Max Cleavage: A Wonder-bra on steroids

"I'll boost your boobs or go bust!"

It's a bold claim, but British bra-maker Emma Clark has come up with an interesting line of bras and swimwear to one-up the Wonderbra for non-surgical cleavage control under the banner of Max-Cleavage. Using a clever selection of gel padded (as opposed to foam) bras, swimsuits, and blouses Ms. Clark has created some real buzz in the fashion industry.

Dissatisfied with the trusty Wonderbra which she says,“In my experience, they simply push up what little bust you do have to the middle of your chest and leave this void at the side." That's an interesting and astute observation.

Another bra is being marketed specifically for the post breast augmentation breast under the pretentious label, "Le Mystere No 9". I've never really thought about a need for this, but they make the point that

"Augmented breasts often have more projection and wider cleavage than natural breasts. Because breast implants are ideal for women with narrower rib cages, high profile implants require more depth in the bra cup. The center gore of traditional bras is too narrow for breast implants and causes poor fitting and loss of support."

I'm not quite sure if I buy this logic the way I think about breast augmentation. The "width" of cleavage is determined by the attachments of the underside of skin to the peri-osteal tissue covering sternum (breast bone) and is also defined somewhat by the medial attachments of the pectoralis major muscle when implants are in the sub-muscular position. Implants themselves do not make cleavage wider unless the lateral dissection is overdone, stretched, or expanded from the contraction of the pectoralis major muscle. Saline implants in the sub-muscular position are notorious for gradual lateral drift.

I tell patients to be wary when asking about whether or not your can narrow one's cleavage. You certainly can do it, but it is an ill-advised manuever. Once those natural attachments are lost, control of the space around an implant can slip out of your control. Uncorrectable deformities, including synmastia, the"uniboob" deformity, can result from over aggressive dissection towards the midline, particularly when the implants are in an "over the muscle" (subglandular) position. Pictured at right is a patient with synmastia.

Rob

Louisville's Top Docs

I'd like to take a minute to thank some of my mentors in Surgery and Plastic Surgery from Louisville, Kentucky who've been recognized in Louisville Magazine's September "Top Docs" issue. I could personally name about a dozen others who were at least as good as some mentioned in various specialities (they have like 15 categories listed) but I didn't see anyone listed among the people I worked with who didn't belong.

From my Plastic Surgery years I had the privilege of working with honorees:

• Dr. Brad Calobrace


• Dr. Mark Chariker


• Dr. Gerry O'Daniel


• Dr. Luis Scheker


• Dr. Mort Kasdan


• Dr. Amit Gupta - Hand Surgery

From my "former life" as a General Surgery trainee I noticed these Doctors singled out as well:

• Bob Linker - Thoracic & Vascular Surgery


• Steve Self - Vascular Surgery


• Tom Bergamini - Vascular Surgery


• Russ Williams - General Surgery

Each of these doctors are truly some of the best of the best. One interesting thing you get to see during training is the wide variations in skill or technique, and I got to personally work with well over 100 surgeons during my nearly decade long series of residencies. During my Plastic Surgery alone it was almost 40 different doctors. I've always told people that if you have a loved one injured and they end up in one of these large trauma centers with training programs, that you should find out who the chief resident is and ask "off the record" which attending physicians they would want (or not want) taking care of them or their loved ones. They usually know the inside info on these things.

Rob

Breast implant deflation attributed to a hornet sting

I've featured a couple of unusual things over the last year which have reportedly caused implants to rupture. Who can forget the the implant that deflected rocket shrapnel , the implant's acting as an airbag, or the images of the Marlin harpooning the fisher-woman on video last year?

I'm not sure I believe this at face value, but there's a story in China that reports a woman's saline breast implant was punctured by a Hornet sting.

From the China Post

Dr. Tseng Ting-chang said a 31-year-old woman who received breast implants three years ago visited his clinic early this week complaining that one of her breasts had deflated after a hornet sting a couple of days before. The woman said the incident took place while she was riding a scooter in the countryside,whilst wearing a low-cut dress.

She took the sting in stride at first, but later was astonished to find that one of her breasts had shrunk a couple of days later. Dr. Tseng said he found saline from the woman's breast implant had leaked, apparently due to the hornet's sting. He said the woman had to undergo surgery to reconstruct her breast. Noting that the woman is quite thin and has little fat tissue under her skin, the doctor said it is possible the hornet's sting could have pierced the saline-filled sack, which is touted as being able to withstand pressure of up to 200 kilograms per square centimeter.

Must have been one of these Japanese "Yak Killer" hornets (native to Japan & Asia)which can be over 2 inches long and possess acidic venom which can dissolve human tissue ,and is strong enough to "kill a Yak" according to local folk-lore. See "Hornet's From Hell" at National Geographic. The venom is notably painful and was described by one entomologist who been stung as being akin to "a hot nail through my leg". An estimated 40 deaths annually come from these stings in Asia.


Below is a 9600x magnifiction of a hornet stinger on Electron microscopy.


For an interesting blog featuring unusual bugs check out this. It's cooler then it sounds!



Now a woman's skin flaps after mastectomy and implant reconstruction can be thinned out from tissue expansion, particularly in thin women who have little residual subcutaneous fat. Most implant reconstructions have the implant placed beneath the pectoralis major muscle, which can add up to 1 cm thick padding. Assuming the average male hornet (unlike the average male human) doesn't exaggerate the size of his stinger, they tend to run about 6-8 mm long according to my homework. It would take a forceful sting to reach a submuscular implant, and even then I'm not sure it would be able to actually pierce it.



Rob

Welcome to the "5th dimension" of breast implants

There's a great primer (for those interested) that can be read here at Plastic Surgery Products Magazine on how surgeons approach and analyze all the processes and steps that go into getting the best results and least complications with breast augmentation procedures.

It's written by my friend and mentor, Dr. Pat Maxwell, who knows as much on this subject as anyone on the planet. I think it's worth paying particular attention to his description of "biodimensional" principles, a now wide taught concept he pioneered. Another interesting thing Dr. Maxwell outlines is to look back at the sequential stages in implant development to see what went wrong (thin shell/thin gel designs in the 1970's) all the way to the sophisticated manufacturing of current and future devices. The engineering and computer modeling of implant designs is indeed impressive.

First Generation (1962-1970)
Thick, two-piece shell
Smooth surface with Dacron fixation patches
Anatomically shaped(teardrop)
Viscous silicone gel
Second Generation (1970-1982)
Thin, slightly permeable shell
Smooth surface (no Dacron patches)
Less viscous silicone gel
Third Generation (1982-1992)
Thick, strong, low-bleed shell
Smooth surface
Round shape
More viscous silicone gel
Fourth Generation (1993-present)
Thick, strong, low-bleed shell
Smooth and textured surfaces
Round and anatomically shaped
More viscous (cohesive) silicone gel
Fifth Generation (1993-present)
Thick, strong, low-bleed shell
Smooth and textured surfaces
Round and diverse anatomical shapes
Enhanced cohesive and form-stable silicone gel
* In accordance with technical parameters established by the ASTM.

Fifth generation devices will hopefully be available late this year or early 2008. While not useful in all scenarios, they offer significant advantages in breast reconstruction and in primary (initial) breast augmentation procedures.

Medicare announces they won't pay for complications - How the F*** is this going to work?

Something dramatic is about to hit health care practices in the United States. The Federal government has announced regulations such that Medicare and Medicaid programs will not pay hospitals for the costs of treating certain “conditions that could reasonably have been prevented.”.

This list will apparently include:

• Injuries from falls in the hospital
• Urinary tract infections
• Surgical Site infections
• Blood transfusion reactions
• Re-operations for retained surgical instruments
• Bedsores and pressure ulcers
  

While no episodes of any of these events is the goal of medicine, it is IMPOSSIBLE to achieve that for a number of reasons. Consider the inpatient population in many locations - older, more obese, more medical co-morbidities, etc....

Only a bureaucrat who's never worked in a hospital could think up a program that's all stick and no carrot to address these. It makes more sense to reward achieving benchmarks rather then to punish oft impossible goals. But even the "carrot" from the feds is usually rotten, as can be witnessed by their attempts to establish similar outpatient medicine practice guidelines under the concept of "pay for performance".

To offset planned medicare fee cuts, they recently had a small trial offering a small 1.5% bonus for compliance with electronic medical reporting and some clinical issues. At the end of the trial, almost none of the large primary care groups could meet the threshold for the bonuses despite spending substancial amounts of capital to upgrade infrastructure to do it. While quality may have been improved, these groups essentially took pay cuts to do it. Does that sound like a program which is going to get much enthusiasm for participating?

WARNING: Trainwreck ahead!

What's going to happen in the real world with the new program as I envision it?

There's going to be not so subtle exclusion of high risk patients from inpatient treatments whenever possible. There will also be tremendous pressure for hospitals to dissociate themselves from physicians who bring older, sicker patients to their facility. Also expect to see lots of dodgy urinary tract infections and phantom pressure sores documented on admission surveys, as apparently making a paper trail will shield hospitals from being left holding the bag.

This whole thing is going to get really ugly as these predictable responses occur. Just look at a report like this report which documents a 40% reduction in complications in specialty Orthopedic hospitals which cherry-pick healthy patients and tell me that the take home message isn't to avoid sick patients! Want to make your catheter-related UTI rates better? Just don't put catheters in elderly patients and let them pee on themselves constantly. That's going to happen, WRITE IT DOWN!

Still not clear to me is what happens to Physicians who treat such complications. Will a Doctor get paid for treating a pressure sore or fractured hip from a fall? You don't even want to imagine the practical fallout from that scenario. I'll be looking forward to that report (scheduled to be released tomorrow) with interest.

A distinction WITH a difference-news story on patients upset with non-plastic surgeons mistakenly featured a non plastic surgeon

I saw a local Dallas new station segment on Plastic Surgery that was unintentionally ironic.

It is introduce with the statement that

"It's a nightmare situation. You've had Plastic Surgery and you don't like the results.....With rapidly rising number of physicians starting to call themselves Plastic Surgeons, (patient)complaints are starting to jump."

The segment features a Dallas doctor doing re-operative surgery on on a woman who 6 years prior, had cheek implants, eyelid surgery, and a brow lift performed and was unhappy. The doctor, takes a not too subtle swipe at how "other Dallas surgeons" don't understand facial aging and aesthetics and have been doing surgery wrong for years.



For some context, you have to understand that Dallas, Texas has some of the heaviest hitters among Plastic Surgeons in the world for facelifts and related procedures. (see my post "Cities known for certain Plastic Surgery procedures" from last spring) Dallas surgeons like Fritz Barton, Steve Byrd, Sam Hamra, Jack Gunter, Rod Rohrich, and others have literally rewritten parts of the vocabulary for understanding the aging face and how to address these changes surgically. Now there's a lot of ways to skin a cat (or rejuvenate a face in this instance), but you dismiss your forebears collective experience at your own peril in Plastic Surgery.

Back to my point! What's the irony of the story about consumer confusion on Plastic Surgery?

The doctor featured isn't even a Plastic Surgeon!

He's an ENT (ear, nose, & throat) surgeon who did not train in Plastic Surgery, but did a loosely regulated apprenticeship with other ENT's in "Facial Plastic Surgery". This type of ENT practice is not equivalent in either training or scope of practice, and most of these fellowships have evolved into tagging along with a cosmetic surgeon rather then actually something resembling training in the full scope of head & neck plastic surgery which is implied by the title.

There is no real standardized curriculum for facial plastic surgery training (as there is for Plastic Surgery) and you can still actually become certified in "facial plastic surgery" without any formal post-graduate training by just submitting a case-log and taking a test if you trained in ENT. I believe that most Plastic Surgeons feel it is a degree not worth the paper it's printed on, but that there's not much that can be done about it (it was actually challenged in court many years ago, but the decisions established that the term "plastic surgeon" could not be trademarked by the American Board of Plastic Surgery).

This in no way means such guys can't do cosmetic surgery well in many instances, but it is just another example of how such titles can confuse and blur distinctions that most patients (and apparently news media) are taking for granted.

Another brief comment on breast implants and suicide rates

The image at right is by artist Sheila Chambers entitled "Before Suicide"

It's funny the way the media seizes on medical issues sometimes. In late July, another analysis of suicide rates among breast augmentation patients was published and it generated enough attention to percolate thru most media services. This study was (I think) the 5th or 6th epidemiological study in the literature flagging breast augmentation as a risk factor for suicide. I wrote about this before here & here, discussing this issue in context to what we do know.


These kind of hyped stories about breast implants inevitably generate questions from patients in the week or two after they break. They're also siezed upon by activists in the breast implant debate as a priori evidence that implants are evil, predictably generating a slew of implausible theories about how breast implants must be causing ______ (cancer, autoimmune disease, suicide, global warming, etc.....)


In the July Annals of Plastic Surgery published a Swedish study titled, "Excess Mortality From Suicide and Other External Causes of Death Among Women With Cosmetic Breast Implants". Almost 3,527 women out of Sweden were followed from as far as forty plus years ago (1965-1993), and what was observed was that there's an increased risk of suicide in women, especially 10 years after the implant surgery.

How big are the numbers we're talking about? Of 175 deaths among study participants, 24 were suicides which was something like twice the expected 12 if you assume that this group was similar to the population as a whole. However, this group of patients is clearly NOT representative of the larger pool of women for risk factors for suicide. In fact, one researcher working "backwards" from suicide rates towards known risk factors suggested that in fact an expected 5x increase in suicide rates should have been observed and speculated that the surgery had actually lowered observed rates of suicide. I don't buy that neccessarily, but it's an interesting hypothesis.

So what are the problems with trying too read much into this if you're asserting some causal relationship?

1. The group of patients and cultural norms in 2007 are arguably different from a group of patients nearly 30-40 years ago. As surgery has become more "democratized" (ie. more people can afford it) and plastic surgery is more mainstream, I'd bet you'll see a dilution effect somewhat down the line as the % of high risk patients shrinks relative to the numbers undergoing the procedure.


2. These databases from (mostly) western Europe don't include patients who were implanted for breast cancer reconstruction or who had surgery done by non plastic surgeons. We have not observed increased rates of suicides in implant breast reconstructions.


3. The largest one of these kind of studies saw differences in suicide rate disappear when the control group was other cosmetic surgery patients rather then the population as a whole.


4. Several dozen large studies have failed to establish any clear mechanism for breast implants causing systemic disease. The United States, Canada, Great Britain, and the European Union have all reaffirmed their positions on this in the last 18 months.


5. These studies weren't designed to prospectively study suicide rates and offer few clues as to the nature of the relationship between breast implants and suicide.

Like several other studies in this area, they found problems with an increased number of women who were substance abusers, alcoholics and had underlying depression. In fact, they found almost a 3x greater rate of deaths attributed to alcohol or substance abuse, or attributed to accidents or injuries that could have been associated with alcohol or drug use.

What's a plausible "wild card" in the mix? Body dysmorphic disorder (BDD). Defined as a preoccupation with a slight or imagined defect in appearance that leads to significant psychological distress, BDD has been found in up to 5%–15% of all cosmetic surgery patients. These patients bring rates of suicidal ideation and suicide attempts that are 10x higher (or more) to the table.

Meredith Vieira discussed the study on the Today show last week with NBC's chief medical editor Dr. Nancy Snyderman who had an excellent summary of this study and how it's applied in day to day practice,

"Now, is this great science? No. Is there sort of an implied link? Maybe. But I don't think this is an indictment of plastic surgery and certainly not breast implants. It may be that if you'd roll back to the '60s when doctors really started doing a lot of these, they weren't screening patients so well. And if a woman has unrealistic expectations or she's psychiatrically not sound, she's not a good surgical candidate. And I think in 2007, you'll have doctors screen plastic surgery patients much differently than they did 30 or 40 years ago...

Good surgeons say no because they don't want problem patients on the back end. If you have a patient with unrealistic expectations, you're going to have a patient who will be unhappy with you forever and ever. And no surgical fee is worth that. So you look at the good--the good plastic surgeons, they're always trying to get the temperature of patients and what they expect, and they'll tell patients no"

Rob

Drug Kingpin who'd had Plastic Surgery nailed by computer voice recognition!

In a story that brings to mind John Woo's "Face-off" which starred John Travola and Nic Cage as an FBI agent and drug dealer/terrorist who "switched faces" via plastic surgery comes this news off the wires.
Ramirez Abadia, a leader of Colombia's biggest drug cartel who had his features deliberately altered by plastic surgery, was identified by Brazilian and American anti-drug agents using advanced voice recognition technology.

A write up can be found here from the Washington Post.

U.S. intelligence agencies have used voice recognition for decades, but the technology has become much more effective in recent years through improvements in software that rapidly analyzes vocal frequency patterns, said Jim Hunter, a partner in the Merlin Risks security firm in Sao Paulo.

"The way you use your voice is as individual as fingerprints," Hunter explained. "If they have a sample of a known voice and they get an unknown sample of sufficient length, they then test the unknown against the known."

The process is more complex than fingerprinting because peoples' voices are different when they speak normally, yell or whisper _ but the software breaks down different frequencies and uses statistical analysis to make matches

Good plastic surgery should not be able to make you unrecognizable to family, friends, or intelligence agencies. How would you alter yourself to evade detection? Let's look at Mr. Ramirez to get some ideas.

If you look at the difference between the "new & improved" drug dealer on the left with some old FBI stock photos on the right & you can see some rather obvious stigmata of plastic surgery.

He apparently was once a handsome man who has been altered into a vaguely humanoid thing. It looks like he's had

• rhinoplasty - note the excessively narrowed upper part of the nose & I think you can see a red scar inside of the left nostril on the upper picture
• Face lift & neck liposuction - his face is kind of globally distorted. On the underside of the neck there appears to be a "dent" which can be from sutures or liposuction. He's also got a very prominent chin cleft which wasn't evident (to me) on the old blurry photos.
• blepharoplasty (eyelids) - he's got a rounded eye and clear ectorpion or "scleral show" (scar contracture which pulls the lid down and shows more of the 'white of the eye') on his left lower lid which a not infrequent complication of lower eyelid surgery
• facial implants - these are made from silastic (silicone rubber). I say this because his face has assumed all these weird geometries along the cheek, chin, and jawline. Facelifts and/or fat grafting can do this to some degree, but my money's on implants.

Rob

D.C. Court of Appeals limits access to experimental drugs

In a court case Abigail Alliance for Better Access to Developmental Drugs v. von Eschenbach that's been working it's way thru the appeal process, the Washington DC US Court of Appeals ruled 8 to 2 yesterday that terminally ill patients do not have a constitutional right to force the FDA and drug manufacturers to allow access to experimental drugs.

The court wrote, "We conclude there is no fundamental right 'deeply rooted in this nation's history and tradition' of access to experimental drugs for the terminally ill," said Judge Thomas B. Griffith, a Bush appointee, citing a Supreme Court decision that rejected the notion of a constitutional right to die.

"Although terminally ill patients desperately need curative treatments ... their deaths can certainly be hastened by the use of a potentially toxic drug with no proven therapeutic benefit. Thus, we must conclude that, prior to the distribution of a drug outside controlled studies, the Government has a rational basis for ensuring that there is a scientifically and medically acceptable level of knowledge about the risks and benefits of such a drug. We therefore hold that the FDA's policy of limiting access to investigational drugs is rationally related to the legitimate state interest of protecting patients, including the terminally ill, from potentially unsafe drugs with unknown therapeutic effects."

Griffith's opinion was a strong bipartisan decision joined by both conservative and liberal members of the D.C. appeals court.

The plaintiff's argument centered around the contention that the policy deprives dying patients of their right to self-defense and violated the Fifth Amendment clause that people cannot be deprived of life, liberty or property without due process of law. While it may sound heartless at first glance, the rejection of this claim does make sense for several reasons and its supported by organizations like the American Society of Clinical Oncology, the National Organization for Rare Disorders, the Marti Nelson Cancer Foundation, and the National Breast Cancer Coalition.

The suit was spearheaded by Abigail’s Alliance for Better Access to Developmental Drugs, and was founded to honor Abigail Burroughs. Ms Burroughs died in 2001 of head and neck cancer at age 21 while fighting to gain access to drugs not yet FDA approved.

In an article in The New Republic, Medical Oncologist and ethics expert, Dr. Ezekiel Emmanuel argues:

“The Abigail Alliance approach would eliminate the kind of careful monitoring on larger groups of patients [that we need] before widespread access becomes available....Instead, unproven drugs would be tested for safety in fewer than 80 people [in phase I trials] and then could be sold to patients. The benefit of a few desperate patients would come at a steep cost for the rest of us.”

Emmanuel and others worry that if people can do end runs around the protocols for testing experimental drugs, the number of patients willing to participate in randomized clinical trials (the gold-standard for drug testing) where half of participants receive the placebo or conventional drug will dry up. If this decision had gone the other way “it would have undermined the entire drug approval process,” said William B. Schultz, a former deputy commissioner of the Food and Drug Administration, who wrote an amicus brief to the court supporting the FDA's position.


Who will be willing to risk receiving a placebo or a conventional therapy instead of the “breakthrough” drug? Not everything new is good in terms of chemotherapy agents. Keep in mind that over 40% of the products that make it to Phase III FDA trials (the step preceding approval) ultimately are abandoned as they prove ineffective and/or prohibitively toxic.

Several other tricky aspects crop up in the scenario of allowing purchase of these drugs if they've been excluded or rejected from clinical trials. It will be VERY expensive in many instances, which is going to exclude the poor. It will also create incentive to "game" the system by having yourself excluded from clinical trials (and avoid the chance of getting the placebo control) in order to pay for the product. Uncontrolled access to the drugs makes it dramatically harder to track adverse events as easily and identify trends between groups.

F-cup cookies - no need to bother with those pesky implants

From Japan comes the F-Cup brand cookie containing nearly 50mg of that "miracle" breast enlarging herb Pueraria Mirifica. This product packaged in the form of a "cute" cookie gives me reason for pause.

What's this herb Pueraria Mirifica anyway?

It's a plant found in Thailand and SE Asia whose root contains phytoestrogens, plant derivatives that can mimic the effect of estrogen in the body. As with many herbal products, god knows how much of the product is actually in an individual cookie. Quality control for most such things is notoriously poor.

Will products like this make my breasts grow?

Possibly, as estrogen makes ductal tissue (the non fatty component of your breast) proliferate. Something like this would likely produce gynecomastia (man boobs) in males.

Should people be taking this without talking to your doctor?

Hell no! These types of herbs are apparently associated with similar risks as estrogen containing birth control pills or hormone replacement. There is literature suggesting (see here) these can make estrogen-responsive breast cancers proliferate or interfere with Tamoxifen (a common medicine used to reduce the risk of breast cancer recurrence that works by blocking estrogen pathways). Estrogen products can also make you more likely to spontaneously develop blood clots in your veins which can cause lethal pulmonary emboli.

It's my fault that health care is expensive? Uncle Uwe (Reinhardt) to the rescue!

There was an editorial in last Sunday's New York Times (next to the story on discrepancies in cancer treatment I wrote about) entitled "Sending back the Doctor's bill." which argued that physician compensation was actually the culprit in US healthcare spending. That came as quite a surprise to many of the doctor's I know. Completely missed by the author is both the expense of training physicians and the "opportunity costs" invested in becoming a Doctor by highly educated people in their early twenties.

For sake of comparison I'll use myself as an example:

• Tuition and living expenses during college ~ $150,000


• Tuition and living expenses during medical school ~ $85,000


• Average wage during my intern year in 1998 ~ $5.80 /hour


• Average wage my 8th year in surgical training in 2005 ~ $9.75 /hour


• Spending ages 22-35 in the library or hospital ~ PRICELE$$

It was not rare to have contemporaries owe more then $250,000 in loans during residency that was accumulating interest at 8%+. Despite commanding salaries that sound impressive, many physicians will not be able to retire that debt until well into their 60's.

The wonderful Surgeon's Blog by Sid Schwab touched on this the other day in a post called "Times Two." which is excellent reading. Dr. Schwab is a general surgeon nearing retirement age who writes the most engaging perspective on surgery I've yet to find on the Internet. He writes,

"Working hard for its own sake, striving for excellence without any tangible recognition will be seen in some -- but hardly most-- doctors if they go on a salary. Because, unsurprisingly (or maybe surprisingly, to pundits) that's not how it works in real life. I've been in the military, and I've worked at VA hospitals. Try getting a case on after three p.m. Try getting a lab test or Xray thenabouts. Work another patient into a crowded schedule? Stay through lunch, after hours, come in early? Sorry. That's what ERs are for. If Alex Berenson (the NYT editorialist) is ok with it, so am I. Sleep, I've discovered, can be a pleasant thing."

Back to the NYT..................Princeton University economics profess, Dr. Uwe Reinhardt, pretty much the "go to guy" for health care economic theory responded with a letter that was published today:

In “Sending Back the Doctor’s Bill” (Week in Review, July 29), you compare the incomes of American physicians with those earned by doctors in other countries and suggest that American doctors seem overpaid.A more relevant benchmark, however, would seem to be the earnings of the American talent pool from which American doctors must be recruited.

Any college graduate bright enough to get into medical school surely would be able to get a high-paying job on Wall Street. The obverse is not necessarily true. Against that benchmark, every American doctor can be said to be sorely underpaid.

Besides, cutting doctors’ take-home pay would not really solve the American cost crisis. The total amount Americans pay their physicians collectively represents only about 20 percent of total national health spending. Of this total, close to half is absorbed by the physicians’ practice expenses, including malpractice premiums, but excluding the amortization of college and medical-school debt.

This makes the physicians’ collective take-home pay only about 10 percent of total national health spending. If we somehow managed to cut that take-home pay by, say, 20 percent, we would reduce total national health spending by only 2
percent, in return for a wholly demoralized medical profession to which we so often look to save our lives. It strikes me as a poor strategy.

As Dr. Reinhardt points out, the low lying fruit in cost-containment (ie. physician reimbursement) was strip mined by the HMO movement and Medicare over 15 years ago. There is wide-spread disenchantment and lack of job satisfaction among physicians that threatens to split wide open over further aggressive pay cuts. You don't have to be a Nobel prize winning economist to understand the inevitable brain drain and service problems you'd create.





Rob

Open mouth insert foot (AGAIN)

This isn't a political blog, but I just have to get this off my chest.

As if a series of $400 haircuts and other campaign gaffes haven't cut Democrat John Edwards off at the knees...... Did he learn nothing from schleping qround with John Kerry?

Edwards the ernstwile poverty crusader and slick-talking shill for the American trial lawyers association has once again stepped in a knee deep pile of political pandering. Catering to the far left-wing of the Democratic party, Edwards recently decried candidates taking any money from Rupert Murdoch's FOX Corp. as it is too partisan for his tastes.

Lo and behold that Edwards had received over $800,000 from one of Murdoch's publishing companies for a self-serving puff piece book he wrote. When his campaign was informed of this hypocrisy, we got the ubiquitous "no comment" and furious spin control.

We do not need people like this in politics!

BTW "nice hair", John.

Back to medcine next week (I promise).

Rob

Today's Plastic Surgery 101 features Bono (?)

I'm just not feeling it today for heavy medical commentary, so I offer up this apocryphal Bono story which always makes me smile!


Allegedly, U2 was playing a concert in Glasgow, Scotland when Bono asked the audience for total quiet. In the silence, he started to slowly clap his hands, once every few seconds. Holding the audience in total silence, he said into the microphone, "Every time I clap my hands, a child in Africa dies."

A voice with a broad Scottish accent, from near the front of the crowd, pierced the silence ...

"Well, fookin' stop clappin' then!"


Rob

Digital nipping and tucking coming to Hollywood

The forthcoming reimaging of the medieval epic, Beowulf, on film is going to feature some technological advances that could revolutionize both movie making and the "arms race" of movie stars having to have (beyond) perfect, youthful faces and figures. Wearing body-suits with LED circuits which give studio animators the ability to have complete control over any number of physical features, actors can have "perfect" faces or bodies made for them with the click of a mouse. A variation of this was used in Lord of the Rings where actor Andy Sirkis created the Golem character on a sound stage in one of these suits.

Angelina Jolie (pictured at right from Beowulf) was apparently "augmented" in a number of subtle ways for the film (as if shes needs it!). This technology has evolved substantially past the odd looking visuals of dreadful "The Polar Express" movie a few years ago to the point where we're threatening photo-realistic landscapes and people that are wholly generated. This begs the point of whether eventually movie stars as we know it could be replaced by voice actors.



The New York Post speculates that this technology can eliminate Plastic Surgery

"Because of this technology, absolute perfection can now be achieved," says Martin Grove, Hollywood Reporter Online columnist. "Dieting, working out and plastic surgery can become a thing of the past because computers can now do all of the work....Body doubles aren't going to be used much at all, and neither are plastic surgeons, for that matter," says Grove. "If more and more directors use this technology, stars won't have to ever work on themselves, they'll just work on getting these jobs."

I suspect that as long as the paparazzi is "kind" enough to continue taking candid pictures of celebrity cellulite off screen that there will be enough business to keep Hollywood Plastic Surgeons gainfully employed.



Ms. Jolie could have used such a digital touch-up for her funky body art collection she's accumulated at this point.

Angelina, please stop with the tats!

Seen below is the "erasure" of Ms. Jolie's relationship with form beau, actor Billy Bob Thornton.