Understanding the Basics of Restrictive Covenants in Employment Agreements.

BACKGROUND: Restrictive covenants are common in contractual agreements involving physicians and need careful consideration to minimize potential conflict during the term of the contract and on physician departure from a group practice or hospital system. METHODS: A general overview of the different components of restrictive covenants is provided, including specific information related to noncompetes, nonsolicitations, and nondisclosure agreements. RESULTS: In general, states will uphold restrictive covenants if the elements of the noncompete are reasonable regarding geographic distance restrictions (e.g., <20 air miles), time restrictions (e.g., <2 years), and scope of services. However, states vary considerably in the interpretation of restrictive covenants. Other components of the contract, such as alternative dispute resolution (mediation and/or arbitration) and buy-out clauses (i.e., liquidated damages provisions), should be considered at the time the agreement is negotiated. CONCLUSIONS: States are balancing the protection of business interests with the protection of free trade. It is important that physicians seek counsel with an experienced health care attorney with respect to restrictive covenants in his or her specific state. A simple, well-written, and reasonable restrictive covenant can often help limit legal conflict and expense.

Measuring Outcomes in Cosmetic Abdominoplasty: The BODY-Q.

The BODY-Q is a condition-specific patient-reported outcome measure that enables a comprehensive assessment of outcomes that are specific to patients undergoing body contouring procedures such as abdominoplasty. The BODY-Q scales were designed to be responsive to the effects of abdominoplasty on health-related quality of life and appearance outcomes. The BODY-Q covers a range of content domains, and the independently functioning scales enable surgeons to tailor the BODY-Q to their needs. The application of the BODY-Q in cosmetic clinics internationally may give rise to better understanding of abdominoplasty outcomes and optimize the care delivered to patients undergoing these procedures.

Shared medical appointments for preoperative evaluation of symptomatic macromastia.

BACKGROUND: Shared medical appointments combine individual patient-physician encounters with a group educational segment. This allows for patients' needs to be addressed individually and for patients to benefit from shared learning. Shared medical appointments enhance knowledge, understanding, and management of disease by providing a variety of perspectives and experiences. In addition, physician-patient contact time and clinic efficiency are increased. This study assesses patient satisfaction and provider efficiency with shared medical appointments for symptomatic macromastia. METHODS: Patients were offered a shared medical appointment or traditional individual appointment. After the appointment, patients completed a satisfaction survey. Provider efficiency was measured by comparing visits per hour. RESULTS: Over 6 months, 26 of 28 shared medical appointment patients and 26 of 29 traditional individual appointment patients completed the survey. Patients reported 89 percent satisfaction with traditional individual appointments and shared medical appointments (p = 0.1), and both groups reported 92 percent satisfaction with thoroughness of care (p = 0.1). Seventy-seven percent of the shared medical appointment group said it was very or extremely likely they would participate in a shared medical appointment in the future. Provider efficiency increased nearly 250 percent, as patients-per-hour averaged 6.4 for shared medical appointments versus 2.67 for traditional individual appointments. CONCLUSIONS: Shared medical appointments for macromastia resulted in high patient satisfaction. Results were comparable to those of traditional individual appointments. No patients were dissatisfied, and provider efficiency improved. Shared medical appointments have unique benefits in patient education without compromising thoroughness or patient satisfaction, and offer an alternative delivery model that improves efficiency.

Access to breast reconstruction after mastectomy and patient perspectives on reconstruction decision making.

IMPORTANCE: Most women undergoing mastectomy for breast cancer do not undergo breast reconstruction. OBJECTIVE: To examine correlates of breast reconstruction after mastectomy and to determine if a significant unmet need for reconstruction exists. DESIGN, SETTING, AND PARTICIPANTS: We used Surveillance, Epidemiology, and End Results registries from Los Angeles, California, and Detroit, Michigan, for rapid case ascertainment to identify a sample of women aged 20 to 79 years diagnosed as having ductal carcinoma in situ or stages I to III invasive breast cancer. Black and Latina women were oversampled to ensure adequate representation of racial/ethnic minorities. Eligible participants were able to complete a survey in English or Spanish. Of 3252 women sent the initial survey a median of 9 months after diagnosis, 2290 completed it. Those who remained disease free were surveyed 4 years later to determine the frequency of immediate and delayed reconstruction and patient attitudes toward the procedure; 1536 completed the follow-up survey. The 485 who remained disease free at follow-up underwent analysis. EXPOSURES: Disease-free survival of breast cancer. MAIN OUTCOMES AND MEASURES: Breast reconstruction at any time after mastectomy and patient satisfaction with different aspects of the reconstruction decision-making process. RESULTS: Response rates in the initial and follow-up surveys were 73.1% and 67.7%, respectively (overall, 49.4%). Of 485 patients reporting mastectomy at the initial survey and remaining disease free, 24.8% underwent immediate and 16.8% underwent delayed reconstruction (total, 41.6%). Factors significantly associated with not undergoing reconstruction were black race (adjusted odds ratio [AOR], 2.16 [95% CI, 1.11-4.20]; P = .004), lower educational level (AOR, 4.49 [95% CI, 2.31-8.72]; P < .001), increased age (AOR in 10-year increments, 2.53 [95% CI, 1.77-3.61]; P < .001), major comorbidity (AOR, 2.27 [95% CI, 1.01-5.11]; P = .048), and chemotherapy (AOR, 1.82 [95% CI, 0.99-3.31]; P = .05). Only 13.3% of women were dissatisfied with the reconstruction decision-making process, but dissatisfaction was higher among nonwhite patients in the sample (AOR, 2.87 [95% CI, 1.27-6.51]; P = .03). The most common patient-reported reasons for not having reconstruction were the desire to avoid additional surgery (48.5%) and the belief that it was not important (33.8%), but 36.3% expressed fear of implants. Reasons for avoiding reconstruction and systems barriers to care varied by race; barriers were more common among nonwhite participants. Residual demand for reconstruction at 4 years was low, with only 30 of 263 who did not undergo reconstruction still considering the procedure. CONCLUSIONS AND RELEVANCE: Reconstruction rates largely reflect patient demand; most patients are satisfied with the decision-making process about reconstruction. Specific approaches are needed to address lingering patient-level and system factors with a negative effect on reconstruction among minority women.

Implant breast reconstruction and radiation: a multicenter analysis of long-term health-related quality of life and satisfaction.

BACKGROUND: Indications for radiotherapy in breast cancer treatment are expanding. Long-term satisfaction and health-related quality of life (HR-QOL), important outcomes after alloplastic breast reconstruction and radiation, have not been measured in irradiated patients by using a condition-specific, validated patient-reported outcomes instrument. The aim was to evaluate patient satisfaction and HR-QOL in patients with implant breast reconstruction and radiotherapy. METHODS: A multicenter cross-sectional survey of patients who underwent implant-based breast reconstruction from three centers in the United States and Canada, with and without radiation, was performed. Satisfaction with breasts, satisfaction with outcome, psychosocial well-being, sexual well-being, and physical well-being outcomes were evaluated using the BREAST-Q(©) (Reconstruction Module). Multivariable analysis was performed to evaluate the effect of radiotherapy on patient satisfaction with breasts with adjustment by patient and treatment characteristics. RESULTS: The response rate was 71 %, with 633 completed questionnaires returned. Mean follow-up was 3.3 years for irradiated patients (n = 219) and 3.7 years for nonirradiated patients (n = 414). Patients with radiation had significantly lower satisfaction with breasts (58.3 vs. 64.0; p < 0.01), satisfaction with outcome (66.8 vs. 71.4; p < 0.01), psychosocial well-being (66.7 vs. 70.9; p < 0.01), sexual well-being (47.0 vs. 52.3; p < 0.01), and physical well-being (71.8 vs. 75.1; p < 0.01) compared with nonirradiated patients. Multivariable analysis confirmed the negative effect of radiotherapy on satisfaction with breasts (ß = -2.6; p = 0.03) when adjusted for patient and treatment factors. CONCLUSIONS: Radiotherapy has a negative effect on HR-QOL and satisfaction with breasts in patients with implant reconstruction compared with nonirradiated patients. The information provided here can inform decision-making and help set appropriate expectations for patients undergoing implant breast reconstruction and radiation.

Understanding the effect of breast augmentation on quality of life: prospective analysis using the BREAST-Q.

BACKGROUND: The aim of this study was to prospectively evaluate patient satisfaction and quality of life with elective breast augmentation. METHODS: Patients with bilateral submuscular breast augmentations prospectively completed the BREAST-Q preoperatively and 6 weeks and 6 months postoperatively; t tests compared preoperative and postoperative scores at 6 weeks and 6 months, and standard indicators of effect sizes were calculated. Logistic regression was used to evaluate the association between patient and surgical factors on satisfaction outcomes. RESULTS: The study sample included 611 female patients with the following characteristics: (1) mean age of 33.5 years; (2) mean body mass index of 21.7; (3) and mean implant volume of 360; with (4) 73 percent having received a silicone implant. Significant improvements were found in patient satisfaction with breasts (p < 0.001), psychosocial well-being (p < 0.001), and sexual well-being (p < 0.001) at 6 weeks and 6 months postoperatively, and all were associated with a very large Kazis effect size of 3.66, 2.39, and 2.56 at 6 months, respectively. However, at both 6 weeks and 6 months postoperatively, physical well-being remained significantly below preoperative baseline scores. In addition, satisfaction with breasts and with the overall surgical experience was significantly lower among older patients (p = 0.01 and 0.02, respectively). CONCLUSIONS: Breast augmentation is associated with high patient satisfaction and significant improvements in quality of life. However, physicians should inform patients that submuscular augmentations are associated with a delay in recovery of physical functioning and be aware that older patients may experience diminished satisfaction and should counsel accordingly. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Professional burnout among US plastic surgeons: results of a national survey.

PURPOSE: Little is known about professional burnout among plastic surgeons. Our purpose is to describe its prevalence among a large national sample of plastic surgeons and identify contributing factors. METHODS: A mailed, self-administered survey was sent to 708 plastic surgeons who were randomly sampled from the American Society of Plastic Surgeons national membership (71% response rate). The dependent variable was professional burnout, measured by 3 subscales from the validated Maslach Burnout Inventory-Human Services Survey. "High" scores in either the emotional exhaustion or depersonalization subscale categories predict professional burnout. The independent variables included surgeon sociodemographic and professional characteristics. χ was used for the bivariate analyses. RESULTS: Nearly one third (29%) of surgeons scored high in subscale categories predictive of professional burnout. Factors associated with high emotional exhaustion scores included surgeon age, 40-50 years (P = 0.03); fair/poor physician health (P < 0.01); ER call (P < 0.01); >60 work hours per week (P = 0.03); primarily reconstructive practice (P < 0.01); private practice (P = 0.01); and group practice (P = 0.02). Factors associated with high depersonalization scores included fair/poor physician health (P= 0.01); ER call (P < 0.01); private practice (P = 0.01); and group practice (P = 0.02). CONCLUSIONS: Nearly one third of plastic surgeons have signs of professional burnout. Middle-aged surgeons and those in poor health are most at risk; along with those who have a reconstructive rather than cosmetic practice, long work hours, ER call responsibility, a nonacademic setting. and group as compared to solo practice. These data have important implications for future workforce shortages and health care quality.

Use of autologous and microsurgical breast reconstruction by U.S. plastic surgeons.

BACKGROUND: Concern exists that plastic surgeons are performing fewer autologous and microsurgical breast reconstructions, despite superior long-term outcomes. The authors describe the proportion of U.S. plastic surgeons performing these procedures and evaluate motivating factors and perceived barriers. METHODS: A random national sample of American Society of Plastic Surgeons members was surveyed (n = 325; response rate, 76 percent). Surgeon and practice characteristics were assessed, and two multiple logistic regression models were created to evaluate factors associated with (1) high-volume autologous providers and (2) microsurgical providers. Qualitative assessments of motivating factors and barriers to microsurgery were also performed. RESULTS: Fewer than one-fifth of plastic surgeons perform autologous procedures for more than 50 percent of their breast cancer patients, and only one-quarter perform any microsurgical breast reconstruction. Independent predictors of a high-volume autologous practice include involvement with resident education (odds ratio, 2.57; 95 percent CI, 1.26 to 5.24) and a microsurgical fellowship (odds ratio, 2.09; 95 percent CI, 1.04 to 4.27). Predictors of microsurgical breast reconstruction include involvement with resident education (odds ratio, 6.8; 95 percent CI, 3.32 to 13.91), microsurgical fellowship (odds ratio, 2.4; 95 percent CI, 1.16 to 4.95), and high breast reconstruction volume (odds ratio, 6.68; 95 percent CI, 1.76 to 25.27). The primary motivator for microsurgery is superior outcomes, and the primary deterrents are time and reimbursement. CONCLUSIONS: The proportion of U.S. plastic surgeons with a high-volume autologous or microsurgical breast reconstruction practice is low. Involvement with resident education appears to facilitate both, whereas time constraints and reimbursement are primary deterrents. Future efforts should focus on improving the feasibility and accessibility of all types of breast reconstruction.

Patterns of use and patient satisfaction with breast reconstruction among obese patients: results from a population-based study.

BACKGROUND: The national obesity epidemic is contributing to an increased proportion of overweight and obese breast cancer patients. The authors' purpose was to determine whether patterns of use and outcomes of reconstruction differed among obese and nonobese patients. METHODS: The authors performed a 5-year follow-up survey of mastectomy-treated breast cancer patients from the Los Angeles and Detroit Surveillance, Epidemiology and End Results Cancer Registries (response rate, 59 percent). Patients were divided into three body mass index categories: normal weight (body mass index<25 kg/m), overweight (25 to 30 kg/m), and obese (>30 kg/m). Outcomes of interest were receipt of reconstruction, type and timing of reconstruction, access barriers, and satisfaction. Chi-square and t tests were used for analysis. Logistic regression was used to identify predictors of autologous reconstruction. RESULTS: Of 374 mastectomy-treated patients, receipt of reconstruction did not vary by body mass index (53 percent normal weight, 48 percent overweight, and 45 percent obese; p=0.43). Receipt did vary by type of reconstruction: significantly more obese patients received transverse rectus abdominis musculocutaneous flaps compared with normal weight patients (53 percent versus 26 percent; p=0.01). No specific access barriers to reconstruction were identified. Patient satisfaction with surgical decision-making and surgical outcomes was similar across body mass index categories. CONCLUSIONS: Obese compared with normal weight breast cancer patients have similar use of breast reconstruction, are more likely to receive an autologous procedure, and report similar satisfaction with surgical outcomes. Future efforts should be directed at decreasing the surgical risk in this challenging patient population. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

The effect of abdominal wall plication on intra-abdominal pressure and lower extremity venous flow: a case report.

Abdominal wall plication is known to cause increased intra-abdominal pressure (IAP). Whether plication-associated increased IAP causes lower extremity venous stasis, a recognized risk factor for DVT, remains unknown. A 55-year-old woman had a unilateral pedicled TRAM procedure for mastectomy reconstruction. Prior to plication, duplex ultrasound measured proximal femoral vein (PFV) cross-sectional diameter and volume-flow. PFV measurements were repeated immediately after plication and on post-operative days (POD) 1, 2, and 4. Bladder pressure was measured at similar timepoints. PFV volume-flow decreased from 0.22 L/min to 0.16 L/min (73% of baseline) immediately post-plication and reached a nadir of 0.08 L/min (36% of baseline) on POD 2. Bladder pressure increased from 13 mm Hg to 19 mm Hg after plication, and peaked at 31 mm Hg after intra-operative trunk flexion to 30°. Thus, abdominal wall plication was associated with increased intra-abdominal pressure and ultrasound-documented lower extremity venous stasis that persisted for 48 h after surgery.