The contrived controversy of childhood vaccination

A recent article in Lake Healthy Living magazine (A Healthy Debate About Vaccines, September 2019) suggested that there is a debate about childhood vaccination. The article was, in my opinion, a well-intentioned but misguided effort that misrepresented the issue as a real debate. This is my response, as a physician, father, and grandfather.

If there is a sacred maxim in medicine, it is this, “Primum non nocere”. It means, “above all else, do no harm”. The reality is that doctors harm patients all the time. Not knowingly, not on purpose, and certainly not out of evil intent. It is an inescapable fact that the art and science of medicine are no more or less perfect than any other human endeavor.

A common thread throughout the course of human history had been the presence of illness and disease. Parallel to this has been the constant striving to relieve the suffering derived from these, beginning with the earliest healer or “medicine man” invoking the spirits he perceived and using those plants and animals available to him, progressing to the physician of today armed with the most advanced tools science can provide.

Slow Mohs for melanoma is a bad idea

“Mohs, which stresses taking thin margins, has no place in treating invasive melanoma.”

It is a classic case of a hammer in search of a nail. Slow Mohs surgery for melanoma not only makes no sense, it is a bad idea that compromises treatment of this potentially deadly cancer.

While Mohs surgery still carries the name of its originator, Dr. Frederic Mohs, the technique has evolved from the 1930’s. Even so, the basic premise is the same. Now called Mohs Micrographic Surgery it is still the exclusive purview of Dermatology. The goal of Mohs is to remove skin cancers with clear margins and as little normal skin as possible. It is always done in an office setting. The skin cancer is removed under straight local anesthesia, the patient bandaged and sent out to a waiting room, and the surgeon examines the specimen to assess the margins. If they are clear, the patient returns to the surgery suite to have the site sutured or otherwise closed in some fashion. If the margins are not clear, the patient is brought back, more skin removed, and the process repeats until clear margins are obtained. Each excision stage takes around 45 minutes or so. With Mohs, the average skin cancer requires 1.7 excisions, which means that many require two or more excisions for clear margins.

Until fairly recently, Mohs was confined to non-melanoma skin cancers such as basal cell and squamous cell. These are typically confined to a small area of skin and are only extremely rarely life-threatening. While Mohs has a place in the treatment of skin cancer, I believe that it is sometimes used in situations where it is not the best option.

Recently, dermatologists have begun to perform something called “slow Mohs” for early melanoma cancer. Invasive melanoma cancer, even an early one, is a potentially life threatening condition. Excision is the primary treatment and wide excision, i.e. taking a wide margin of skin around the cancer, is the sine qua non of melanoma treatment.  There is no place for taking close margins, even for the earliest, non-invasive melanoma, melanoma in situ. Mohs, which stresses taking thin margins, has no place in treating invasive melanoma. Even with very early, non-invasive melanoma in situ, the accepted standard is wide margins of no less than 5 mm.

The term “slow” Mohs reflects the fact that the process always takes more than one day. Processing a melanoma specimen takes 1-2 days. Therefore, the patient is sent home with their open wound bandaged and made to return a few days or up to a week later for either closure or yet another excision. One patient referred to me underwent three excisions over the course of three weeks! This is painful and distressing to patients and increases the risk of infection. There is no excuse for this. This is not the case with traditional wide excision.

I spoke to a dermatopathologist who processes a lot of slow Mohs specimens. She is not a fan of the procedure because of the way the specimen is taken and has to be processed. This makes it difficult, if not impossible, to establish the final margin, which is the closest the melanoma comes to the final surgical margin. Let me stress this: the goal of melanoma cancer excision is not to remove it with the smallest possible margin, which is the goal of slow Mohs. It is to remove the cancer with a generous margin, usually deemed to be 5 mm or more. Most slow Mohs excisions take only a 1-2 mm margin. This small difference can be the difference between curing the cancer and experiencing a recurrence, or worse.

Why the recent push for Mohs in treating a life threatening cancer? I believe that Mohs for melanoma reflects a misguided ordering of priorities. The first priority in treating melanoma is to cure the patient. The concern over reconstruction and the cosmetic result are important, but clearly secondary to that critical primary goal. In 1957 Drs. Harold Gillies and D. Ralph Millard, Jr., two of the pre-eminent plastic surgeons of the last century, wrote, “Too often, the general surgeon will ask courteously whether sparing such and such a bit will make the repair easier. He is genuinely trying to help in the repair and forgetting his primary duty. The answer must be, “I couldn’t care less. You remove the malignancy so it does not recur, whatever the deformity, and let me worry about the repair”.

Slow Mohs attempts to force a deadly cancer into the same treatment category as non-melanoma skin cancers, which are not life threatening. Ask any general or plastic surgeon what they think about slow Mohs and you will hear almost universal condemnation of the procedure. Even among dermatologists, slow Mohs is controversial. The bottom line is that it simply makes no sense. I would never allow myself or anyone I know to be treated for any melanoma using slow Mohs.

Downton Abbey and #MeToo

I went to see the new Downton Abbey movie reluctantly. My wife and her friends, all fans of the popular series, set up the evening for our group of five couples. None of the husbands were thrilled but we have all been married long enough to know that now and then you take one for the woman you love. Surprisingly, it was an excellent movie and very engaging (I am not just saying this because I know my wife might read this). There was even one moment of action involving a gun, so it wasn’t all tea and crumpets.

Downton Abbey provides a glimpse into life in a time where women were rather lightly regarded in society. What influence they had was largely in the background, exerting influence on the men in their lives, for example. Several female characters bemoaned their lack of stature, even among the aristocracy. This was not surprising, given the societal norms of the times. What was interesting, though, was the general theme of the movie previews. Two previews were for movies about female empowerment. One was a for a biopic about Harriet Tubman and the underground railroad. The other was about a movie adaptation of the book, Little Women. I am seeing this more and more and I do not think it is my imagination that the theme of women’s empowerment seems to be everywhere. From the U.S. women’s soccer team victory celebration to countless commercials on television, there is a continual thread about women overcoming victimization or societal obstacles to fulfilling their individual destinies. Either implicitly or explicitly, the cause is always male domination and subjugation of women.

What began as the #MeToo movement to address sexual violence and sexual harassment in the workplace has morphed into a general movement of women’s rights and empowerment. It is the women’s liberation movement for the age of the internet and social media. I am not a social scientist or scholar in such issues but I do have an interest in them. I am “privileged white male”. I have an office full of women, I am married to a woman, I have two daughters and a daughter-in-law, and three granddaughters. I try my best to be the best boss, husband, father, and grandfather that I can be. I can say the same for most of the men I know. I am all for women’s empowerment, rights, etc, but this emphasis on promoting this everywhere I look has bothered me and I am not sure why. So, I asked someone.

The person I chose is a close female friend who I know retired relatively recently from a top level corporate job in a very male-dominated engineering environment. I asked Susan what she thought of all the recent media emphasis on women’s empowerment. Her answer surprised me.

Susan feels insulted and marginalized. She said that it is as though all of her decades of hard work, and that of her peers in the business/technical world to overcome male barriers to advancement and acceptance were for naught. Susan dealt with discrimination, sexual harassment, not being taken seriously, making less than her male peers for the same work, covering for less than competent male co-workers. She overcame those to become a senior executive. She said that, over the years, she saw major changes in the workplace such that she feels that, today, there are no real barriers to women being as successful as they choose to be and are willing to work for. She challenges the premise that there are male dominated, systematic, societal rules in play to hold women back.

I look at my own field of medicine. Today, women make up just over 50% of all medical students in the U.S. In the corporate world, the numbers are less impressive, with recent reports that only around 6% of CEO’s of Fortune 500 companies are women. Many explanations have been given, nearly all based, at least in part, on the premise of some form of gender discrimination. One different explanation, proffered by no less than Dr. Jordan Peterson, a clinical professor of psychology at the University of Toronto, boils down to this: women are not willing to be the disagreeable, aggressive type or make the sacrifices necessary to become a CEO at this elite level. He does not feel it reflects either female weakness or male privilege.

An interesting assessment of the #MeToo movement for general female empowerment was provided by Heather MacDonald, an attorney and fellow at the Manhattan Institute, an economic think tank. In her words:

#MeToo is going to unleash a new torrent of gender and race quotas throughout the economy and culture, on the theory that all disparities in employment and institutional representation are due to harassment and bias. The resulting distortions of decision-making will be largely invisible; we will usually not know of the superior candidates for a job who were passed over in the drive for gender parity. But the net consequence will be a loss of American competitiveness and scientific achievement.

She goes on:

“Pressures for so-called diversity, defined reductively by gonads and melanin, are of course nothing new…….however pervasive the diversity imperative was before, the #MeToo movement is going to make the previous three decades look like a golden age of meritocracy. No mainstream institution will hire, promote, or compensate without an exquisite calculation of gender and race ratios.”

The sordid Weinstein, Spacey, Epstein, and Lauer episodes that appear to have fueled the #MeToo movement are sad, sorry tales of abuse and victimization of women by serial abusers, but they are aberrations and not representative of men in general. To paint us with the same brush is unfair to all the men who have championed women and never victimized anyone. To further expand these isolated incidents of sexual harassment to represent the state of women in the workplace today is a stretch and unfair to women who persevered and changed the culture. It perpetuates that cult of victimization which, I feel, is definitely pervasive in the U.S. today and ignores all the work of women, like Susan, who came before.  

Oscillo (Oscillococcinum) for Flu

The Jokes on you

Flu season 2019 is upon us. Trust me, you don’t want to get the flu. By that I mean the Flu, influenza virus, i.e. the real flu, not simply a winter cold. The flu is a cold on steroids. It is to a cold what King Kong is to a gorilla. It can kill you. I have had the flu. There were moments when death almost seemed preferable to the misery of high fever, pounding headache, every muscle aching, even your skin painful.

I believe in vaccinations. Are they perfect? No. Can they cause side effects? Yes. Are they 100% effective? No. Do they work? A resounding yes. I get my flu vaccine every year. Everyone should, especially health care workers and those working around more vulnerable populations, such as children, elderly, and the sick.

Oscillo at Walgreens. Just $33.99 for 30 pills. You will notice the left slot is sold out.

If you experience the onset of flu-like symptoms- fever, chills, achy muscle, headache, cough- oseltamivir (Tamiflu) has been shown to be effective in reducing the severity of symptoms and cutting down the duration of the flu by 1-2 days. It should ideally be started within 24 hours of the onset of symptoms. If taken after 48 hours of onset of symptoms, it won’t do much good.

Among over-the-counter formulations for flu, arguably the king of the hill is Oscillococcinum, or Oscillo, with $18 million in sales in 2008, the last year for which I could find figures. It is the No. 1 over-the-counter drug for flu in Europe. This is a medication manufactured by the  French company, Boiron. Like Oseltamivir, Oscillo claims to reduce “the severity and duration of flu-like symptoms”. That is where all similarity ends. Read on and laugh (or not) with me.

The first part of the joke that is Oscillo is in the name. It comes from oscillococcus, a bacterium “discovered” in 1925 by a French physician, Joseph Roy. He examined blood from victims of the Spanish Flu of 1917 and saw “oscillating” bacteria, to which he attributed the flu, as well as other diseases later proved to be viral. The joke is that oscillococcus doesn’t exist. Never did. It is a made up bug. https://www.homeowatch.org/history/oscillo.html

How did an imaginary bacterium came to be used to treat the flu? Roy proposed that his bacterium caused a host of conditions in addition to the flu, including cancer, scabies, syphilis, and tuberculosis. For reasons that are unknown, he chose as his source of oscillococcus for his medication, the heart and liver of Muscovy ducks. In a coincidence that could make you believe the universe has a sense of humor, it turns out the reservoir for Avian (bird) influenza A is largely in wild ducks. You just can’t make this stuff up. As they say, even a blind squirrel finds a nut now and then. Could it be that Roy inadvertently stumbled onto a treatment for flu, somewhat like Fleming’s discovery of penicillin?

The punch line of this medical joke came when homeopathy entered the picture. Never ones to let facts or science stand in their way, practitioners of homeopathy continue to cling to the delusional ideas of their founder, Dr. Samuel Hahnemann, a German physician, in 1796. Yes, you read that right. 1796. Hahnemann’s two key concepts were that “like cures like” and the law of “minimum dose”. The first means that to cure an illness, you administer something that produces similar symptoms in healthy people. To cure a fever, you give something that would make a healthy person feverish. To treat abdominal pain, you use something that causes abdominal pain. And, so on. “Like cures like” has never been proven and there is zero scientific support for it. Period.

The second is the law of minimum dilution, i.e. the more dilute a medicine, the stronger it is. Minimum dilution would be funny if people did not take it seriously. Homeopathic medications are formulated based on a system of dilution. A 1C dilution means that the medicine is diluted 100 times. To make a 2C dilution, you take that final product and dilute another 100 times, and so on. By the time you get to a 13C dilution, this would be equivalent to one drop of a substance in all the water on earth. Boiron’s Oscillococcinum is diluted to 200C. This would equate to one molecule in the known universe! In simple, chemical terms, Oscillo is plain water.

Homeopaths get around the fact that their medicine contains not a single molecule of the original substance by claiming that the water retains a “memory” of the substance. I don’t have adjectives suitable to do justice to how ridiculous this is. If you believe this, you will believe anything.

How does a medication based on an imaginary germ, diluted to the point where not a single molecule of the original preparation remains become a popular medication to treat the flu over, not years, but decades? Even more remarkable is that several reviews that I pulled up gave it 5 out of 5 stars! There is no explanation other than the triumph of faith over reason or perhaps the power of placebo. It has to one of the greatest jokes played on the public in medical history, a real thigh slapper. At $1 per pill, Oscillo’s Boiron must be laughing all the way to the bank.  

The shot heard (not quite) round the world

Money talks and, at up to $2500 per patient, it practically shouts.

No, this isn’t about the historical gunshot in Lexington, Massachusetts that marked the start of our revolutionary war of independence. I am referring to a shot much less revolutionary and much more controversial: the O-shot for women. What’s that you say? What is the O-shot?

If you are a woman and watch television, read women’s magazines, or access social media, you have probably come across the O (for orgasm)-shot. It is the brain child of Dr. Charles Runels, an internist with an extensive, somewhat checkered, resume best known for his use of platelet rich plasma (PRP) for everything from facial rejuvenation, also known as the Vampire Facelift, to enhancing sexual responsiveness with the O-shot and its male equivalent, the P (for priapism or penis)-shot.

The O-shot involves taking a woman’s own blood, spinning this in a centrifuge to isolate a small fraction of plasma with a high concentration of platelets, then injecting this into the clitoris and “G-spot” (anatomists and physicians still doubt the existence of this mythical spot which has never been pinpointed). Why platelets? Platelets are tiny fragments in the blood that play a crucial role in blood clotting. They are not true cells, lacking some fundamental structures, like a nucleus. They contain a great deal of growth factor hormone and this is supposed to be the source of their therapeutic properties, some of which sound a little too good to be true.

The goal of injecting PRP into these highly sensitive, erogenous areas is to enhance responsiveness in achieving an orgasm , as well as stronger orgasms. How does it do this? Well, no one really knows. You see, there are really no studies to determine how the O-shot works, or whether it truly works at all. In theory at least, the O-shot increases blood flow to the area and “regenerates” the tissues. “Regenerate” as used here sounds suspiciously like a weasel word; it sound great but means little without further explanation.

Clinical use of PRP is analogous to the use of stem cells. Both are supposed to have amazing regenerative effects but no one knows how they work, or how best to use them. While the science of both is intriguing and, in some cases, promising, the promotion and marketing of these products for a dizzying array of purposes has far outstripped the science and proof of efficacy in nearly all cases is lacking. That has not dissuaded practitioners like Runels and the many who have followed in his footsteps, paying him for the use of his trademarked “O-shot” label. Money talks and, at up to $2500 per patient, it practically shouts. How long the effect lasts is variable but is on the order of eight months to a year or so. Like Botox, the O-shot must be regularly repeated.

It is disconcerting how many supposedly legitimate gynecologists and other practitioners have leaped onto this particular bandwagon. When I Googled “O-shot”, I came up with 1.67 BILLION results!! Scrolling through the first few dozen pages of results to find unbiased articles in the mass of hits for practices extolling its virtues and offering the procedure, was like looking for the proverbial needle in a haystack. I did find one on the website for the National Center for Biotechnology Information (NCBI) of the National Library of Medicine, a usually reliable database. This was submitted by a pair of Egyptian gynecologists who appeared to accept the claims of the O-shot uncritically, drawing their conclusions from Runels himself. This isn’t science. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6030616/#B45

I have to hand it to Dr. Runels. Many promoters of questionable medical treatments are loathe to undergo those treatments themselves. Not him. He began by injecting his own penis with PRP  around 2010 and, as the story goes, the results were so impressive that his sexual partner insisted that he inject her and share the wealth. Reportedly, both reaped the benefits of explosive post-treatment sexual performance. Voila, the O-shot was born. Medicine advances in mysterious ways.

What about all the positive reviews from former patients? As I have repeatedly said, testimonials are an unreliable and unscientific way to assess medical treatments. This goes double for online reviews. For one thing, positive reviews ignore the large role that the placebo effect may play, especially in something which is as much mental as it is physical. For another, I suspect women for whom the O-shot doesn’t work are going to be slow to admit they wasted thousands of dollars on an unproven procedure. Despite claims that the O-shot is painless, with near immediate results, I have read several reviews of painful injections followed by painful swelling and tenderness for weeks afterwards. Procedures which claim near universal success with no downside make me skeptical as few invasive procedures, especially in an area so charged with psychological, psychosocial, emotional, relational, and sexual overtones, are so uniformly effective. In addition to its supposed sexual benefits, the O-shot is also touted as a treatment for urinary stress incontinence and certain vaginal conditions, such as lichen sclerosis. Again, there is little support for this from reputable studies.

Jen Gunter, MD

One staunch critic of Dr. Runels and the O-shot is Dr. Jen Gunter, a Canadian obstetrician/gynecologist and pain medicine specialist who takes Runels and his O-shot to task for failing to offer any data supporting the claims made for this procedure. She has uncovered a number of disturbing facts from his past, which are readily accessible. https://drjengunter.com/2017/11/26/the-troubling-backstory-behind-the-o-shot/ In 2009 he was disqualified as a clinical investigator by the FDA for injecting vulnerable subjects with an unnamed vaccine without approval for this from an institutional review board, a requirement for just about any study involving human subjects. The subjects in this case were homeless persons from a local shelter. https://www.fda.gov/media/75937/download

Also in 2009, he was fined $5000 by the Alabama State Board of Medical Examiners for misuse of hormone replacement therapy in two women and was restricted from prescribing hormones for two years. In addition, Dr. Gunter raises ethical concerns about Runels’ experimenting in the manner described above using his sexual partner, which appears to be a breach of the doctor/patient relationship according to the American Medical Association’s Code of Medical Ethics Opinion 9.1.1.

The topic of orgasms is one guaranteed to generate great interest. Given the poorly understood and often elusive nature of the female orgasm, it is not surprising that many women uncritically seek out methods to achieve what they believe they are entitled to and, for whatever reason, are not getting. Even for me, as a physician, it was difficult to sort through the hype from legitimate information regarding the O-shot. I fear what it will come down to is that women have to decide who is the more credible, Dr. Runels or Dr. Gunter. I know who I would choose.

Confidence is wonderful…until it becomes overconfidence.

“It ain’t what you don’t know that gets you in trouble; it’s what you know that just ain’t so.”

Samuel Clemens

I am going to make some generalizations here. As with all generalizations, there are exceptions, but I believe my premise holds true enough to be valid.

The trajectory of medicine seems hellbent on lowering medical care to the lowest common denominator. More and more medical “professionals” are entering the arena, claiming enough education and experience to provide treatment independent of physicians. These include nurse practitioners, physician’s assistants, pharmacists, optometrists, and will doubtless include evermore para-medical professionals. Think EMTs, massage therapists, etc. This doesn’t even include such fringe practitioners who already promote themselves as alternatives to physicians, e.g. homeopaths, acupuncturists, reflexologists, Frankhauser manipulators, and a veritable army of “alternative” medicine providers. Every legislative session in state and federal government seems to include one or more bills related directly to expanding the “scope of practice” of a non-physician group.

One example of this is the expansion of vaccinations to pharmacies. Pharmacists do not receive any training in direct patient care. They don’t learn how to treat patients or manage complications of treatment. They go through a training program that involves self-study and learning the mechanics of performing an injection. You can train anyone to give injections; children with diabetes learn to give themselves insulin shots. The problem is that once you give pharmacists license to evaluate patients and autonomously dispense vaccines, it is a pretty short hop to evaluating patients and writing prescriptions themselves. Pharmacists have worked well with physicians for generations. Seeking autonomy now, makes little sense.

A recent experience was telling. I had to get the diptheria/tetanus/pertusis (DTaP) vaccine for the impending arrival of my newest granddaughter. For expediency, and out of curiosity, I went to my local Walgreens for this. After a short wait, I was ushered into a small room with a young pharmacist who was clearly nervous. No history was taken, no inquiry as to allergies, no blood pressure or vital signs. When he performed the injection, he expressed surprise that so little material was injected and examined the syringe for, I suppose, any defects. The vaccine volume was 0.5 cc, a minute amount so this was perfectly expected but it clearly surprised him. I walked away with little in the way of increased confidence in this avenue for vaccinations.

Physicians, the most highly educated, trained, and experienced medical professionals are no longer directing medical care. We are being bypassed and disenfranchised largely by legislators, many of whom take positions based, it seems, largely on who has the most effective lobbyists or provides the greatest number of potential voters. The ship of medicine will soon no longer have a captain, only a bunch of sailors, each claiming autonomy to sail on their own. I believe this is a recipe for disaster.

The common denominator among non-physician providers seems to be a high level of confidence they can provide medical care as well, and often better than, physicians. Is this confidence merited? Perhaps, in some situations; certainly not all. Time will tell. Unfortunately, patients, which includes everyone of us, will be the guinea pigs in this massive medical experiment. It behooves us to appreciate and consider the DunningKruger Effect.

https://www.bosshardtandmarzek.com/blog/confidence-is-overrated-the-dunningkruger-effect.html

Medicaid- the failed promise of Obamacare

“It is health insurance by sleight of hand”

Like many social programs, Medicaid, government subsidized health insurance for the indigent, was based on the laudable premise that the poor deserve good health care. Its implementation, however, has been less than stellar. In fact, I and half of my physician colleagues consider it a failed program. To us, having Medicaid is very much like having no insurance at all. I don’t really care if my staff file Medicaid claims. I know that when I see a Medicaid patient we will have to battle for payment and, when it comes, it will not cover my costs of practice for that care. It is less hassle to see them for free.

You see, I am in the trenches, seeing patients every day. Medicaid is not an abstraction; I deal with it constantly. It is telling that on Medicaid forms I am not a physician; I am a “vendor”. I do have one luxury. I am not a family physician, dealing with all comers. As a specialist, I am not called on to see many Medicaid patients. When I do, it is usually for an emergency situation. In those, insurance is moot since I will care for any patient regardless, if they are in urgent need. Most of my colleagues do the same. It is what we do as physicians. For elective care, it is different. Let me give you an example.

The most common problem for which I used to see Medicaid patients electively was for breast reductions. Large breasts are a legitimate medical problem, causing all sorts of misery to women who possess them- constant back, neck, and shoulder pain; rashes; nerve issues in their arms; limited ability to engage in physical activities, and social embarrassment. My breast reduction patients are probably, as a group, my happiest patients after their surgery. Because Medicaid paid so poorly for breast reductions, although I saw their patients for this problem, I had to limit it to no more than one or two a month. Most physicians who will see Medicaid patients ration how many they will see in a given period.

Some have opined that physicians have an obligation to see Medicaid patients and that not doing so is a breach of our responsibility as physicians. https://www.statnews.com/2017/12/28/medicaid-physicians-social-contract/ I counter by saying that a practice made up largely of Medicaid patients is likely not sustainable. Medicaid pays two thirds of what Medicare pays for care and many physicians regard Medicare as too low given all the costs of medical practice these days, costs which only seem to grow year by year. No, physicians aren’t starving but we are working harder and harder for less and less pay and physician burnout rates have skyrocketed. https://www.ama-assn.org/practice-management/physician-health/what-should-be-done-about-physician-burnout-epidemic

My typical Medicaid breast reduction patient was both obese and huge; these were the largest breasts I saw, and the most difficult to reduce. One day, I was interviewing a patient and noticed that she came from Jacksonville, FL, over a three hour drive away. I asked her why she had driven so far to see me, bypassing literally dozens of plastic surgeons. Her answer shocked me. She said I was the only plastic surgeon within a three hour drive who would see Medicaid patients for breast reductions.

This led me to reflect on what I was doing by accepting Medicaid’s terrible reimbursement and constant battle to obtain payment in a timely fashion. Medicaid professes to be full insurance. So long as even a single plastic surgeon in the state accepts Medicaid’s payment for breast reduction, Medicaid can claim this as an offered service, even if patients have to drive hours to see a specialist. By participating, I was perpetuating the charade that Medicaid truly provided this service. That was the last time I accepted a Medicaid breast reduction patient.

This is the little known lie of Medicaid. Yes, patients on Medicaid have “medical insurance” but they will have difficulty finding participating physicians, wait long periods to be seen, and have to drive long distances. The last can be difficult for indigent patients if only for the cost of gas. A 2017 survey found that only 50% of physicians accept Medicaid patients and wait times are on the order of a month for new patients. It is eerily similar to what I saw in Venezuela. The government claims to provide all citizens with universal health care however, when you try to obtain health care, you cannot find a doctor, hospitals are bereft of necessary supplies, and patients find themselves without recourse. It is health care in theory, not fact.

When I heard that expansion of Medicaid was one of the central tenets of Obamacare, I could hardly believe it. This is what you get from politicians to whom something like Medicaid is an abstraction, all the while providing themselves with arguably the best health insurance on the planet. Medicaid as the answer to the uninsured is a sad, sick joke and those who uncritically promote this are either clueless or, worse, disingenuous. It is health insurance by sleight of hand: now you see it (when you sign up), now you don’t (when you need it).

Tha’rs mold in them thar hills

Is mold toxicity the new cash cow for unscrupulous practitioners?

Mold, fungi, yeast. They are literally everywhere. Yeast are so ubiquitous that you can make sourdough bread starter just by leaving some warm water mixed with flour out in the open for a few days. Yeast from the environment will populate the liquid and ferment the flour. Likewise, mold and fungi are found anywhere there is a dark, mildly humid environment. This has not changed from time immemorial.

What has changed is that now we are blaming all sorts of ills and medical problems on these universal agents. All manner of symptoms are blamed on exposure to “toxic” mold. Take your pick: cough, nasal congestion, skin irritation, wheezing, fever, muscle aches, joint pain, asthma, shortness of breath, headache, confusion, “brain fog”, depression, fatigue, sleep disturbances, and much, much more. Even cancer and death have been attributed to mold exposure.

In medicine, we have known for decades that in some instances patients may become ill from a variety of molds and fungi. Few are pathogenic (disease causing) on their own. Most are what we call opportunistic, i.e. they take advantage of an already compromised individual. In almost all instances of infection, the patient is already ill or has some other reason to have a weakened immune system. Patients with cancer, HIV/AIDS, transplant patients on anti-rejection drugs, and those with chronic illnesses are susceptible to molds and fungi that would not make a healthy person sick.

Thinking long term is not a strong suit of the young

Thinking long term is not a strong suit of the young

Among the controversies surrounding breast implants, and there are many, is the claim that many patients are not fully informed about the risks and limitations of the surgery, both immediate and long term. It is true that some surgeons gloss over risks or underplay them but I, and many, if not most, of colleagues try to properly inform patients regarding the good and the bad of the surgery. One problem is that many young women do not seem to want, or be able, to really think long term when it comes to breast implants.

My typical cosmetic breast augmentation patient is a young girl anywhere from 19 to late twenties, but the range is from 18 (I won’t do anyone younger, and really don’t like doing augmentations in patients this young except under unusual circumstances) to 60’s. The older the patient, the more comfortable I am, up to a point. I like the maturity of older women, the different perspective that life, having babies, being married, being in the working world, etc. brings them. I am more confident that they will listen to me and really consider what I tell them about implants. I worry less they will approach the operation with rose-colored glasses.

I start every consult the same way. I say something along these lines, “If you forget everything else I say, remember this. Breast augmentation takes your natural breast, that you are dissatisfied with, and does something to it that is both unnatural and irrevocable. It cannot be totally undone. It sets you on a path that is unpredictable. No one can say for any individual exactly what time and circumstances will do to them, their breasts, or their implants.”

Young women seeking breast implants face decades with a man-made medical device in a very important, sensitive part of their body which not only changes for all sorts of reasons over time but is also the site of the most common solid cancer in women. The lifetime risk for breast cancer in any woman is a scary 8-10%. Breasts will change, with weight gain or loss, from pregnancy and breast feeding, from the long term effects of aging and the pull of gravity. Breasts with implants are subject to all sorts of unique changes; some occur so gradually that big changes over time may go unnoticed. Implant pockets can contract or, conversely, stretch over time. Implants can shift too far every which way. There is no way to predict which women will experience particular changes.

I have had older women come to my office who basically have hard rocks on their chest and seem surprised when I tell them their breasts are too firm. Some are now second guessing their decision of decades earlier to get implants and a few tell me they were never informed that they might experience problems later in life.  

I try to prepare patients as well as I can. I really do. I tell them all of the above and more. I tell them implants are not expected to last a lifetime and that they almost certainly face at least one more operation someday, at their cost, to deal with issues directly related to having implants. Easily more than half of my consult time is spent on the risks and complications of implants.

I often wonder what my patient hear when I discuss risks of surgery

With many young patients, I cannot help but wonder if they really hear me or pay attention. Many to come to my office with their minds already made up. A few even have their date for surgery scheduled before they ever see me. I really cannot recall an instance where I talked a young patient out of a breast augmentation. Often, I see my consult going something like this:

Me: “If you get breast implants now, you will have bigger breasts but you will be subject to all the risks of implants for as long as you have implants. ”

The patient hears: “Blah, blah, blah, implants, blah, blah….bigger breasts, blah, blah…..implants…….”

I even have an 8 page, single-spaced, typed summary of my consult that I give patients to review but I wonder if even this makes them think long term.

Many things make me believe that a lot of young women really do not think long term. Tattoos are one. I see more and more attractive young women that are tatted to beat the band. Did they consider that those brilliantly colored, sharp tattoos on taut skin will someday be faded, blurred blotches on wrinkled skin? Do they consider how it might limit them professionally someday?

Another area where I wonder how much consideration is given to the long term is the Brazilian Butt Lift. A disturbing number of young women are allowing their buttocks to be injected with sometimes astounding amounts of their own fat, sucked from some other place. They seek the Kardashian, Minaj, JLo bubble butt derriere seemingly without a thought of what time and gravity will do to that to those massive man-made mounds. Looking good today, whatever current fashion seems to dictate that to be, seems more important than taking the long view and considering consequences.

I, like most plastic surgeons, feel that breast implant surgery is a legitimate surgical option for women seeking more breast fullness, to correct other problems, e.g. assymetry, or to reconstruct a breast. So long as patients are properly informed and understand the downside as well as the upside of surgery, there is no reason not to offer this procedure. A number of women with implant problems claim they were never properly informed.

That’s one of the fallacies of “informed consent”. We can talk all we want to patients but we really never know how much of what we are saying they hear, understand, or take into consideration in their deliberations. We don’t know what they will recall of this discussion decades later. No one thinks the bad things will ever happen to them….until they do. All they see is a goal- full, beautiful breasts- and fail to see all the pitfalls and obstacles to obtaining that with our imperfect technology, techniques, and devices. They don’t look down the road a decade or two, or three, and try to imagine what they might have to deal with as a result of having implants now. When it comes to breast implants, living in the present is something the young seem to be very good at. Thinking decades down the road, not so much.

The Adventure Continues

I have been blogging for several years, first on a blogspot blog that I opened up and used for my own amusement. For a while, I was one of the founding members of the Orlando Sentinel blog site, Hypeorlando, and used that as my soap box after my weekly column in the Sentinel, which had run on Sundays for nearly 25 years, was shut down due to the continual contraction of printed newspapers.

Now, I have taken the plunge, well and truly. I have obtained my own personal domain, rtbosshardt.com, along with a WordPress blog. I have put my money where my mouth (or pen, or whatever you call it in these electronic days) is, to the tune of a whopping $108 for a two year commitment. Now, I confront the most daunting challenge any writer can face- an empty page. What do I have to say that is worth the reader’s time to read? Time will tell. I hope you will join me on this next adventure. It will be interesting to see if I fly, or crash and burn. Either way, it should be entertaining.

R. Bosshardt