a BMI of 30. This lowers the risk of complications during surgery.
In addition to lowering their BMI in the short-term, healthy eating and exercise habits should be built into the patient's regular routine -- instead of simply trying to lose weight for a procedure, patients should have a thorough understanding about proven facts about calories and exercise. Without these habits good habits in place, any improvement provided by body contouring can be easily undone.
As always, an educated patient is a good patient. Do your reading and learn to separate fact from fiction. The NEJM article suggests asking the simple question: "How could someone actually know that?" when confronting a nutrition or exercise-related belief. Not a bad way to start sorting fact from fiction when it comes to your health and wellness.
And as for that last surprising fact? People expect that sex burns 100-300 calories, but on average it's closer to 21, or about the caloric value of a Hersheys Kiss.

THE 11 MOST OVERRATED COSMETIC SURGERY PROCEDURES

New cosmetic procedures often fail to live up to their original promise. Some may even do harm. We investigate the innovations that you might want to reconsider.

THE "VAMPIRE" FACE-LIFT

This ghoulish-sounding treatment for the signs of aging was introduced in 2009 and has since been mentioned on 200,000 Web pages. It involves injecting the patient's own pale yellow blood plasma around the eyes and mouth, borrowing a technique used to promote healing after orthopedic surgery. It's not actually a face-lift, and it's not FDA approved for use in the face. There are no independent studies proving its cosmetic benefits, though some doctors believe the growth factors in plasma can gradually stimulate collagen production.

LASER LIPOSUCTION

Using a laser to enhance traditional liposuction may sound like a scientific advance, but many doctors have their doubts. Six years ago, surgeons began promoting the device as an efficient way to melt fat with high heat before removing it from the body. In reality, so-called SmartLipo and similar procedures add both time and money to the typical technique. First, a laser wand is inserted under the skin, then another tube vacuums out the fat. The benefit of the heat is better skin tightening, with more elasticity and less bruising, says Barry DiBernardo, a plastic surgeon in Montclair, New Jersey. The downside? "There is the added risk of burns, large scars, tissue hardening, and prolonged pain," said Steven Teitelbaum, a plastic surgeon in Santa Monica, in a debate with DiBernardo at last year's meeting of the American Society for Aesthetic Plastic Surgery. (Cynosure, the company that makes SmartLipo, acknowledges "a very small" number of "uncomplicated" burns from the procedure. In one study, laser-assisted liposuction was seen to have fewer complications than the traditional method, according to the company.)

THE STEM-CELL FACE-LIFT

They may be the great hope of modern medicine, but stem cells—those blank slates of the body that can turn into nerves, bones, or cartilage—have yet to revolutionize aesthetic surgery. It's been a decade since scientists discovered that fat happens to be loaded with the cells. Almost immediately, surgeons began to claim—with no proof—that the stem cells in fat improved skin quality and started calling fat injections a stem-cell face-lift, says Rod J. Rohrich, chair of plastic surgery at the University of Texas, Southwestern, in Dallas, and the coauthor of a recent paper on the subject. But the idea that fat injections could replace a traditional face-lift is "high on marketing and short on science," Rohrich says. "Stem cells have great promise, but there is so much conjecture." Currently, there is no FDA-approved device to separate stem cells from fat and no consensus on the number of cells needed for rejuvenation or how many treatments are necessary. "We don't even know if stem cells are critical—or if they are doing anything at all," says Rohrich.

SCULPTRA AND ARTEFILL FOR LIPS

Approved in 2004 for patients with facial wasting (a hollow-cheeked appearance usually associated with HIV infection), Sculptra is a chemical that can be injected into the face to stimulate collagen growth. "You put it in and watch it grow over a period of months," says Claudio DeLorenzi, a plastic surgeon in Kitchener, Canada, who says the best results are seen in the temples and cheeks. But one place it should never be used, says DeLorenzi, is in the lips: "It can result in ugly bumps and lumps, or the lips may end up a size that no one counted on." Similarly, Artefill, a mixture of Plexiglas-­like beads and cow collagen, is approved only for filling smile lines. As the collagen is absorbed, the body forms scar tissue around the beads, DeLorenzi explains. "In the lips, this can result in clumps and nodules, and there is no way to get rid of the stuff other than to cut it out." Cosmetic surgeons often disagree, but on this subject they are virtually unanimous: Only temporary fillers such as Juvéderm and Restylane should be used in the lips.

SILICONE CHEEK IMPLANTS

The news for women who want to add volume to their cheeks is good: Facial fillers have all but replaced the silicone implants that were standard in the '90s. Back then, implants were anchored below the skin, adding plumpness that in some cases, like that of surgical early adopter Jocelyn Wildenstein, verged on the extreme. "Implants can migrate and cause infection and nerve injuries, and the aesthetic result is difficult to reverse," says Stafford Broumand, an associate clinical professor of plastic surgery at Mount Sinai Medical Center in New York City.

ULTHERA

Women in their 40s and 50s had high hopes for Ulthera, a no-incision ultrasound treatment approved for eyebrow lifts that was soon put to use in other areas of the face and neck. There's only one problem: Even when the face is slathered with numbing cream, the procedure can be painful. Really painful. "We gave eight patients full-face Ulthera treatments. They all liked the results, and they all said they would never do it again because of the pain," said Arie Benchetrit, a Montreal plastic surgeon, at a recent plastic-surgery meeting. "One patient asked to stop midtreatment." An improved, lower-frequency version designed to reduce the pain without compromising the results was rolled out in October.

FAT INJECTIONS FOR BREASTS

There's a good reason "fat injection" is the latest catchphrase in cosmetic breast augmentation. The results look good and feel natural, and unlike a scalpel, the needles leave no scars. But there are often downsides. Multiple procedures may be necessary and, with few exceptions, provide, at most, a one-cup-size enlargement. A study by Mihye Choi, an assistant professor of plastic surgery at NYU School of Medicine, found that half the volume created by shots of fat disappears into the body within months. More worrisome, there is concern that, years later, stem cells in the fat might stimulate cancer.

BRACHIOPLASTY

Anyone seeking an upper-arm lift to look sleeker in a sleeveless dress may want to keep a cardigan on hand. Only those with very little extra skin and good elasticity qualify for the type of brachioplasty operation in which fat is extracted through an incision that can be hidden in the armpit. For the rest, surgery to reduce arm wattle will result in a scar that runs from armpit to elbow. Nerve problems are also a possibility, and the incision can pull apart and become infected. Brachioplasty may be a great option for the Biggest Loser crowd—women whose arms look like bat wings after massive weight loss—but not for those who just want to dress like Michelle Obama.

BUTT IMPLANTS

Brazilians are famously adventurous when it comes to surgery—they invented the "full-body lift," after all—but the nation's thong-wearing beachgoers have turned their backs on butt implants. "Even in the hands of expert surgeons, the reoperation rate for gluteal augmentation with implants is 13 to 25 percent," says John Sherman, a surgeon at Weill Cornell University Medical College in New York City who surveyed studies on the subject. "You're putting an implant in a place where there is no anatomical pocket and then constantly sitting on it," says Sherman, who does not perform the surgery. Risks include infection, wound opening, loss of feeling, and extrusion. As a result, fat injections in this part of the body have become more common.

ZERONA FAT-MELTING LASER

This high-tech slimming technique promises to help patients lose inches without the drudgery of dieting, with maybe just a little unpleasant tingling. The patient lies on a table—20 minutes on the back, 20 on the stomach—while a red laser flashes from the machine's arms to target and drain fat deposits below the skin. When combined with diet, exercise, and supplements that flush fluid from the body, some people do lose body fat—a half-inch here, a half-inch there—but not the rolls of fat that many want to get rid of. Nobody can say for sure how much is caused by the lasers and how much is the result of diet and exercise (although the laser on its own caused fat loss in a Zerona-sponsored clinical trial). For patients who report no benefit at all from a full course of six sessions costing $1,700, Zerona is, in the words of one critic, "a wallet-ectomy."

FOOT LIFTS

Except in summer sandals, the foot is rarely on public display—but that doesn't mean vanity stops above the ankle. Foot surgery is available to make pointy shoes fit better and to shorten second toes that extend beyond big ones; there's lipo for the little toe in cases where it's not little enough, and injections of hyaluronic acid to add padding to the balls of the feet (dubbed the "Loub job," after Christian Louboutin). The complications, however, can be brutal. It took one New York City socialite more than three years to recover from shots in her soles that caused nerve injury and forced her to wear sneakers. "When patients ask to alter the architecture of a foot that has no real disabilities, I advise against it," says Rock Positano, a New York City podiatrist and director of the non­operative foot and ankle service at the Hospital for Special Surgery.

GYNECOMASTIA

Arlington Heights, Ill. - Persistent breast enlargement (gynecomastia) negatively affects self-esteem and other areas of mental and emotional health in adolescent males, reports the April issue of Plastic and Reconstructive Surgery®, the official medical journal of the American Society of Plastic Surgeons (ASPS).

Even mild gynecomastia can have adverse psychological effects in boys, according to the study by ASPS Member Surgeon Dr. Brian I. Labow and colleagues of Boston Children's Hospital. They believe their findings have important implications for early intervention and treatment, including male breast reduction in appropriate cases.The researchers administered a series of psychological tests to 47 healthy boys, average age 16.5 years, being evaluated for gynecomastia. The results were compared to those of a group of boys without breast enlargement. Sixty-two percent of the gynecomastia patients had mild to moderate breast enlargement. As in previous studies, many of the boys with gynecomastia were overweight or obese: 64 percent, compared to 41 percent of the comparison group. Patients with gynecomastia had lower scores on a standard quality of life assessment, indicating problems in several areas. Even after adjustment for weight and body mass index (BMI), the patients had lower scores for general health, social functioning and mental health. They also had lower scores for physical health, but this was attributed to being overweight.
Breast enlargement was also associated with lower scores for self-esteem. This, along with impairment in emotional areas of quality of life, appeared directly related to gynecomastia, rather than being overweight.
Boys with gynecomastia also scored higher on a test of attitudes toward food and eating. However, there was no difference in the rate of clinical eating disorders between groups.

BRITAIN'S NATIONAL HEALTH SERVICE DIRECTOR WEIGHS IN ON MINIMALLY INVASIVE PROCEDURES

Patients who have non-surgical cosmetic treatments are being exposed to "unreasonable risks" and "permanent damage" because of a lack of appropriate training for those carrying them out, the man leading a review of plastic surgery standards has said. NHS medical director Sir Bruce Keogh said his report on the state of the industry, ordered after the faulty PIP breast implants scandal, would make recommendations to make sure patients "were in safe hands" when it is released later this month.It is believed this will mean a new law requiring everyone from beauty therapists to medically-trained doctors to have additional formal qualifications before carrying out treatments. Sir Bruce said he was worried that non-surgical procedures - which include dermal fillers, or laser treatment for wrinkles or hair reduction - make up 90% of the sector but are largely unregulated. "All too often we hear of cases that shine a light on poor practices in the cosmetic surgery industry," he said. "I am concerned that some practitioners who are giving non-surgical treatments may not have had any appropriate training whatsoever. "This leaves people exposed to unreasonable risks, and possibly permanent damage. "And our research has shown that the public expect procedures that are so widely available to be safe whereas they are largely unregulated."There is a clear need for better quality, recognised training for the people performing these operations. "My review will make a number of recommendations for making sure people who choose to undergo these procedures are in safe hands."

STERILIZATION PROTOCOL

In view of recent allegations concerning violations of sterilization standards in a Tulsa oral surgeon's office, I thought I would address this issue.  The number one priority in surgical procedures is patient safety.  Sterile technique is also a top priority with any surgical intervention, whether it be in the office or hospital/surgical center operating room.

Any needle or knife blade used to violate the skin is a pre-packaged, sterile, one-time use instrument.

In the surgical center and hospital setting, sterilization procedures of instruments and equipment used on the surgical field are carefully monitored to insure complete sterility.  I rely on the hospital and surgery center to follow strict protocols in their sterilization procedures.  Although I do not personally get involved in the sterilization process, I have complete trust in the facilities in which I operate in and I would not hesitate to have surgery personally or have one of my family members undergo surgery in these facilities. The two facilities used for my major surgical procedures are St. John Medical Center and Union Pines Outpatient Surgical Center.  Both facilities are accredited by the Joint Commission on the Accreditation of Health Care Facilities which periodically inspects and issues accreditation to these facilities based on multiple standards including sterilization protocols.

For office surgical procedures, we also follow strict sterilization procedures. Similar to the hospital/surgical center, any needle or knife blade used to violate the skin is a pre-packaged, sterile, one-time use instrument. All instruments used for surgery are personally cleaned and inspected by me prior to sterilizing in a
Ritter M9 Ultraclave Steam Sterilization Unit.
For each sterilization cycle, chemical indicators are used to assure minimum sterilizing conditions have been achieved. In addition, periodic biological monitoring is performed using CDC (Centers for Disease Control) and OSHA guidelines.  All functions of the sterilizer are monitored and inspected periodically by a certified technician.

As a board certified surgeon, I make sterility a top priority in any surgical procedure. My goal is to achieve a safe and successful surgical outcome. Despite our best efforts, infections do occur. Occasionally I am asked, "why did I get an infection"?  I wish we knew the answer to that question.  There are multiple reasons that some patients are more pre-disposed to infection. For some patients, their immune system is not strong enough to fight bacterial or viral organisms.  We know that bacteria and viruses are within our body and on the skin. Usually our immune system is good enough to keep these organisms in check to prevent clinical infection. Smoking and nicotine products can compromise blood supply and lead to a higher risk of infection. Previous radiation therapy can compromise blood supply and cause healing issues and infection in a surgical procedure. Diabetes and other disease states put the patient at higher risk for infection. Poor home conditions and hygiene may play a role in certain patients. Certain medications such as steroids can pre-dispose to infection.

If infections occur, many of the current organisms are more aggressive, can cause more tissue damage and scarring, and are more difficult to treat. Culture and sensitivity studies guide us as to the appropriate drug to treat the infection.  Fortunately, infections are rare and usually can be eradicated.

Please feel free to discuss infection issues and ask questions prior to any surgical procedure. Infections complicate your life, but also complicate my life and increases stress levels for both of us. I will do everything within my power to prevent infection!!