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