Blog — Notes of a Plastic Surgeon

Welcome to my blog. I am a plastic surgeon in Seattle and have been in private practice since 1991. I've seen more than a few interesting faces and cases through my years spent in the exam room, the operating room and the emergency room. And I have an opinion on just about everything relating to plastic surgery (and a lot of unrelated stuff). If you like my blog, let me know. Thanks for reading! Lisa

From the Wall Street Journal, June 10, 2020

June 11th, 2020 — 10:10am

Thank you for reading.  Be kind.  Stay strong. Dr. Lisa Lynn Sowder

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Breast Lift at the Time of Breast Implant Removal : Is It Safe???

June 1st, 2020 — 9:30am

I saw a patient recently who would benefit a lot from having a breast lift at the time of implant removal and that was what I recommended.  She had read on Dr. Facebook that it was safer to delay the lift.  This launched me into a discussion about the blood supply to the breast, which to a layperson, is a pretty arcane topic.  I had to reveal myself for the lousy visual artist that I am and draw out a diagram of the blood supply to the breast with and without implants.  Later I was able to find a pretty good diagram of the breast with and without an implant and add some red squiggles of my own representing blood vessels.

Let’s walk though it:  The unoperated breast has a very rich blood supply with vessels traveling from the chest wall, through the pec and straight into the breast tissue and also blood vessels traveling more superficially, about 1 cm under the skin surface from the periphery of the breast.

A breast that has an implant or had and implant has a much altered blood supply.  The placement of the implant necessitates division of the centrally located vessels and thus results in a breast that is dependent on the peripheral vessels.  This is not to be regarded as a terrible thing; it’s just a trade off and many surgical procedures also disrupt blood vessels and change the pattern of blood supply (tummy tuck and face lift are two examples).

Trouble arises when a surgeon does not recognize the altered blood supply.  The most common procedure I do which requires deep appreciation of this altered anatomy is when I do a breast lift following removal of a breast implant.  I use a very different technique than I use when doing a lift on a breast that has never had an implant.  See this blog for a step by step explanation of a regular breast lift.  When an implant has been removed, the peripheral vessels must be preserved or the breast tissue, including the nipple, will lose its blood supply and necrose which is a nice way of saying it will die.  When I have just removed an implant, I am on HIGH ALERT in regards to blood supply and also in a position to select the layer of breast tissue that is safe to undermine in order to shape the breast.  This sounds creepy but I can place one hand in the implant pocket and the other on the surface of the breast and judge the thickness of the breast tissue and location of the blood vessels.  In a delayed case where I wait several months for the breast to heal, I cannot do this because the pocket where the implant had been has disappeared and thus there is no way for me to do the one hand in and one hand on trick.  In delayed cases, there will also likely be some scarring and tethering of the tissues that can make safe dissection difficult as well.   The very worse case scenario is if a patient who has had implant removed has a lift by surgeon who is not really mindful of this altered anatomy.  Using a normal breast lift technique would have a very high risk of tissue necrosis.

so, IMHO, doing a lift at the same time of implant removal has some real advantages.  I hope this blog and my fabulous illustration add some clarity. Thanks for reading and I would be honored if you followed me on Instagram @sowdermd and @breastimplantsanity.

Dr. Lisa Lynn Sowder

Breast Contouring, Breast Implant Removal, Breast Implants, Breast Lift

Returning to Elective Surgery in the New World Order of COVID-19.

May 11th, 2020 — 12:41pm

 Washington State is starting to open up following our stay-at-home order.  I am really looking forward to getting back to what I love – taking care of patients.  We have worked very hard along with our national societies and governmental agencies to put in place procedures to keep ourpatients and ourselves as safe as possible.  I am over 60 as are three of our four anesthesiologist and our nurse manager and you will find us here, doing our jobs.  We would be foolish to pretend that there is no increased risk during these times. 

SMALL BUT NASTY

We have put together the following informed consent form for patients during this time.  Like all informed consent forms, it is meant not to frighten but to rather inform patients and remind them that surgery, even elective plastic surgery, is never risk free.  All patients undergoing surgery during this pandemic will be given this form and be required to sign off on it.  And remember, me and my staff are signing off on this increased risk every day we show up for work.  Should you have questions about our protocols, don’t be afraid to ask!  

 

 COVID-19 RISK INFORMED CONSENT

 I                                               (patient name) understand that I am opting for an elective treatment/procedure/surgery that is not urgent and may not be medically necessary.

I also understand that the novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. I further understand that COVID-19 is extremely contagious and is believed to spread by person-to-person contact; and, as a result, federal and state health agencies recommend social distancing.  I recognize that Dr. Shahram Salemy and Dr. Lisa Sowder and all the staff at Madison Tower Plastic Surgery and Madison Tower Surgery Center are closely monitoring this situation and have put in place reasonable preventative measures aimed to reduce the spread of COVID-19. However, given the nature of the virus, I understand there is an inherent risk of becoming infected with COVID-19 by virtue of proceeding with this elective treatment/procedure/surgery. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this elective treatment/procedure/surgery, and I give my express permission for Dr. Shahram Salemy and Dr. Lisa Sowder and all the staff at Madison Tower Plastic Surgery  and Madison Tower Surgery Center to proceed with the same.

I understand that, even if I have been tested for COVID and received a negative test result, the tests in some cases may fail to detect the virus or I may have contracted COVID after the test. I understand that, if I have a COVID-19 infection, and even if I do not have any symptoms for the same, proceeding with this elective treatment/procedure/surgery can lead to a higher chance of complication and death.

I understand that possible exposure to COVID-19 before/during/after my treatment/procedure/surgery may result in the following: a positive COVID-19 diagnosis, extended quarantine/self-isolation, additional tests, hospitalization that may require medical therapy, Intensive Care treatment, possible need for intubation/ventilator support, short-term or long-term intubation, other potential complications, and the risk of death. In addition, after my elective treatment/procedure/surgery, I may need additional care that may require me to go to an emergency room or a hospital.

I understand that COVID-19 may cause additional risks, some or many of which may not currently be known at this time, in addition to the risks described herein, as well as those risks for the treatment/procedure/surgery itself.

I have been given the option to defer my treatment/procedure/surgery to a later date. However, I understand all the potential risks, including but not limited to the potential short-term and long-term complications related to COVID-19, and I would like to proceed with my desired treatment/procedure/surgery.

 

Thanks for reading and I would be grateful if you followed me on Instagram @sowdermd and @breastimplantsanity.  Dr. Lisa Lynn Sowder

 

 

 

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A must read article about COVID-19

March 19th, 2020 — 1:52pm

Please read this article for some excellent information of COVID-19.  

My office and ambulatory surgery center is shutting down for at least a month.  We will have a skeleton staff answering the phone and I will be available in person for only those who really need a face to face with me.  I am 63 and thus at high risk despite enjoying excellent health and feeling and sometimes acting like I’m 14.  I thank all my patients who have had to reschedule their surgery and I thank everyone who takes this seriously.  And for those who don’t, get a clue already.

Stay safe, stay strong, stay sane, and stay in touch.

Dr. Lisa Lynn Sowder.   Follow me on Instagram @sowdermd and @breastimplantsanity.

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Can Surgery Be A Placebo?????

February 21st, 2020 — 11:45am

A few weeks ago I listened to an excellent Hidden Brain Podcast about placebos and not just the sugar pill kind of placebo.  This podcast recounted an amazing clinical trial done way back in 2002 which put the very common procedure of arthroscopic knee surgery for osteoarthritis to the test.  I will summarize that study here but I really encourage everyone to listen to the podcast.  There are also some links to the original paper published in the New England Journal of Medicine.

In this controlled trial involving patients with osteoarthritis of the knee, the outcomes after arthroscopic lavage or arthroscopic débridement were no better than those after a placebo procedure.

So here we go with my summary:  180 patients with osteoarthritis of the knee were randomly assigned to one of three groups.  The assignments were controlled for severity of disease.

Group 1 : Routine arthroscopic surgery to wash out and clean up any irregularities in the knee joints

Group 2:  The incision was made, the arthroscope was inserted and the knee joint washed out (lavaged) but nothing else was done.

Group 3:  An incision was made but the arthroscope was never inserted.

The patients did not know which group they were in nor did their families or the nurses who cared for them after surgery.   The surgeon and the operating team did not know which procedure the patient would have until the patient was on the OR table and anesthetized and the randomization envelope was opened.  For groups 2 and 3, a video of standard knee surgery was played and the OR team sort of faked the movements of the surgery and the time in the OR was the same for all groups.  One surgeon did all of the cases.  Group 1 is the real operation, Group 2 is the lavage group and Group 3 is the sham procedure.     Now some commentary on this study.  These patients had honest to goodness osteoarthritis of the knee confirmed by history, exam and X-Rays.  This was not a group of patients with ill defined and subjective complaints.  These were patients with objective disease. .

Follow up at two years showed no statistically significant difference in relief of symptoms as reported by the patients or function as measured by walking and climbing stairs between Group 1 (real surgery), Group 2 (lavage only) and Group 3 (sham surgery).   Think about this for a moment……….An arthroscopic clean out of the knee joint had no more effect than a superficial skin incision.  

I remember the reaction to this study when it was published.  At that time I did a lot of my surgery at Seattle Surgery Center and I had the opportunity to hob nob with a lot of orthopedic surgeons.  The ortho bros often teased me for all the unnecessary surgery I do.  Yeah, it’s true.  The vast majority of cases I do are unnecessary.  This study allowed me to tease them about their “scoping for dollars” practices.  I think a lot of scoping for dollars still goes on (mostly because patients request it) but maybe a little less since this paper smacked everyone upside the head.

Isn’t it just amazing what the human mind can do?  It can convince the body that the sugar pill was the real thing or even that the sham surgery was the real thing!

Thanks for reading and really you should listen to this podcast!   And as usual, I would be honored if you followed me on Instagram @sowdermd and @breastimplantsanity.  Dr. Lisa Lynn Sowder

 

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Some suggestions for New Year’s Resolutions

December 31st, 2019 — 12:30pm

 

I cannot improve on this list of Woody Guthrie’s.

blog new yearsThanks for reading and Happy New Year!

And I would be honored if you followed me on Instagram @sowdermd and @breastimplantsanity.

Dr. Lisa Lynn Sowder

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Smash the Wellness Industry by Jessica Knoll

December 3rd, 2019 — 1:08pm

I am so pleased to share this opinion piece from the New York Times. My husband and I were celebrating our 25th anniversary in Paris last June when I came across it while paging through the International Edition of the New York Times while awaiting my Croque Monsieur at a tiny sidewalk cafe.

Croque Monsieur: 8 billion calories and totally worth it. Bon Appetit!

Smash the Wellness Industry

Why are so many smart women falling for its harmful, pseudoscientific claims?

By Jessica Knoll

New York Times

June 8, 2019

A few months ago, I had lunch with the writer behind one of my favorite movies of the year, the agent who made the deal and the producer who packaged the project. I wanted to hear all about the process and perhaps find an opportunity to collaborate. When the server came to take our order, I flashed to that scene in “Romy and Michele’s High School Reunion” when Mira Sorvino walks into a diner in a striped skirt suit and asks the waitress, “Do you have some sort of businesswomen’s special?”

Had there been any sort of businesswomen’s special that day, our group probably couldn’t have ordered it. Someone was slogging through the Whole30 program, someone had eliminated dairy, and someone else was simply trying to be “good” after a “bad” weekend. The producer said it didn’t matter how “good” she was. She had lost the baby weight and though she may look tolerable in clothes, under the Spanx her stomach was a horror show. The writer said she had so much cellulite on her thighs she looked diseased. I gazed around the restaurant, longingly, wondering what the men eating cheeseburgers were talking about.

At one time, I too would gleefully have torn myself apart. I despised my body, and my devotion to changing it amounted to years of unpaid labor, starting with a bout of bulimia in high school. In preparation for my wedding, I worked out twice a day on 800 calories. From there I moved on to counting macros, replacing rice with cauliflower pellets, 13-day cleanses, intermittent fasting and an elimination diet that barred sugar, dairy and nightshades like potatoes.

Every new regimen ended in the same violent binge. I’d wait for my husband to go to bed so that I could obliterate the pantry without him asking, “Are you O.K.?” For the next few days, I would throw myself on the altar of “clean eating,” only to start the cycle all over again.

I called this poisonous relationship between a body I was indoctrinated to hate and food I had been taught to fear “wellness.” This was before I could recognize wellness culture for what it was — a dangerous con that seduces smart women with pseudoscientific claims of increasing energy, reducing inflammation, lowering the risk of cancer and healing skin, gut and fertility problems. But at its core, “wellness” is about weight loss. It demonizes calorically dense and delicious foods, preserving a vicious fallacy: Thin is healthy and healthy is thin.

Almost three years ago, I moved to Los Angeles from New York. After death and divorce, moving is supposed to be the most stressful thing you can go through, and eating became my salve. I had a second book and a screenplay due, a new city to explore and friends to make, but I could hardly focus on any of that for how crazy I felt around food. So I did a desperate thing. I searched “intuitive eating” online.

Thanks to a stint at a health magazine, I had a glancing understanding of the philosophy, which encourages a return to the innate wisdom we had as babies — about when to stop eating, what tastes good and how it makes our bodies feel. I might have sought it out sooner if not for the part where you learn to accept how your body looks once you stop restricting food, even if that version of your body is larger than you would like.

The search led me to a nearby dietitian who is considered by some to be one of the founding mothers of intuitive eating. I picked up the phone.

Intuitive eating has been around for decades, but it’s suddenly receiving a lot of attention. Perhaps it’s because women are finally starting to interrogate the systems that hurt and exploit us. Perhaps it’s because we’re driven and ambitious and we need energy — not lightheaded, leafy-greens energy but real energy, the kind that comes from eating the hearty foods men eat.

I had paid a lot of money to see a dietitian once before, in New York. When I told her that I loved food, that I’d always had a big appetite, she had nodded sympathetically, as if I had a tough road ahead of me. “The thing is,” she said with a grimace, “you’re a small person and you don’t need a lot of food.”

The new dietitian had a different take. “What a gift,” she said, appreciatively, “to love food. It’s one of the greatest pleasures in life. Can you think of your appetite as a gift?” It took me a moment to wrap my head around such a radical suggestion. Then I began to cry.

Two years into my work with her, I feel lighter than I ever have. Food is a part of my life — a fun part — but it no longer tastes irresistible, the way it did when I told myself I couldn’t have it. My body looks as it always has when I’m not restricting or bingeing. I’m not “good” one day so that I can be “bad” another, which I once foolishly celebrated as balance.

Occasionally, when I’m stressed, I comfort myself with food, and my dietitian assures me that’s an acceptable kind of hunger too. Emotional eating is a coping mechanism. We’re told it is an unhealthy habit, one we must break, but that’s another wellness lie. It is not vodka in our morning coffee. My binges stopped once I stopped judging myself for wanting to eat the foods “wellness” vilified, sometimes for reasons other than physical hunger.

I no longer define food as whole or clean or sinful or a cheat. It has no moral value. Neither should my weight, though I’m still trying to separate my worth from my appearance. They are two necklaces that have gotten tangled over the course of my 35 years, their thin metal chains tied up in thin metal knots. Eventually, I will pry them apart.

Most days, I feel good in my skin. That said, I am probably never going to love my body, and that’s O.K. I think loving our bodies is not only an unrealistic goal in our appearance-obsessed society but also a limiting one. No one is telling men that they need to love their bodies to live full and meaningful lives. We don’t need to love our bodies to respect them.

The diet industry is a virus, and viruses are smart. It has survived all these decades by adapting, but it’s as dangerous as ever. In 2019, dieting presents itself as wellness and clean eating, duping modern feminists to participate under the guise of health. Wellness influencers attract sponsorships and hundreds of thousands of followers on Instagram by tying before and after selfies to inspiring narratives. Go from sluggish to vibrant, insecure to confident, foggy-brained to cleareyed. But when you have to deprive, punish and isolate yourself to look “good,” it is impossible to feel good. I was my sickest and loneliest when I appeared my healthiest.

If these wellness influencers really cared about health, they might tell you that yo-yo dieting in women may increase their risk for heart disease, according to a recent preliminary study presented to the American Heart Association. They might also promote behaviors that increase community and connection, like going out to a meal with a friend or joining a book club. These activities are sustainable and have been scientifically linked to improved health, yet are often at odds with the solitary, draining work of trying to micromanage every bite of food that goes into your mouth.

The wellness industry is the diet industry, and the diet industry is a function of the patriarchal beauty standard under which women either punish themselves to become smaller or are punished for failing to comply, and the stress of this hurts our health too. I am a thin white woman, and the shame and derision I have experienced for failing to be even thinner is nothing compared with what women in less compliant bodies bear. Wellness is a largely white, privileged enterprise catering to largely white, privileged, already thin and able-bodied women, promoting exercise only they have the time to do and Tuscan kale only they have the resources to buy.

Finally, wellness also contributes to the insulting cultural subtext that women cannot be trusted to make decisions when it comes to our own bodies, even when it comes to nourishing them. We must adhere to some sort of “program” or we will go off the rails.

We cannot push to eradicate the harassment, abuse and oppression of women while continuing to serve a system that demands we hurt ourselves to be more attractive and less threatening to men.

And yet that is exactly what we are doing when we sit around the lunch table and call our stomachs horror shows.

There is something called the Bechdel test for film. Developed by Alison Bechdel in 1985, an American cartoonist, the idea is that the film must satisfy three requirements to pass: (1) feature at least two women who (2) talk to each other about (3) something other than a man. Sounds simple, but a shocking number of films have failed to pass.

In 2019, I want to propose a new kind of test. Women, can two or more of us get together without mentioning our bodies and diets? It would be a small act of resistance and a kindness to ourselves.

When men sit down to a business lunch, they don’t waste it pointing out every flaw on their bodies. They discuss ideas, strategies, their plans to take up more space than they already do. Let’s lunch like that. Who’s eating with me?

Jessica Knoll is the author of the novels “Luckiest Girl Alive” and “The Favorite Sister.”

Thanks for reading and I would be honored if you followed me on Instagram @sowdermd and @breastimplantsanity.  Dr. Lisa Lynn Sowder.  And…….you gotta eat at least one Croque Monsieur before you die.

 

General Health, Highly Recommended Reading, Stuff I love

En Bloc Capsulectomy: A Skillful Dissection by Investigative Reporter Jolene Edgar for RealSelf

November 26th, 2019 — 10:56am

I do a lot of breast implant removals and the topic of en bloc capsulectomy often comes up.  I am so glad to see this this very well researched and well written article by Jolene Edgar.  She has interviewed me and several other plastic surgeons regarding our approach to the breast implant illness patient.  If you are considering breast implant removal for any reason, be sure to check out this article.  https://www.realself.com/news/breast-implant-illness-en-bloc-implant-removal

Thanks for reading and I would be honored if you followed me on Instagram @sowdermd and @breastimplantsanity.

Dr. Lisa Lynn Sowder

Breast Implant Illness, Breast Implant Removal, Breast Implants, Patient Beware, Patient Safety

Halloween Owl is a Mother’s Friend

October 29th, 2019 — 12:20pm

Happy Halloween!

blog halloween owl

“I’ve come for my candy.”

If you have young kids at home, you need to meet the Halloween Owl.  He is your best friend this time of year.

This is how he operates.   You help your  children set aside at least half of their sugary treasure to donate to the Halloween Owl.  They put their donation into a nice decorated paper bag with “Halloween Owl Only” written on it with big black letters.   After the children are in bed, their tummies aching from all of that crappy candy, the Halloween Owl taps on the window to claim his share of the bounty which he shares  with all of his woodland friends.    There is little pushback from the children as they imagine the owls and raccoons and possums enjoying their once a year treat.  And in Seattle, where I live, there are occasionally reports of coyotes in the city limits and once a report of a cougar in one of our city parks.   Those are big critters and they need lots of candy and the children may be even more generous with their donation.

My children are young adults now and they are wise to the Halloween Owl but it worked great for years.  So if your kids are young, give it a try.  Just make sure that you put the candy at the very bottom of the garbage can.

Thanks for reading and i would be honored if you followed me on Instagram @sowdermd and @breastimplantsanity.   Dr. Lisa Lynn Sowder

Children, Now That's Cool

“It’s All in Your Head”—Medicine’s Silent Epidemic

October 11th, 2019 — 8:18am

A fascinating article about the mind-body connection.  This is from a recent Journal of the American Medical Association.  

 

Viewpoint

September 16, 2019

“It’s All in Your Head”—Medicine’s Silent Epidemic

Matthew J. Burke, MD, FRCPC1,2

Author Affiliations Article Information

JAMA Neurol. Published online September 16, 2019. doi:10.1001/jamaneurol.2019.3043

It’s all in your head” is a phrase sometimes said by physicians to patients presenting with symptoms unexplained by medical disease. As a neurologist specializing in neuropsychiatry, nothing bothers me more than overhearing medical colleagues proclaim this one-liner at the bedside or snicker about these patients during rounds. Unbeknownst to them, I also hear my patients’ version of being on the other end of this phrase and find myself constantly trying to repair the damage that these words can cause. Whether physicians like to admit it or not, medically unexplained symptoms encompass a vast terrain of clinical practice. In neurology, these symptoms fall under functional neurological disorder, but every specialty has their own variants and favored terminologies (eg, chronic fatigue syndrome, fibromyalgia). The inadequate management of this segment of medicine represents a silent epidemic that is slowly eroding patient-physician relationships, perpetuating unnecessary disability, and straining health care resources.

The irony of “it’s all in your head” is that although this phrase is often used inappropriately and dismissively, it is technically correct. The problem does indeed lie within the head. More specifically, it lies within the brain and its complex networks that we are just beginning to understand. Over the past 10 years, neuroimaging research studies have consistently identified brain abnormalities in patients with medically unexplained symptoms—yes, biologically based changes in the activity and connections of brain regions, such as the amygdala, prefrontal cortex, temporal-parietal junction, and other structures.1 These brain circuit abnormalities provide physiological explanations for once mysterious links between regions implicated in emotional processing and the generation of “physical” symptoms (eg, pain, fatigue, weakness). Jean-Martin Charcot, MD, a famous 19th century French neurologist and early pioneer of this field, reportedly insisted that a “functional lesion” would be found when microscopes were sufficiently powerful.2 Well, our microscopes are getting better, and we are now starting to see evidence of the predicted functional or software disruptions in the brain. We still do not fully understand what causes these software problems; however, recent research suggests a multifactorial etiology, including genetic predisposition, environmental risk factors (eg, childhood adverse events), and psychological stressors.3

Despite the growing scientific literature, there has been minimal shift in physician attitudes toward these patients. Physicians seem quite comfortable with the idea of structural brain lesions causing psychological symptoms, such as a frontal lobe stroke causing depression or a temporal lobe tumor causing delusions. However, the reverse causality of psychological factors (borne of the same substrates—neurotransmitters, neurons, and synaptic connections) leading to neurological or systemic symptoms is often hastily dismissed and remains highly stigmatized. Thus, many physicians either simply ignore these kinds of symptoms or wrongfully assume that patients are malingering.

Based on such attitudes, a typical physician-patient interaction may proceed as follows: (1) the physician provides a rundown of normal investigations, (2) the patient is told they have no known medical diagnoses, (3) a brief awkward exchange occurs, and (4) little further explanation, guidance, resources, or facilitation of an appropriate referral process is given. Even if the infamous phrase is not explicitly stated, this sequence leaves the patient to infer for themselves that it must be all in their head. Unfortunately, they do not perceive this as, “I have a real dysfunction of networks in my brain,” but instead understandably conclude that, “they think I’m crazy” or “faking it.”4 Sometimes, patients may hear the distant utterance of, “Maybe you should see a psychiatrist,” as they exit the office door, but in this context, such advice is rarely productive.

Many of these patients can be so offended by this encounter that they quickly seek multiple second opinions and subsequent rounds of pricey and unnecessary investigations. Depending on the jurisdiction and medical record system, the original physician may be completely unaware of these additional rounds of care. Mounting negative and invalidating clinical interactions can become a source of distress and cause medical trauma. At this point, patients often either fall through the cracks or stumble on a fringe medical specialist or alternative medicine practitioner who may offer the “physical” diagnosis they’ve been yearning for. This could include a growing list of unsubstantiated metabolic deficiencies, infectious disorders, or autoimmune hypersensitivities. Anecdotally, the most common current example seems to be the diagnosis of chronic Lyme disease by unvalidated assays.5 Let me be clear that many of these practitioners are well intentioned and can offer holistic approaches that medicine could learn a lot from. However, there appears to be a subset that take advantage of these patients’ desire for a “physical” diagnosis and exploit their vulnerabilities.

For the patient, receiving such a concrete, “organic” diagnosis often quells mounting anxiety, which in itself could be partially therapeutic. However, now wedded to their given diagnosis with no knowledge of their actual software problem, patients do not see a need to address underlying factors that may be contributing to their disorder nor do they receive the multidisciplinary care that they may so badly need. The saddest part of this epidemic is that if addressed early, these symptoms may be reversible; however, with delays to proper diagnosis and management, prognosis worsens considerably.6

So how can we prevent or interrupt this concerning trend? Often, the first step to addressing a problem in medicine is providing data to prove that the problem exists. This is where the challenge begins and what makes this a silent epidemic. The magnitude of this crisis is difficult to demonstrate because these patients largely elude the billing codes used for case ascertainment in large population-based studies. This is because of a combination of gaps in current billing and diagnostic codes (country specific) and because of the fact that codes are not being used appropriately by many physicians. The latter may happen for multiple reasons, including lack of comfort with these diagnoses and concerns of medicolegal ramifications.

Despite a few isolated efforts to estimate prevalence7 and health care costs,8 the evidence base needed to sway research granting organizations, government policy makers, and health care and insurance systems has been largely elusive. I am optimistic that it is only a matter of time until the scope of this crisis is fully appreciated. I see firsthand the high patient volumes and health care resource utilization that currently escape record keeping. I raise these concerns to my colleagues, who wholeheartedly agree, but the conversation ends there and the silence continues. I am hopeful that new research technologies, such as natural language processing, could identify these patients in medical records despite the lack of adequate billing code data and that improved records systems will better track these patients through different health care pathways.

To address the epidemic itself, we desperately need more clinicians and researchers dedicated to interrogating the complex interfaces of mind, brain, and health. Currently, there are small pockets in different specialties, but these are not nearly commensurate with the volume and impact of these disorders. Second, and arguably more importantly, we need to fundamentally change the culture within the medical community to eliminate the negative connotations associated with these disorders. This change requires buy-in from hospital and health care leadership and a supportive infrastructure. These patients have complex conditions and require additional upfront consultation time, resources, and collaborative care. To prevent the cycles described previously, physicians need to be incentivized to take the time necessary to optimize the initial patient encounter. This includes delivering and explaining the diagnosis in a transparent and supportive context,9 providing patient-friendly resources (eg, https://www.neurosymptoms.org/), and referring appropriately for interdisciplinary management (eg, physical therapy, occupational therapy, psychotherapy). New educational and training initiatives across medical and allied health professions will be critical for enabling a successful transition.

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Article Information

Corresponding Author: Matthew J. Burke, MD, FRCPC, Division of Cognitive Neurology, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, KS-274, Boston, MA 02215 (mburke11@bidmc.harvard.edu).

Published Online: September 16, 2019. doi:10.1001/jamaneurol.2019.3043

Conflict of Interest Disclosures: Dr Burke is supported by funding from the Sidney R. Baer Jr Foundation.

Disclaimer: The content of this article is the opinion of the author and does not necessarily represent the official views of Harvard University or the University of Toronto (and their affiliated academic health care centers) nor the Sidney R. Baer Jr Foundation.

Additional Contributions: I thank Saadia Sediqzadah, MD, SM (Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada), for her helpful comments and review of the manuscript. Dr Sediqzadah did not receive compensation for her contributions.

Thanks so much for reading and I would be honored if you followed me on Instagram @sowdermd and @breastimplantsanity.  

Dr. Lisa Lynn Sowder

General Health, Highly Recommended Reading

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