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: Highly Recommended Reading


“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

Off to college? Words of wisdom.

August 26th, 2019 — 9:35am

Four years ago I sent my twin sons off to college. Last Saturday I help their little sister move into her dorm.  And then I cried.  A lot. 

For those parents doing this for the first time, second, third or fourth time,  and for all those lucky youngsters heading off to college, let me share this wonderful essay with you.

blog off to collegeCoping with the angst of dropping off your child at college by Kent Hickey.

From the Seattle Times, August 29, 2014.

All around the country freshmen are filling up suitcases for college. Their parents’ heads are filling up too, mostly with “remember when.”

As we prepared to send our first off to college, my mind kept revisiting all those Saturday mornings in parks when our kids were little. They loved to sneak acorns into my pockets and run away laughing as if they had pulled off some grand caper. One day I caught the eye of an older gentleman as he walked by. “Enjoy it while you can,” he said. “This passes fast.”

It has. And that first college drop-off was a big moment for all of us, especially for our daughter, though one likely eclipsed by that even bigger moment when she finally received the highly anticipated and much practiced “Dad’s Wisdom for College” talk.

I found the perfect setting a few days before departure: a car ride to the grocery store, doors locked and vehicle in motion to guard against the inevitable triggering of the daughter’s flight response.

Here it is:

“Introverts draw energy from solitude. Extroverts draw it from company. Know who you are and find your balance.

“Dads are awesome; boys are not. Always do what Dad would think is right. Never do what a boy thinks is right.

“The single most stupid thing done in college is almost always done while drunk. And, while getting high on marijuana may not necessarily lead to doing equally stupid things, it will lead to doing fewer things. Don’t be stupid.

“God has been a friend in your life every day, whether you’ve known it or not. Bring your friend to college with you and spend time with your friend every day.

“You will never really leave your home.”

It’s hard to say what the daughter took from these pearls, especially with all the other messages, often mixed, that young people hear as they prepare to head off for college:

Explore, find yourself; just make sure you earn a marketable degree that guarantees high lifetime earnings. Don’t be afraid to meet new people, but be wary given all those sexual assaults on campuses. Become a lover of learning without obsessing over grades, though they will likely decide your future.

Colleges are now keenly aware of how hard the drop-off is on my generation, the baby boomers. Upon our arrival on campus the daughter was quickly immersed in her orientation. The same experience awaited parents. I’ve never felt so nurtured, or exhausted.

There were days of parent orientation, each session starting with a “Relax, it will all be fine.” Heck, the school’s president even gave out his personal cell number, just in case we needed to chat, and I don’t even think it was fake. When did we become so needy?

My folks, who were of the World War II and Korean War generation, drove me from our home in Kalamazoo, Mich., to Marquette University in Milwaukee 35 years ago. We had one stop along the way, at the Mars Cheese Castle in Kenosha, went straight to my dorm upon arrival and quickly deposited the contents of one suitcase in my room.

Then Mom gave me a tearful hug, Dad an awkward handshake. Right after I moved in, they moved on. No dayslong orientation for them, and hardly one for me. My first lesson was given that very night by two sailors who tried to mug me when I got lost in an alley behind some dorms. I ran away and hid in a dumpster. A passing grade, if not a very courageous one.

Yes, a lot has changed, but one thing hasn’t. That drop-off moment is just really hard.

Right after the final goodbye the daughter gently slipped an acorn into my hand. I’m glad I had already said all that I wanted to say. I couldn’t talk anymore.

Kent Hickey is president of Seattle Preparatory School.

Thanks for reading!  Dr. Lisa Lynn Sowder

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

 

Children, Highly Recommended Reading

Off to college? Words of wisdom.

August 23rd, 2016 — 10:11am

A year ago I sent my twin sons off to college.  This year it will be a little easier. 

For those parents doing this for the first time and for all those lucky youngsters heading off to college, let me share this wonderful essay with you.

blog off to collegeCoping with the angst of dropping off your child at college by Kent Hickey.

From the Seattle Times, August 29, 2014.

All around the country freshmen are filling up suitcases for college. Their parents’ heads are filling up too, mostly with “remember when.”

As we prepared to send our first off to college, my mind kept revisiting all those Saturday mornings in parks when our kids were little. They loved to sneak acorns into my pockets and run away laughing as if they had pulled off some grand caper. One day I caught the eye of an older gentleman as he walked by. “Enjoy it while you can,” he said. “This passes fast.”

It has. And that first college drop-off was a big moment for all of us, especially for our daughter, though one likely eclipsed by that even bigger moment when she finally received the highly anticipated and much practiced “Dad’s Wisdom for College” talk.

I found the perfect setting a few days before departure: a car ride to the grocery store, doors locked and vehicle in motion to guard against the inevitable triggering of the daughter’s flight response.

Here it is:

“Introverts draw energy from solitude. Extroverts draw it from company. Know who you are and find your balance.

“Dads are awesome; boys are not. Always do what Dad would think is right. Never do what a boy thinks is right.

“The single most stupid thing done in college is almost always done while drunk. And, while getting high on marijuana may not necessarily lead to doing equally stupid things, it will lead to doing fewer things. Don’t be stupid.

“God has been a friend in your life every day, whether you’ve known it or not. Bring your friend to college with you and spend time with your friend every day.

“You will never really leave your home.”

It’s hard to say what the daughter took from these pearls, especially with all the other messages, often mixed, that young people hear as they prepare to head off for college:

Explore, find yourself; just make sure you earn a marketable degree that guarantees high lifetime earnings. Don’t be afraid to meet new people, but be wary given all those sexual assaults on campuses. Become a lover of learning without obsessing over grades, though they will likely decide your future.

Colleges are now keenly aware of how hard the drop-off is on my generation, the baby boomers. Upon our arrival on campus the daughter was quickly immersed in her orientation. The same experience awaited parents. I’ve never felt so nurtured, or exhausted.

There were days of parent orientation, each session starting with a “Relax, it will all be fine.” Heck, the school’s president even gave out his personal cell number, just in case we needed to chat, and I don’t even think it was fake. When did we become so needy?

My folks, who were of the World War II and Korean War generation, drove me from our home in Kalamazoo, Mich., to Marquette University in Milwaukee 35 years ago. We had one stop along the way, at the Mars Cheese Castle in Kenosha, went straight to my dorm upon arrival and quickly deposited the contents of one suitcase in my room.

Then Mom gave me a tearful hug, Dad an awkward handshake. Right after I moved in, they moved on. No dayslong orientation for them, and hardly one for me. My first lesson was given that very night by two sailors who tried to mug me when I got lost in an alley behind some dorms. I ran away and hid in a dumpster. A passing grade, if not a very courageous one.

Yes, a lot has changed, but one thing hasn’t. That drop-off moment is just really hard.

Right after the final goodbye the daughter gently slipped an acorn into my hand. I’m glad I had already said all that I wanted to say. I couldn’t talk anymore.

Kent Hickey is president of Seattle Preparatory School.

Thanks for reading!  Dr. Lisa Lynn Sowder

 

Children, Highly Recommended Reading

Male journalist takes on Redbook’s Web Site. IMO male journalist wins.

October 7th, 2013 — 1:42pm

Seattle Plastic Surgeon shares Wall Street Journal Article from Saturday, Oct. 5, 1013:

Words Assured to Tick Off Any Man by Joe Queenan

Redbook’s website has just published a list of things you should never say to a man. Why not? Because they will make him go ballistic. The list includes such incendiary remarks as: “Your tummy is so cute,” “Do whatever you want,” “Do you think I actually believe you?” “You’re just like your dad” and the real, Katy-bar-the-door, no quarter-asked-and-none-given haymaker in this epic inter-gender brouhaha, “I really don’t respect you.”

[image] Illustraction by Nishant Choksi

Redbook, for whatever reason, is feeding impressionable young women totally false information about the male psyche. No man I know would go ballistic just because a woman said, “Your tummy is so cute.” Nor would he lose it if she said, “Well, you are a bit on the chubby side.” Or even “My, aren’t you the chunky little butterball!”

Men don’t care about their “tummies.” Never have. Never will. If they did, alcohol would have gone out of style a long time ago. Weenies might care about their tummies. Or hipsters. But not actual men. Besides, men do not refer to their flabby stomachs as “tummies.” They call them “beer guts.” At least Redbook could try to get the lingo right.

A deeper question is where this dubious material comes from. Who says “Your tummy is so cute” to a boyfriend, a partner, a spouse? Not any woman I’ve ever heard of. Did anyone actually poll men about this stuff? Or women?

The rest of the list is no better. Men don’t care if their partners do not believe them. They kind of expect it. Men also don’t care if you tell them to go ahead and do whatever they want. This is what men do anyway. It is also what women do. It is what everyone on the planet does.

Similarly, few men would object to being likened to their fathers. To most men, that’s actually the highest praise imaginable, unless your dad is named Joseph Stalin or Timur the Tartar. No, with the obvious exception of the confrontational “I really don’t respect you,” none of these remarks is even vaguely discombobulating.

And even if a man took exception to being told that he was not “respected,” he would not automatically go ballistic. He would write it off as an ill-advised comment uttered in the heat of battle. He would figure that it was par for the interpersonal course.

The list contained in Redbook is inane, misleading and stupid. It’s like those lists: “174 Things That Drive Women Wild in Bed,” or “Seven Things You Should Never Say to a Bisexual Pyromaniac.” The lists are compiled by amateur sociologists, office cut-ups, puckish ne’er-do-wells and editorial interns who are trying to get their assignments wrapped up before they go back to high school.

This is not to deny that there are phrases that will make men go ballistic. Oh no, there are lots of those. Here are just a few things you should never say to a man with whom you are having any kind of serious relationship.

“I spent all the money. All of it. On Josh Groban tickets.” “I was thinking of gaining 130 pounds. I’m feeling gaunt.” “No, you cannot invite Macho Man and Bennie the Blade over to our 35th anniversary party.” “You know the $5,000 from your Christmas bonus that you thought I was investing in safe, short-term bonds? I took a flier on a penny stock issued by a boiler room in Boca Raton. The company makes pocket-size defibrillators.” “Your mother could give Medusa a run for her money.” “You know the kid you thought was your firstborn son? Wrong!”

And finally: “I told the four guys from the Bronx that you are no longer interested in paying the vig. I did OK, right?”

 

Thanks for reading!  And if you don’t subscribe to the Wall Street Journal, you should.  It has some of the best journalism out there and it’s not just about money and business.  Dr. Lisa Lynn Sowder

For Men Only, Highly Recommended Reading, Male Plastic Surgery, Stuff I love

I’m so sad about Nora Ephron.

June 27th, 2012 — 4:32pm

Seattle Plastic Surgeon wonders how she will survive the rest of her “aging journey” without Nora Ephron. 

I am so sad to hear of Nora Ephron’s death.   I wonder how I am going to survive the next few decades of life without having another pithy Nora Ephron book to make me laugh out loud about the adventures and misadventure of making the transition from youth to middle age to older to old.   I am hoping to hear in the next few days that Nora was finishing her book about the ultimate transition at the time of her death.  If anyone could make that funny, it would be Nora. 

I’ve enjoyed Nora’s writing for decades, but it’s really been since I became a “woman of a certain age” myself that I have truly appreciated her wonderful take on this journey of life and her wise wit (or maybe it’s witty wisdom).

I Feel Bad About My Neck and I Remember Nothing are her most recent books and I devoured both of them in one sitting.  I read I Remember Nothing on a flight from Seattle to Boston and I’m sure the dudes on either side of  me thought I was off my meds.  Can anything other than a Nora Ephron book  make flying coach, middle seat, so much fun?  I think not.

Rest in peace Nora and thank you for the laughs and tears and your amazing humor and humanity.  I’m going to load all your books onto my Kindle and read them – again. 

Lisa Lynn Sowder, M.D.

Aging Issues, Highly Recommended Reading

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