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

Category: Government and Politics


Being a woman and a surgeon isn’t always easy but it sure beats the alternatives: Being a woman and not being a surgeon or being a surgeon and not being a woman.

January 16th, 2018 — 2:36pm

I participate in a few doctor only on line message boards and forums.  A topic that has been front and center the past few months has been the #METOO movement and some of the challenges women in medicine face.  I’d like to share a few of my own stories.  Fortunately none of them include Harvey Weinstein.

I finished medical school in 1983.  1/3 of my graduating class were women.  These days women comprise more than 50% of most medical school classes.  I did my general surgery residence at the University of Utah, not exactly a bastion of progressive ideas.  Surprisingly about 20% of the surgery residents were women.  I felt very little discrimination but maybe I was just to busy and exhausted to notice?  I did get a couple of evaluations that I thought were just hilarious and still do. They were both from the Latter Day Saints (Mormon) Hospital.  One described me as “defensive, argumentative and with a chip on my shoulder”.  The other described me as “a sharp little gal”.  My boyfriend at the time just about split a gut laughing when he saw these. He was also a general surgery resident and never got such amusing reviews.

I had a few interesting experiences with male patients.  When I was doing an Intensive Care Unit rotation as a wet behind the ears intern at the University Hospital, I helped with a middle aged Mormon Elder who was crashing badly from acute pancreatitis.  (If you have never heard of this disease, count yourself lucky).  I was cleaning his penis in preparation to place a catheter so we could monitor his urinary output.  This man was very ill and a little delirious.  He looked at me and said “Doc, I’ll give you 10 minutes to stop that”.  It never crossed my mind to take offense at this.  It added a bit of levity (ha, ha) to a very serious situation.  I got to know this gentleman quite well during his ICU stay and he was a totally stand up guy.  On the gastroenterology rotation during my third year, I was doing a colonoscopy on an elderly man and he twisted his torso and neck to look me right in the eye and asked “What is a pretty little thing like you doing here?”  At the time, I thought that was actually a very good question!  This fellow grew up in a time where women rarely worked outside the home and certainly did not become surgeons.  Again, since I was the one with the scope, I felt no animosity towards him.

Dr. Henry Neal in 1990 with his girl residents, me, Sue Wermerling and Kimberley Goh. Can you tell that he secretly loves us?

My first year of my plastic surgery residency (after 6 years of general surgery) three of the four residents were women.  This was a fluke of the computer based residency matching system.  The chairman of plastic surgery, Dr. Henry Neale was a good old boy from the south.  He kept a bull whip in his desk drawer.  Really.  He was a great surgeon and ran a powerful department.  We operated our brains out and he had our back every day.  Dr. Neale was very, very politically incorrect.  He pondered if Sue, Kim and I would start cycling together and once stated he should put a Kotex machine in the resident’s office.  Well, the three of us just dished it right back at him and we did end up cycling together.

There was one occasion where I really felt harassed.  I was a 4th year general surgery resident on call at a private hospital in Ogden, Utah.  Late one night there was knock on my call room door.  I opened it to find an elderly staff surgeon with alcohol on his breath with a fifth of Southern Comfort (yuck!) in his hand.  He wanted to know if I wanted to party.  This scene was so ludicrous that I laugh out loud just thinking about it.  Most residents given the choice of sleep vs. party would pick sleep no matter whom was holding the bottle.  This man’s son was a medical student who had rotated on my service a few months previously.  I told the party hound horn dog that he had three seconds to leave or I would tell his son.  I think he was gone before I hit “two”.  I never assisted him on a case again which was no loss on my part because he was a lousy surgeon.  No, I did not file a complaint or make a fuss of this.  Again, he grew up in a different time.

I’ve had a few really weird patient encounters in private practice related to my gender.  Years ago when I was pregnant with my twin sons and could barely fit through a door, I had a mentally unstable older man with a skin cancer on his scalp the size of a poker chip.  This, gentle readers, is what we surgeons call a GREAT CASE.  The mentally unstable older man was quite the cad with many comments about my huge belly and the certain studhood of my husband.  He also had many bizarre ideas about selenium deficinecy and sexual function.  I was not sad to send him on his way once he had healed.  A few years later I had an elderly woman come in with another neglected and ginormous skin cancer who shrieked when she saw me and declared that “women are stupid and I won’t have one for my doctor”.  Oh well, that great case went to my partner who has a Y chromosome.  She was nasty to him too.

As I write this blog, I can’t really think of any weird encounters in recent years.  I think in the 26(!) years since I started practice that being a woman surgeon or woman astronaut or woman programmer or even race car driver has become sort of a no big deal which suits me just fine.  Recently my 17 year-old daughter took a field trip with her computer science class to the Microsoft campus just outside of Seattle.  She attends an all girl high school and they were given a tour by an all female coding team.  The advice given to these bright young students by these bright young and not-so-young techies was to work hard, advocate for yourself and don’t take things too personally.  I think that is good advice regardless of your gender or your workplace.

Thanks for reading and follow me on Instagram @sowdermd and @breastimplantsanity.  Dr. Lisa Lynn Sowder, girl surgeon.  And there will be an upcoming blog about delayed childbearing which is something I don’t recommend but sure worked for me.

General Health, Government and Politics, It's All About Me., Plastic Surgery, Surgical Eductaion

ICD-10. It’s heeeeeeeere.

October 1st, 2015 — 10:30am
Don't worry Barbie. There's an IDC-10 for that squirrel encounter!

Don’t worry Barbie. There’s an IDC-10 for that squirrel encounter!

Today, October 1, 2015, is the day that doctors have to switch from ICD-9 to ICD-10 diagnosis codes.  Up until today, we doctors had to rely on a mere 18,000 ICD-9 codes to describe patient diagnoses.  Doctors rely on these mandatory codes for reimbursement from insurance companies.  Years ago, when I was doing a lot of insurance work, I had many of these codes memorized.  A couple of examples of ICD-9 codes I used a lot were 611.1 for overly large breasts, 173.30 for skin cancer and 873.50 for a gnarly dog bite to the face.

The new federally mandated version, ICD-10 expands the number of codes to around  from 18.000 to 140,000 codes.  That’s a lot of codes!

Here are a few examples I might possibly need to use for cases I see in the emergency room when I am on call:  Walked into a lamppost, initial encounter W22.02XA.  And if that patient walks into the lamppost again, ICD-10 has it covered:  “Walked into a lamppost, subsequent encounter, W22.02XD.  And for that occasional patient who suffers a burn while waterskiing: V91.07XA.  I occasionally treat animal bites and in the bird department I am covered.  There are 72 codes which cover ducks, macaws, parrots, geese, turkeys and chickens.  And if the chicken bite occurs in a chicken coop, there is an add on code for that!   And if it’s a squirrel bite, of course there is a code.  But what is it something other than a bite?  There’s a code for “other encounter with a squirrel.”  Doesn’t that just make your imagination run wild???

And sometimes, I’ll see a patient late at night in the ER who along with their chicken bite and/or lamp post  injury presents with a bizarre personal appearance (R46.1) and/or a very low level of personal hygiene (R46.0). I hope they don’t take it personally because in the middle of the night, both those codes just may apply to me!

I have to keep reminding myself that the feds who mandate this stuff are from the government and they are here to help.   Sometimes I just have to scratch my head.   I wonder if there is a code for that??????

Disclosure:  I borrowed heavily form an article in the Wall Street Journal written by Anna Wilde Mathews for this topic.

Thanks for reading!  Dr. Lisa Lynn Sowder

Financial Issues, Government and Politics, This Makes Me Cranky.

Very effective sunblock blocked by the FDA.

June 10th, 2015 — 11:33am

 

Border patrol K-9 unit trained to sniff out illegal sunscreen.

Sparky is especially trained to sniff out illegal sunscreen. Woof.

This is an article from the May/June 2015 King County Medical Society Bulletin.  It’s a little long and technical but just hang onto that attention span and read it!

Packing a Sunscreen Souvenir

Tourists Grab UVA Treatments Common Elsewhere, Illegal Here

By Barbara K. Gehrett, M.D.

Some international travelers are returning with pharmaceutical souvenirs – new UVA sunscreens available in Europe, Canada, Mexico, and other countries and not yet approved in the United States.

Ninety-five percent of the solar UV radiation that reaches earth is UVA.  It has a wavelength between 320 and 400 nanometers and is present during all daylight hours, summer or winter, cloudy or clear.  UVA passes through glass and penetrates deep into skin.  It is responsible for more damage to basal keratinocytes in the epidermis than UVB.

Most UVB damage occurs in the superficial layer of the epidermis, producing suntan, sunburn, and aging skin.  Protection from UVB with sunscreens reduces the risk of non-melanoma skin cancers.

Two short-acting, barrier-type UVA sunscreens have been approved for use in the U.S.  These are zinc oxide and oxybenzone.  Dermatologists argue that their protection is limited and requires repeated application because they break down quickly.

Ecamsule is a longer-acting “chemical filter” made by L’Oreal and is one component of a U.S. approved lotion, Mexoryl.  The FDA turned down the application to release ecamsule as an over-the-counter UVA sunscreen, although it has been available in Europe since the late 1990s.  It is regulated there as a cosmetic, which has a different standard than the drug category it falls into in the U.S.  All sunscreens in Europe must give both UVA and UVB protection.

Eight UVA sunscreen products have been languishing in line (one since 2003) for FDA consideration.  Congress and President Barack Obama attempted to pressure the FDA by passing the Sunscreen Innovation Act in December of 2014.  This new law requires the FDA to issue an approval or disapproval ruling within 60 days of receiving a complete application for sunscreen.   All eight of the new UVA sunscreens were expeditiously disapproved by the FDA early in 2015.

The FDA wants long-term data on safety before approval will be given.  Typically this means two Phase 3 clinical trials, which are expensive and time-consuming.  It is possible ;that future data on skin cancer protection from other countries would move the agency.  Or perhaps ;the procedural review taking place at the agency will result in a different set of criteria for sunscreens.

In the meantime, U.S. travelers stocking up on sunscreen  when they are outside the country are violating the Food, Drug and Cosmetics Act by importing unapproved drugs.  According to WebMD, the FDA does not generally pursue violators, unless the quantities involved are egregious.  One other work of warning:  online purchases should be made with caution, because of international counterfeiting of drugs.

Thanks for reading!  And keep using that lousy U.S. approved sun creen.  It’s better than nothing.   Dr. Lisa Lynn Sowder

General Health, Government and Politics, Skin Cancer, Skin Care, This Makes Me Cranky.

Is your plastic surgeon’s in-office OR certified? You should ask!

June 27th, 2014 — 1:20pm

Seattle Plastic Surgeon is off to Spokane to inspect an in-office operating for the American Association for Accreditation of Ambulatory Surgery Facilities, Inc.  (AAAASF)

cc inspector

Inspector Dr. Lisa Lynn Sowder

I am off to my hometown, Spokane, this weekend both to visit family but also to inspect the in-office operating room of one of Spokane’s plastic surgeons for AAAASF.  I’ll be snooping around and looking not only at the facility’s physical space and equipment and medical supplies, I will be scrutinizing their policies and procedures, staff education and certification and looking through about a dozen patient charts.  It’s a very comprehensive evaluation for what is considered by many (me included) the Gold Standard in Accreditation.

One very important thing that sets AAAASF apart from some other accreditation authorities is that AAAASF not only looks at the facility and patient care, they look closely at surgeon qualifications.

In many states including Washington State, anyone with an MD license can play surgeon.  In fact, all MD  licenses from the Washington State Department of Health state “Physician and Surgeon” even if the MD has not set foot in an operating room since medical school.  There are no restrictive “scope of practice” laws in Washington.  Crazy, huh?  Oh, and a little scary.

Fortunately AAAASF thinks that surgery should be performed by surgeons, meaning those of us who have formal training and board certification in surgery.  AAAASF even requires that the procedures done in an in-office OR be within the scope of practice of the surgeons board certification.  And by board certification they mean a board which is recognized by the American Board of Medical Specialties (ABMS) and not some self-designated board.  The American Board of Plastic Surgery is recognized by ABMS whereas the self-designated American Board of Cosmetic Surgery is not.

Also, AAAASF requires that the surgeons using the in-office OR have hospital operating privileges for the procedures performed in the in-office OR in an accredited hospital within 30 minutes of the in-office OR.  It may be shocking to some, but some franchise cosmetic surgery businesses fly non-plastic surgeons in from out of state  to do liposuction for a few days and fly them back home.

So if you are looking into having a procedure done in an in-office operating room, it would be prudent to check to see if they are accredited by AAAASF.  If they aren’t, why not???

Thanks for reading and be sure to do your homework!  Dr. Lisa Lynn Sowder

 

Government and Politics, Patient Beware, Patient Safety, Plastic Surgery

The Revolution of Outpatient Surgery

June 20th, 2014 — 10:26am

Seattle Plastic Surgeon blogs about how much surgery has changed in just a few decades.

Sometimes it just astounds me how much surgery has changed since my days as a medical student.  There was a time when hernia patients spent  an entire week in the hospital following surgery.  They were admitted the night before, a bazillion lab tests were done, they got an enema after dinner and a sleeping pill before bedtime.  After surgery, they were given morphine injections, Jello and broth and bed baths.  Their incisions were checked everyday and after a week their stitches came out and they finally went home.  Fast forward to today and a hernia patient checks into an outpatient surgery center in the morning and by lunch time is home eating a ham sandwich and watching Breaking Bad reruns.  How did all of this happen in just over twenty to thrity years?blog AAAASF

Many of the changes have come about for economic reasons.  Keeping someone in the hospital for a week costs as much or more than a brand new Mini Cooper.  Insurance companies began to balk at these costs when I was a surgery resident in the 80’s.  I remember being shocked (shocked!) the first time some bozo from an insurance plan told me to discharge a hemorrhoid patient after just two days in the hospital.  I was used to waiting until those patients had managed to have their first bowel movement post op.  It was just, well, tradition.   So we started sending them home earlier and they did fine.  In fact, they did better than they if they were in the hospital being poked and prodded and woken up at midnight for vital signs.

Anesthesia has changed a lot too.  Back in the day, general anesthesia was almost guaranteed to leave a patient vomiting for a day or two after surgery.  These days, the anesthetic agents are much less nauseating and the anti-nausea medications much more effective.  And with spinal anesthesia, nausea is very rare.  I have not had to admit a patient to the hospital for nausea and vomiting and dehydration in at least ten years.

And surgical procedures have changed.  Take that hernia patient and his ham sandwich.  Thirty years ago he would have a six inch long incision in his groin and sutures tied so tightly that standing up straight would be difficult.  He would need a lot of narcotic pain meds which would make him nauseated.  He wouldn’t be able to keep the Jello down so he would need an intravenous line for a few more days.  He can’t go home until he can eat.  In contrast, these days the hernia is usually fixed from the inside out.  He has a couple of little incisions where the fiber optic scope was inserted to gently pull the hernia sac back into the abdomen when it belongs.  Then a plug of mesh is used to fill up the defect.  It’s slick and so much more gentle on the patient than fixing a hernia from the outside in.  Our patient is a little bit sore but will likely feel good enough to return to his desk job in a day or two, narcotic free.

So despite all the griping about our health care delivery system, it is actually getting better, more convenient and safer.   Now if someone could figure out how to make it less expensive.  But that’s another blog.

Thanks for reading!  Dr. Lisa Lynn Sowder

 

 

General Health, Government and Politics, New Technology, Postoperative Care, Preoperative Care

F.D.A. Announces Stricter Rules on Tanning Beds

June 3rd, 2014 — 4:19pm

Seattle Plastic Surgeon is delighted with the new rules regarding the use of tanning beds.  

She just wonders what took so long????????

 

blog sun damage

Check out this article in the New York Times.  

Thanks for reading and don’t forget your sunscreen this summer.  Dr. Lisa Lynn Sowder

 

Aging Issues, General Health, Government and Politics, Skin Cancer, sun damage

Obamacare – how it will affect my practice

December 3rd, 2013 — 2:48pm

Seattle Plastic Surgeon discusses how Obamacare will affect (or not) her practice.

blog obama careThere was a time about 10 years ago when I would have been totally stressing out over the changes coming with the Affordable Care Act a.k.a. Obamacare.  But that was then and this is now and I’m not stressing out because I don’t think Obamacare is going to affect the way I treat patients.  You see, I have not contracted with any third part payers – insurance, HMO’s, PPO’s, Medicare, Medicaid, etc. – for almost 10 years.  The only financial agreements I have for providing patient care is with my patients.

Years ago, I withdrew my contracts with all the third party payers because of lousy reimbursements and even lousier service and most of all, their interference with patient care.   Believe me, I tried to make nice with the insurance industry suits but after tearing my hair out for a couple of years, I just decided not to play any more and took my ball and went home.  And now I am so glad I did.

My patients don’t have to worry if I am “on their plan” because I am not on any plans.  And I don’t have to worry about signing lousy contracts that will put me back into the third party payer circle of hell I was in ten years ago.

I like to keep it clean, direct and transparent.  You come in with a problem.  If I think I can help, I let you know what it will cost.  (Actually most of my prices are posted on my web site.  Imagine that!)  You pay me to operate on you.  If your health plan may cover the procedure I am performing, we provide you with the information and documentation you need to take to your health plan for reimbursement.

This has worked so well for me for almost a decade and I cannot imagine going back.  I acknowledge that my situation is very different that that of a heart surgeon or a family practice doc.   But my guess is that in the next few years, more physicians will push away from their marsupial relationships with Big Insurance and Big Government and embrace a practice that allows for individualized patient care, high quality, transparent financial interactions and doctor happiness.

Thanks for reading!  Dr. Lisa Lynn Sowder

Financial Issues, Government and Politics, Health Care Costs

The FDA finally catches up with the use of Botox for crows feet.

September 12th, 2013 — 2:29pm

The FDA’s approval of Botox for the treatment of crows feet makes Seattle Plastic Surgeon smile.

Botox is the best treatment for crows feet.

Botox is the best treatment for crows feet.

I’ve been using Botox for the treatment of crows feet (both my patients’ and my own!) for well over ten years.  But I had been using Botox off lable which means that the FDA had not yet approved Botox for this particular area.

Well, finally, the FDA has issued its approval stating that Botox is safe and effective for the temporay treatment of crows feet so now I can begin crowing about what an excellent treatment Botox is.  In fact, Botox is by far the fastest, safest and most effective way to tame these creases that pop up with smiling.

Thanks for reading and keep smiling.  Dr. Lisa Lynn Sowder

Botox, Government and Politics, Non-invasive

The Wizard of Insurance by Alan Rockoff, M.D.

April 23rd, 2013 — 3:06pm

Seattle Plastic Surgeon shares an essay about the crazy alternative universe of health insurance by dermatologist, Dr. Alan Rockoff.

Who is that man (or woman) behind the great Health Insurance Curtain???

Who is that man (or woman) behind the great Health Insurance Curtain???

The Wizard of Insurance by Alan Rockoff, M.D.

Thirty years ago, many college patients I saw were covered by a school health policy written by a company I will call James S. Fred Insurance. Because this happened long before electronic claims submissions, we knew that ours were handled by someone named Lucille.

For reasons I no longer recall, I found myself strolling in downtown Boston one afternoon, when I saw a large office building that listed none other than James S. Fred Insurance as a major tenant. I took the elevator to the 17th floor, went in, and asked for Lucille.

Sure enough, sitting in a quiet cubicle, there she was: a pleasant older woman who did the college accounts, a small cog in a massive wheel. When I introduced myself, Lucille recognized my name and greeted me warmly.

“I never expected to meet you in person,” I said, “But since I have, perhaps I can tell you about a problem we’re having with reimbursement. I described the issue. Lucille took out a large manual, listing the terms of the company’s college coverage. “Here it is,” she said, showing me the relevant paragraph.

I thanked her and took the book. But when I read the paragraph, I saw that it didn’t say what she said it said. I pointed this out.

“My goodness,” said Lucille. “You’re right. We should be reimbursing you for that, shouldn’t we?”

So that was it. The massive insurance giant in the glass-and-steel skyscraper turned out to be a little old lady in a cubicle who couldn’t read the manual. It was like pulling back the curtain and finding out that the Wizard of Oz was a geezer with a wind machine.

I thought of this last week when I had a talk about my own personal coverage with a Midwest insurer. The issue turned on their responsibility for covering a service provided by a physician who does not participate in Medicare at all. (Yes, I am on Medicare now.)

Last year, I spoke with a human at the company who explained that all I needed to do was confirm that the provider was not Medicare affiliated. This year, after paying a few claims, they apparently changed their mind and sent letters demanding payback and saying they would only pay what Medicare would have, even if Medicare actually didn’t.

I appealed. The appeal was denied. I could not reach a human. I gave up.

Then last week, Jeanette called from Chicago. She described herself as Head of the Appeals Division, in a voice that sounded like Marian, the no-nonsense librarian from “The Music Man.”

“Our policy is based on what’s in the manual,” she said. “Let me see if I can find it. Oh, here it is.” Then she read a passage about doctors who don’t accept Medicare assignments. “We ask them to submit claims anyway,” she explained.

“Forgive me,” I said, “but a doctor who doesn’t accept assignment is a Medicare provider, just one who won’t accept as full payment what Medicare allows. My doctor is not a Medicare provider at all. He can’t submit a claim, because he doesn’t have a Medicare provider number.”

“My goodness,” said Jeanette. “I think you may be right. Have you documented this for us?”

“With every claim,” I said. “I followed your company’s instructions, and attached to every claim my doctor’s letter saying he doesn’t participate in Medicare. You should have a dozen or so copies of this letter. If you can’t find any, I’ll be happy to send another.”

“Oh, here it is!” said Jeanette. “Yes, I see. We need to rectify this.”

I danced a mental jig around the room. Lucille must be long retired, but I’d love to invite her and Jeanette for tea.

“I’m really grateful to have the chance to speak to person,” I told Jeanette. “Thanks so much for listening.”

You could hear Jeanette glow right through the phone. “Why, you’re welcome,” she said. “You’ve made my whole day!”

Faceless bureaucracies can seem intimidating, impersonal, malevolent, diabolical, Kafkaesque.

But sometimes, they’re just little old ladies who have trouble reading manuals. To find out, just follow the yellow brick road.

Dr. Rockoff practices dermatology in Brookline, Mass.

This essay was excerpted from Skin and Allergy News Online Newsletter.  Thanks for reading and be sure to look behind the curtain!

Dr. Lisa Lynn Sowder

 

 

 

 

 

 

Government and Politics

The Physician Payment Sunshine Act – your tax dollars hard at work

April 19th, 2013 — 2:13pm

Seattle Plastic Surgeon is a little bit offended by the Physician Payment Sunshine Act but then again she is quite the Girl Scout and not easily bribed.  And where is the Congressional Payment Sunshine Act?

Sunshine is an excellent disinfectant.  Could we get it to shine a little on our politicians?????

Sunshine is an excellent disinfectant. Could we get it to shine a little on our politicians?????

The Physican Payment Sunshine Act is a nearly 300 page document about to land on the desk of doctors.  It is part of the Obama administrations ACA and is meant to keep those of us in the  medical industrial complex honest.

I must be living under a rock but apparently we doctors have been bought by the pharmaceutical and medical device companies who apparently make it a practice to shower us with fancy trips and meals and golf outings and all the pens and pocket protectors a doctor would ever need.  And all of this bribery makes us doctors prescribe drugs and use devices for patients that we otherwise would not.   Say what???????????

Maybe my memory is failing me but I just cannot think of an incident where I have used a medication or a device that I did not think was in the best interest of my patient.

I, like most doctors, do attend seminars and workshops and even anatomic cadaver labs to learn about new products and devices and how to use them and, yes, the sponsoring companies do feed us if  these events occur at mealtime.  Maybe we are just going to have to start brown bagging it lest we be overly influenced by all those Subway Sandwiches and Diet Cokes.

Sorry to sound so cranky but I’m just wondering when the sun is going to shine on those who are shining it on me.  I think they need a little cleaning up too.

Thanks for reading.  Dr. Lisa Lynn Sowder

Government and Politics

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