Plastic Surgeon Financial Compensation-Incentivization Models in Surgical Care Delivery: The Past, Present, and Future.

BACKGROUND: Surgeons are critical for the success of any health care enterprise. However, few studies have examined the potential impact of value-based care on surgeon compensation. METHODS: This review presents value-based financial incentive models that will shape the future of surgeon compensation. The following incentivization models will be discussed: pay-for-reporting, pay-for-performance, pay-for-patient-safety, bundled payments, and pay-for-academic-productivity. Moreover, the authors suggest the application of the congruence model-a model developed to help business leaders understand the interplay of forces that shape the performance of their organizations-to determine surgeon compensation methods applicable in value-based care-centric environments. RESULTS: The application of research in organizational behavior can assist health care leaders in developing surgeon compensation models optimized for value-based care. Health care leaders can utilize the congruence model to determine total surgeon compensation, proportion of compensation that is short term versus long term, proportion of compensation that is fixed versus variable, and proportion of compensation based on seniority versus performance. CONCLUSION: This review provides a framework extensively studied by researchers in organizational behavior that can be utilized when designing surgeon financial compensation plans for any health care entity shifting toward value-based care.

Complications With Time-to-Ambulation Following Skin Grafting for Burn Patients: A Meta-Analysis and Systematic Review.

Accurate models are fundamental tools for risk-stratification, therapy guidance, resource-allocation, and comparative-effectiveness research. Enhanced recovery after surgery (ERAS) protocols increase early post-operative recovery rates in surgical patients. The uniqueness of burn injuries and their post-operative care requires developing a specialized protocol, enhanced recovery after burn surgery (ERABS). To develop such a protocol, we need to examine post-operative practices, like time-to-ambulation, and their effect on post-operative complications. We evaluated evidence supporting complications such as graft loss, thrombolytic events, and pain, relating to the timing of post-surgical ambulation. A literature search on early-ambulation and skin-grafting was performed by two independent researchers. No time limit was set for publication dates. Relevant studies relating to ambulation of adult burn patients (>18 years of age) and their post-surgical outcomes were captured using search terms. Of the 888 studies retrieved from the query, 11 were used for review and meta-analysis. Our review revealed minimal evidence exists relating to thromboembolic events and time-to-ambulation in post-operative burn patients. The evidence that does exist found no significant difference in the number of events between early- and late-ambulation groups. Increased pain during rest and ambulation was shown in patients with delayed ambulation after five or more days. One study found an increased infection rate in late-ambulatory patients. The primary conclusion from this review is that further studies must be performed examining the correlation of thromboembolic events and infection rates with post-operative time-to-ambulation. Based on current literature, early ambulation should be included as part of a future model of ERABS.

Impact of FDA Updates on Public Interest in Breast Implant-associated Anaplastic Large Cell Lymphoma.

In the United States, the Food and Drug Administration (FDA) is responsible for protecting the public health by assuring the safety, efficacy, and security of drugs, biological products, and medical devices. In that role, FDA releases timely updates with regard to medical devices and their possible adverse effects. However, the impact of such FDA updates on public interest has not been studied. The timing of multiple FDA updates regarding Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) was noted from September 2014 to September 2019. Impact on Public interest related to ALCL was measured using Google Trends and the number of YouTube video uploads. These objective markers were used to compare the public interest during FDA updates versus weeks with no FDA updates. Five major updates were released by FDA regarding BIA-ALCL during the past 5 years. Google Trends demonstrated a significant increase in public interest regarding ALCL during the week of FDA release, with a mean score of 69 ± 20.82 when compared with a mean score of 10.68 ± 4.71 (P < 0.001) during weeks with no FDA release. The mean number of YouTube videos uploaded during the period of FDA release was 11.8 ± 9.42, which was significantly higher than the mean of 2.42 ± 1.31 videos (P < 0.001) during the period of no FDA updates. FDA updates correlates with temporal increase in public interest. Plastic surgeons should be aware of FDA information releases on BIA-ALCL and anticipate an increased interest in additional information from patients and the public.

The First Reported Case of Metoprolol-Induced Pemphigus Foliaceus in the United States: A Critical Report and Review of Literature.

Pemphigus is a rare family of autoimmune disorders characterized by epithelial and mucosal blisters. Pemphigus foliaceus (PF) commonly affects the scalp, face, and trunk. Lesions often arise as superficial blisters and develop into scaly, crusted erosions. Management includes corticosteroids with immunosuppressants. Novel therapies include immunoadsorption and active clinical trials. We present the only reported case of metoprolol-induced PF in the United States (US), with an extremely complicated hospital course.  A 66-year-old male patient with a history of hypertension, diabetes, and hyperlipidemia presented to his doctor with a blistering, pruritic rash that started after switching to metoprolol for hypertension treatment.  PF is very rare in North America. Given its solely superficial penetration, it creates no direct fatal complication. However, the developing blisters and subsequent wounds are susceptible to a wide array of secondary infections, which can be life-threatening.

The Added Benefit of Combining Laser Doppler Imaging With Clinical Evaluation in Determining the Need for Excision of Indeterminate-Depth Burn Wounds.

Background Managing indeterminate-depth burn wounds remains challenging. Laser Doppler Imaging (LDI) has been validated for burn wound depth and can influence the clinical assessment. Our study investigated the value of LDI as an adjunct in determining the need for excision. Methods Seventy American Burn Association (ABA)-verified burn centers were surveyed. A controlled pre-test assessment without LDI and post-test assessment with LDI of 100 indeterminate-depth burn wounds was conducted to evaluate the influence on the clinical judgment among different health professionals. Relative risk, analysis of variance (ANOVA), paired t-test, and intention-to-treat were used for analysis. A p-value [Formula: see text] 0.05 was considered significant.  Results Among 32 burn centers, three confirmed using LDI. Six thousand grader-image interactions were analyzed. There was a significant difference in the predictive accuracy for pre-LDI and post-LDI assessments when all graders were considered (51.9% ± 7.0 vs. 72.9% ± 7.9; p < 0.0001). Post-LDI assessment added 20.9% more accuracy than the pre-LDI assessment. The post-LDI assessment was 1.4 times more likely to correctly predict the need for excision and skin-grafting than the pre-LDI assessment. All groups had an improved performance post-LDI: Group 1 (physicians), 51.9 ± 7.5 versus 76.4±5; Group 2 (nurses), 52.1 ± 6.1 versus 72.7±7.7; and Group 3 (others), 51.7 ± 9.2 versus 68.6 ± 10.1. No statistical difference was observed between groups (p = 0.92).  Conclusion LDI makes the clinical examination of indeterminate-depth burn wounds more accurate. For every five LDI evaluations performed, one assessor changed their treatment plan as a result of this imaging technique. LDI is cost-effective and increases the accuracy of determining the severity of indeterminate-depth burn wounds.

Two False Negative Test Results in a Symptomatic Patient with a Confirmed Case of Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) and Suspected Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis (SJS/TEN).

The recent outbreak of COVID-19 has put significant strain on the current health system and has exposed dangers previously overlooked. The pathogen known as severe acute respiratory syndrome coronavirus 2 (SARS-COV-2), is notable for attacking the pulmonary system causing acute respiratory distress, but it can also severely affect other systems in at-risk individuals including cardiovascular compromise, gastrointestinal distress, acute kidney injury, coagulopathies, cutaneous manifestations, and ultimately death from multi-organ failure. Unfortunately, the reliability of negative test results is questionable and the high infectious burden of the virus calls for extended safety precautions, especially in symptomatic patients. We present a confirmed COVID-19 case that was transferred to our burn center for concern of Steven Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) overlap syndrome after having two negative confirmatory COVID-19 tests at an outside hospital. A 58-year-old female with a history of morbid obesity, HTN, gout, CML managed with imatinib, and chronic kidney disease presented as a transfer from a community hospital to our burn center. The patient was admitted to her community hospital with febrile, acute respiratory distress. Imaging and clinical presentation was consistent with COVID-19 and lab tests for the pathogen were ordered. During observation, while waiting for results, she was placed under patient under investigation (PUI) protocol. Once negative results were obtained, the PUI protocol was abandoned despite ongoing symptoms. Subsequently, dermatological symptoms developed and transfer to our burn center was initiated. After a second negative test result, the symptomatic patient was transferred to our burn center for expert wound management. Given the lack of resolve of respiratory symptoms and concern for the burn patient population, the patient was placed in PUI protocol and an internal COVID-19 was ordered. The patient's initial exam under standard COVID-19 airborne precautions revealed 5% total body surface area of loss of epidermis affecting bilateral thighs, bilateral arms, and face. A dermatopathological biopsy suggested a bullous drug reaction with an erythema multiform-like reaction pattern versus SJS/TEN. Moreover, the internal COVID-19 test returned positive. The delayed positive test results and complicated hospital course with our patient required us to scale back and notify every patient and staff member whom they came in contact with, across multiple institutions. We suggest that whenever a suspected COVID-19 patient is transferred to a specialized center, they should be isolated and re-checked before joining the new patient population for treatment of the unique condition.

Hemosiderotic Dermatofibroma: A Rare and Atypical Variant Capable of Clinically Resembling Melanoma.

A dermatofibroma (DF) is a common, benign tumor composed of fibroblastic and histiocytic cells. DF presents clinically with several different reported variants. One rare variant is hemosiderotic DF (HDF), which is made up of small blood vessels and hemosiderin deposits. HDF can be indistinguishable, clinically, from melanoma, making the use of other pathological tools crucial in the diagnosis. We report the case of a 25-year-old male medical student from the Caribbean who presented to our clinic with a single asymptomatic pigmented cystic lesion on his left posterior calf. The cystic lesion was excised surgically. Histopathology examination of the excised mass revealed a moderately cellular, poorly demarcated, dermal, fibrohistiocytic proliferation. Pathology consultation confirmed a diagnosis of HDF.

Get on your boots: preparing fourth-year medical students for a career in surgery, using a focused curriculum to teach the competency of professionalism.

INTRODUCTION: Few educational programs exist for medical students that address professionalism in surgery, even though this core competency is required for graduate medical education and maintenance of board certification. Lapses in professional behavior occur commonly in surgical disciplines, with a negative effect on the operative team and patient care. Therefore, education regarding professionalism should begin early in the surgeon's formative process, to improve behavior. The goal of this project was to enhance the attitudes and knowledge of medical students regarding professionalism, to help them understand the role of professionalism in a surgical practice. METHODS: We implemented a 4-h seminar, spread out as 1-h sessions over the course of their month-long rotation, for 4th-year medical students serving as acting interns (AIs) in General Surgery, a surgical subspecialty, Obstetrics/Gynecology, or Anesthesia. Teaching methods included lecture, small group discussion, case studies, and journal club. Topics included Cognitive/Ethical Basis of Professionalism, Behavioral/Social Components of Professionalism, Managing Yourself, and Leading While You Work. We assessed attitudes about professionalism with a pre-course survey and tracked effect on learning and behavior with a post-course questionnaire. We asked AIs to rate the egregiousness of 30 scenarios involving potential lapses in professionalism. RESULTS: A total of 104 AIs (mean age, 26.5 y; male to female ratio, 1.6:1) participated in our course on professionalism in surgery. Up to 17.8% of the AIs had an alternate career before coming to medical school. Distribution of intended careers was: General Surgery, 27.4%; surgical subspecialties, 46.6%; Obstetrics/Gynecology, 13.7%; and Anesthesia, 12.3%. Acting interns ranked professionalism as the third most important of the six core competencies, after clinical skills and medical knowledge, but only slightly ahead of communication. Most AIs believed that professionalism could be taught and learned, and that the largest obstacle was not enough time in the curriculum. The most effective reported teaching methods were mentoring and modeling; lecture and journal club were the effective. Regarding attitudes toward professionalism, the most egregious examples of misconduct were substance abuse, illegal billing, boundary issues, sexual harassment, and lying about patient data, whereas the least egregious examples were receiving textbooks or honoraria from drug companies, advertising, self-prescribing for family members, and exceeding work-hour restrictions. The most important attributes of the professional were integrity and honesty, whereas the least valued were autonomy and altruism. The AIs reported that the course significantly improved their ability to define professionalism, identify attributes of the professional, understand the importance of professionalism, and integrate these concepts into practice (all P < 0.01). CONCLUSIONS: Although medical students interested in surgery may already have well-formed attitudes and sophisticated knowledge about professionalism, this core competency can still be taught to and learned by trainees pursuing a surgical career.

Changing characteristics of facial fractures treated at a regional, level 1 trauma center, from 2005 to 2010: an assessment of patient demographics, referral patterns, etiology of injury, anatomic location, and clinical outcomes.

INTRODUCTION: Despite improvements in automotive safety, motor vehicle collision (MVC)-related facial fractures remain common and represent preventable injuries. This study examines the changing characteristics of facial fractures treated at a regional, level I trauma center, from 2005 to 2010. METHODS: We identified all patients with facial fractures admitted to our hospital, from 2005 to 2010, by querying the North Carolina Trauma Registry, using International Classification of Diseases, Ninth Revision codes. Prospectively collected data, sorted by year, were descriptively analyzed for demographics, referral patterns, etiology, anatomic location, and clinical outcomes. RESULTS: Number of patients with facial fractures increased from 201 per year to 263 per year (total n = 1508). Although transport distances remained constant at ∼85 miles, standard deviation increased from 37 to 68 miles. Transport time increased from 87 to 119 minutes. Referrals came from 28 surrounding counties in 2005 and 43 counties in 2010. Regarding etiology, MVCs decreased from 40% to 27%, all-terrain vehicle crashes decreased from 6% to 2%, falls increased from 8% to 19%, and bicycle accidents increased from 3% to 6%. Regarding anatomic location, frontal sinus fractures increased from 8% to 37%, zygomaticomaxillary fractures increased from 9% to 18%, nasoethmoid fractures decreased from 12% to 6%, orbital floor fractures decreased from 6% to 3%, and mandible fractures decreased from 28% to 18%. Single-site fractures increased from 75% to 90%. Length of intensive care unit and hospital stay remained stable at 3 and 7 days, respectively. CONCLUSIONS: Despite a decrease in MVC-related facial fractures, the overall increase in facial fractures referred to our trauma center is due to a growing number of patient transfers from rural hospitals, where a paucity of qualified surgeons may exist.

Management of recurrent hernia after components separation: 10-year experience with abdominal wall reconstruction at an academic medical center.

PURPOSE: Separation of the components has become the standard of care for abdominal wall reconstruction, especially in the setting of infected, previously infected, or contaminated wounds. Although the safety and efficacy of this technique have been established, less is known about long-term outcomes. This article focuses on the management of recurrent hernia after components separation for abdominal wall reconstruction. METHODS: We performed a retrospective, institutional review board-approved study of components separation for abdominal wall reconstruction at an academic medical center, over a 10-year period. RESULTS: Between 2000 and 2009, we performed components separation in 136 patients (mean follow-up, 4.4 years). Twenty-six patients (19.1%) developed recurrent hernia (mean age, 49.8 years; body mass index, 30.7; previous abdominal operations, 3.5; hernia size, 342 cm; length of stay, 9.1 days). Mean time to recurrence was 319 days. Of the 16/26 patients who underwent repair of recurrence, 15 had successful repair, leaving 11/136 patients (8.1%) with persistent hernia. Of the 26 recurrences, 22 (85%) occurred within the first half of the study. Repair of recurrent hernias was accomplished by placement of additional mesh in 14/15 patients. CONCLUSIONS: Recurrent hernia after components separation may be related to procedural learning curves and can be successfully treated through repeat repair, yielding high rates of successful abdominal wall reconstruction.

Comparison of outcome after mesh-only repair, laparoscopic component separation, and open component separation.

Component separation (CS) has been advocated as the technique of choice to reconstruct complex abdominal hernia defects, especially in the setting of gross contamination. However, open CS was reported to have relatively high incidences of wound complications. Minimally invasive approaches to CS were proposed by several surgeons to reduce wound morbidity. To date, there are limited comparative data between minimally invasive CS (MICS) versus open CS. In this article, we reviewed existing literature on open CS versus MICS with respect to their recurrence and complication rates. Our analysis appeared to show that MICS has comparable recurrence and complication rates relative to open CS although our analysis had several limitations. To demonstrate the management of complications after MICS, we reported our experience of using MICS to repair a recurrent incisional hernia in a 63-year-old man after a perforated ulcer.

Utility of the omentum in pelvic floor reconstruction following resection of anorectal malignancy: patient selection, technical caveats, and clinical outcomes.

This study assesses the usefulness of the omentum in the reconstruction of complex perineal defects, following abdominoperineal resection or pelvic exenteration, for anorectal malignancy. Between 2000 and 2008, 70 patients (mean age: 59 years) with anorectal malignancy underwent abdominoperineal resection (n = 57) or pelvic exenteration (n = 13) and were reconstructed by primary repair alone (n = 13), primary repair with omentum (n = 16), myocutaneous flap alone (n = 28), or myocutaneous flap with omentum (n = 13). Patients with and without omental flaps were compared by Student t test and chi2 analysis. Omental flaps were based on a single pedicle, tunneled in the retrocolic plane lateral to the ligament of Treitz, and transposed across the sacrum to the pelvic floor. In total, 29 patients had pelvic floor and perineal reconstruction with the omentum, and 41 patients had reconstruction without the omentum. Incidence of major pelvic complications (abscess, urinoma, deep vein thrombosis, flap dehiscence, hernia, bowel obstruction, fistula) was greater in the "no omentum" group (25/41 patients, 61%), compared with the "omentum" group (6/29 patients, 21%) (P < 0.01). No differences were observed regarding age, stage, incidence of radiotherapy, blood loss, length of stay, or mortality. Use of the omentum as a primary flap, or in combination with a myocutaneous flap, in the reconstruction of complex perineal defects, is associated with a decreased incidence of postoperative complications, strongly supporting the use of the omentum in pelvic floor reconstruction.

Incisional ventral hernias: review of the literature and recommendations regarding the grading and technique of repair.

Despite advances in surgical technique and prosthetic technologies, the risks for recurrence and infection are high following the repair of incisional ventral hernias. High-quality data suggest that all ventral hernia repairs should be reinforced with prosthetic repair materials. The current standard for reinforced hernia repair is synthetic mesh, which can reduce the risk for recurrence in many patients. However, permanent synthetic mesh can pose a serious clinical problem in the setting of infection. Assessing patients' risk for wound infection and other surgical-site occurrences, therefore, is an outstanding need. To our knowledge, there currently exists no consensus in the literature regarding the accurate assessment of risk of surgical-site occurrences in association with or the appropriate techniques for the repair of incisional ventral hernias. This article proposes a novel hernia grading system based on risk factor characteristics of the patient and the wound. Using this system, surgeons may better assess each patient's risk for surgical-site occurrences and thereby select the appropriate surgical technique, repair material, and overall clinical approach for the patient. A generalized approach and technical considerations for the repair of incisional ventral hernias are outlined, including the appropriate use of component separation and the growing role of biologic repair materials.