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Entries by Dr. Daniel Kaufman (9)


Getting Naked on the Internet: What does the law say?

Telemedicine and Cyber Security

The Health Information Portability and Accountability Act (HIPAA) is a federal law that protects the privacy of your personal health information (PHI). HIPAA includes several rules and provisions that set guidelines and requirements for the administration and enforcement of HIPAA. The relevant ones for the exchange of PHI in the digital cyberspace are the Privacy Rule1, the Security Rule2, and the aptly named Health Information Technology for Economic and Clinical Health (HITECH) Act3.

Telemedicine is a burgeoning field of medicine that incorporates digital technology such as electronic health records (EHR), information sharing, and videoconferencing to enhance the interaction between physicians and their patients, and ultimately, improve the delivery of healthcare. Having been a plastic surgeon for several years now, I’m all too familiar with meeting people at social events, and immediately getting bombarded with intrusive and unusual questions and requests as soon as my chosen profession is ousted. Sure, it’s unlikely that a woman will disrobe and expose herself in front of me and my wife at a friend’s dinner party, but get us into an online “private” videoconference call, and who knows what body parts will make an abrupt entrance into the conversation. Physicians must approach with caution, says American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) President Stephen S. Park, M.D. in a recent article4. But, for me and most physicians I know, I feel like the cat is already out of the bag. Considering the amount of texts, emails, online chats, phone conversations over internet and satellite lines, and selfies of both pre- and post-op patients I’ve been privy to, I’m sure I’ve already broken too many laws, and completely disregarded the good doctor’s advice. The truth is, though, that we’ve only begun to scratch the surface.

Telemedicine may involve the electronic exchange of PHI which is protected under HIPAA law. Security considerations with telemedicine involve making sure unauthorized third parties cannot eavesdrop on or record a videoconferencing session where sensitive PHI is transmitted seamlessly, and unfortunately, innocently. Recently, a monumental data breach at one of the nation’s largest insurance providers has spurred a bipartisan political effort to reexamine HIPAA as it relates to telemedicine, possibly adding costly and cumbersome requirements to encrypt EHR data5. Additionally, a recent report done by BitSight Technologies, a cyber security risk analysis and management firm, found that healthcare and pharmaceutical companies ranked the lowest among the four industry categories studied6. Suffice it to say, people are taking heed of this emerging new threat.

The aforementioned laws, rules, and regulations guide the generation, maintenance, and implementation of telemedicine HIPAA compliance. We must be cautioned, though, that HIPAA compliance does not necessarily equate to actual cyber security, and that simply meeting standards set forth in these regulations may not be enough. As more public attention and scrutiny rise to the forefront of media exposure, look for the healthcare industry to take the cyber security threat much more seriously.

Daniel Kaufman, MD
Discreet Plastic Surgery



My breasts are cold!!

“My breasts are cold!!” said a patient of mine in her last postop visit. We did a breast augmentation with saline implants just a few weeks ago, and her postop recovery has been smooth and uneventful. It’s been an unusually cold winter this year, with Arctic blasts and heavy snowstorms, so this kind of complaint shouldn’t be surprising. I guess my southern colleagues and readers have already tuned out, I don’t remember my plastic surgeon buddies in Miami complaining about any snow, but they don’t only do breast implants in Miami you know…

Cosmetic plastic surgery, being elective in nature, is always risky business. We surgeons take the utmost effort to warn our patients about all reasonable risks and alternatives to our various procedures. But, “your breasts might feel cold when it’s cold outside” is usually not part of my consultation. In the grand scheme of things, unless you find yourself in the perfect storm of running a saline implant breast augmentation private practice in Alaska, cold breasts are probably down at the bottom of your risk list. But it is an interesting phenomenon that happens due to the specific heat of water – greatest of all substances known to man. Water, which is for all intents and purposes the major component of saline, can absorb lots of energy, and thus, is hard to heat and hard to cool. Consequently, when it’s cold outside, your saline breast implants are going to get cold. And the bigger the implants, the colder you’ll be. Now once they get cold, it’ll take just as much time in warm weather, indoors or outdoors, for them to warm up.

I find it hard enough to go thru the list of relevant risks as it is, but I suppose as long as we have cold weather and saline breast implants, cold implants are a relevant risk. Now, when I mention it in my consultations, I get more chuckles from my patients than anything else. So, I suppose that little bit of comic relief is a good effect in what is, in the least, an arduous process of informed consent. Now back to all this cold winter weather, I suppose it’s just global warming….

Daniel Kaufman, MD
Discreet Plastic Surgery 


Everybody Needs a Marijana – Marketing of Medical Practices in the Information Age

A young doctor asked me the other day how new patients, excluding patients who were referred by other doctors or previous patients, find their way to my practice. We were hanging out in a crowded party in a loud room so I couldn’t elaborate too much, but I managed to belt out one word that would sum it up: Marijana. That is actually the name of the Director of Marketing, Advertising, and Web Presence in my plastic surgery practice – Discreet Plastic Surgery. If you ask her, she’d probably tell you that she NEVER expected to be working for a plastic surgeon. But if you ask me, she’s an integral part of our practice, and should be so for all doctors, especially those in private practice.

As I finished up my training in plastic surgery and went into private practice, I soon realized that free market forces are constantly working to edge me out of the market. Competition is fierce, and people in large markets have many choices in obtaining plastic surgery, as they do in other professional services. A few print ads and radio talk shows later, I further realized that in today’s world, the majority of marketing dollars in a doctor’s practice must be geared towards their internet presence. Even your print ads eventually all end up as PDF files in the “media” section of your website – funny that people still put so much weight on how many times their doctor shows up in “People” magazine. I guess a comment about whether or not Kim Kardashian had a Brazilian butt lift really makes you an expert…

So where do I get started? …you ask. Easy. Just like most questions asked in life these days, the simple answer is: “Google it!” I have no financial disclaimer here so “Bing it” or “Yahoo it” works just as well, and is in fact, recommended as well. Seeing what internet content is out there associated with your name, an old article that you published, a hospital website listing you as a physician, a yellow pages or rate-a-doc style website, or any other peculiar locations, is of paramount paramount. In our office, we started doing our search engine optimization (SEO) by calling each of these websites and online listings and getting all the details right, including linking to our own website. From there, you will soon see how rapidly you’ll be approached from different directions regarding potential help. There’s a huge market for this work, and it rarely goes unnoticed.

As in any rapidly progressing internet-based enterprise, getting someone on your side who knows the tricks of the trade is the key to success. Sure, you can outsource all of these services away, and many do. But, when you add in all the costs of internal office marketing, advertising in a wide gamut of different media, and other costs of brand development, you have a full-time job on your hands. Please beware doctors, stick to doing what you do best. Get an expert on your side. Get yourself a Marijana!

Dr. Daniel Kaufman
Discreet Plastic Surgery


Dealing With Pain As A Physician

I admit it! I was channel surfing between CSPAN and the Lehrer News Hour...

...and not so accidentally, stumbled upon one of the Kardashian sisters getting some sort of "minimally-invasive" facial rejuvenation procedure in a posh Miami medical office. The procedure was fairly routine, but what really caught my eye was the incredible amount of pain this young lady was willing to endure. I reflected back to my training in Plastic Surgery and General Surgery, and realized how little attention we paid, as a community, to pain.

I often find myself bringing up to my patients a "Postop Pain Plan", only to find them caught in a moment of bewilderment. "I thought I'm not gonna feel anything", I hear sometimes. In recent years, the increasing dumbing down of medicine and plastic surgery in pop culture media, has some people denying the existence of pain after surgery. Furthermore, of the ones that do expect some postop pain, few expect to define a specific plan for managing that pain. Albeit, they come to me with much greater concerns about their appearances, but nonetheless, the change in appearance comes at a price.

As plastic surgeons, we need to address the issue of pain in a more sincere and serious manner. We need to stop painting rosy pictures and admit to our patients that surgery is painful, that what they are asking us to do is, unfortunately and necessarily, inflict pain. We need to implement a Pain Plan. A simple, lay-term, and effective protocol addressing individual patients' postop pain control needs. We also need to document the plan and incorporate it into our informed consent plan.

As patients, we need to inquire within. Ask our surgeons about the nature of the pain, the duration, the severity. We need to request a specific plan, and decide preoperatively how to manage the pain. But most importantly, we need to stop believing everything we see and read in the lay media. We need to realize that elective surgery is surgery nonetheless. It hurts, and we ask for it. So let's treat it like the serious business it is.


Buyer's Remorse In Plastic Surgery

Medical Spa Plastic Surgery"OMG!! what did I do?! ...

I must be crazy to do this!" said my patient only hours after her tummy tuck. She was in some pain and distress, as the anesthesia was wearing off, and began a tirade of self-disparaging statements reflecting all her worst fears and anxieties about the surgery.

I stopped what I was doing, and sat down with her on the recovery room bed to calm her down. It's amazing how comfortable those recovery room beds are...and the patients seem to really like it when I take my time to explain and review things with them. She did fine after some pain meds and a little small talk, and on her 1 week postop visit, was happy as a clam with her new flat tummy. And that's when I realized just how common "buyer's remorse" is in plastic surgery.

Plastic surgery, especially cosmetic surgery, is elective. That means that it isn't surgery that you need, but surgery that you want. Oftentimes, people overlook the pain and discomfort that is inherent to any surgery. Although, most people who have had plastic surgery, and, gladly, the vast majority of my patients, will say that they are happy with the decisions that they made, a certain segment of the patient population will always have difficulties in adjusting to the postoperative demands, no matter how carefully they were selected by the surgeon or how well surgery was performed.

Every plastic surgeon hones his/her patient selection skills over years of education, training, and practice. The goal of every plastic surgery practice is to only have happy patients. As this is an ideal that will probably never be reached, we surgeons must realize that some of our patients will be unhappy, at various stages of the postoperative period. Those patients need special attention, understanding, and a compassionate review of clinical details. They must be empowered, and be actively involved in the procedures of postoperative recovery. It's also important to give your patients options as to colleagues who may serve as second opinions.

As a patient, if you find yourself unhappy with the results of a cosmetic procedure, take a deep breath and fret not, as it depends on the timing. Most early remorse cases are due to the unexpected, and probably poorly managed, pain and discomfort. Moreover, remorse is clearly correlated with incidence of complications of surgery. In the case of the former, simple and more precise pain control and behavior modification is all that is needed. In the latter, both preoperative and postoperative miscommunication between patient and surgeon is the usual contributing factor. As difficult as it is to do, as a patient you must communicate with your surgeon, even if you believe that he/she is responsible for a poor outcome.

We must realize that we can all end up being the patient who regrets having plastic surgery. It can happen if you're the best patient, or if you have the best doctor. What's important for both of you is to keep the lines of communication open so that proper, just, and adequate resolution is reached. No patient should abandon his/her doctor, and the opposite is just as true.


Surgery for Free???

"I want my surgery for free" my friend tells me... Just how many times have we (plastic surgeons) heard that before?

Obvious to me, that meant that my surgical fee will be waived. Oddly enough, for my friend, an intelligent person in her own right, this meant something completely different. She thought the entire surgery was actually for free. After a slightly awkward moment, I asked her if she knew anything about surgical fees and healthcare costs. To my astonishment, she had absolutely no idea. Being the consummate educator that I am, I decided to use this conversation as a teachable moment to instruct my friend about the economics of plastic surgery. Delving further into the topic, I found that one of the most popular Google searches regarding plastic surgery is plastic surgery costs. Frankly speaking, plastic surgery cost is so paramount, that if you listen to some of my friends and colleagues at our trade meetings, it seems that cost is so often the only determinant factor indicating performance of the surgery or not. In light of these glaring facts, here's a brief primer on the topic.

In performing cosmetic and plastic surgery there are three basic fees that must be considered:

1) the surgical fee,

2) anesthesia fee, and

3) facility fee and materials costs.

The surgical fee is the simplest to understand, and frankly the easiest to negotiate. Basically, it is what the surgeon takes home. From this fee the surgeon pays for all the costs incurred in becoming and being a surgeon. This may included school loans, malpractice insurance fees, office rent or mortgage, staff salaries, and other costs, to name just a few. The surgical fee is determined by the judgement of one person alone, the surgeon. Depending on his/her practice expenses, he/she determines the fee, and is ultimately the one able to negotiate it. More often than not, when plastic surgery fees are negotiated and consequently lowered, the change in price comes from this portion of the overall cost of the surgery.

The anesthesia fee, one often overlooked by many, is the hardest one to negotiate. Basically, it is what the anesthesiologist takes home. This fee may depend on several factors, including the nature of the surgery, the nature of the anesthesia administered (local, regional, or general), the time of surgery, and other technical issues as well. The anesthesia fee is usually determined ahead of time between the surgeon, anesthesiologist, and/or the surgical facility, and thus, it is usually not subject to much negotiation.

The facility fee, also one that is difficult to understand, generate, and consequently, negotiate, is composed of many elements that may not be readily seen. These include the costs of nursing care, medical materials and drugs used during surgery, and other costs of running an ambulatory surgery facility. Again, this is usually a fixed price that most commonly is not subject to negotiation, especially with the operating surgeon. Additional material costs may be added, for example, when using breast or facial implants or other materials related to specific cosmetic surgery.

During your plastic surgery consultation, when the time comes to talking about the costs of surgery, it is always worthwhile to ask about each one of these fees, as some may be negotiable. The fact that cosmetic surgery is not covered by medical insurance, and is thus a luxury item paid for by discretionary income, has actually contributed to it becoming so affordable and within reach to larger segments of the population. Plastic surgery is one of the last vestiges of the healthcare industry where free market forces act to shape the economic transactions between producer (doctor) and consumer (patient). The more knowledgeable and informed you are, the better the chances you'll get a better product and bigger bang for your buck. A cautionary note, however, is that in plastic surgery, as in most industries, you get what you pay for. Your quality assurance is the doctor's credentials and bedside manner, their specialty-specific board certification, and surgical center accreditation. If all of those factors are satisfactory, then feel free to shop around. And remember, an educated consumer gets the best deal.


Plastic Surgery & Medical Tourism

Medical tourism just doesn’t make a whole lot of sense.

In recent years medical tourism has become an option increasingly available to potential plastic and cosmetic surgery patients. These potential patients often imagine that inexpensive, high-quality surgical care can be obtained by traveling to such countries as India, Mexico, Costa-Rica, Thailand, and the Dominican Republic. Add to that the price-conscious “savvyness” of the internet coupon generation, and the options increase exponentially. The guiding principles often celebrated by proponents of medical and cosmetic surgery tourism are the promotion of patient consumerism and, most notably, cost savings.

In the age of global digitalization, outsourcing of various business practices has become commonplace. Beginning with the export of information technology and call center jobs, outsourcing has now extended its reach to include medicine, surgery, and even plastic surgery. Several developments have facilitated this trend. Prohibitive health care costs at home, increasing denials of insurance claims and decreasing provider reimbursement rates, increasing overall demand for plastic surgery, long waiting times, and lastly, and perhaps most importantly, cost savings, have all contributed.

Medical tourism is marketed on the basis that health care can be off-shored much like the production of computers and cell phones or the provision of professional services such as bookkeeping and accounting. Good surgical care, however, involves more than just the technical act of surgery itself. It requires extensive and careful preoperative consultation, deliberate formulation of reasonable treatment plans, and implementation of proper postoperative care. Yet, such goals are unlikely to be achieved when patients fly to a foreign country, undergo surgery, recuperate oftentimes for less than a week, and return home with no plan for follow-up care. Furthermore, with increasing numbers of reports about patients traveling abroad and returning home with serious complications, the merits of “globalizing” health care must be questioned.

All too often I consult with patients who tell me of lamentable stories of “plastic surgery gone wrong” abroad. The informed consent process, a standard component of patient-physician communication in the United States, involving full disclosure of risks and benefits of treatment, risks and benefits of alternative forms of treatment, and consequences of not undergoing treatment, is virtually non-existent. Most of the time, the patient cannot even recall the name of the surgeon, or even identify him/her in person preoperatively. In all of medicine, but especially in elective plastic surgery, in order for choices to be made in a meaningful and appropriate manner, patients need to receive accurate and comprehensive information. Inadequate communication before surgery and the seemingly non-existent culpability lead some patients to have procedures that in health care settings with higher standards would never be deemed as falling within the professional realm of care.

When considering the cost savings purported to be an attractive feature of medical tourism, one must always consider the added costs of revisional surgery and medical care incurred with the potential for adverse outcomes. These costs increase on the whole when one considers the increasing frequency of surgical complications incurred with surgery in health care settings that do not meet the standard of care. Medical travelers often purchase cosmetic surgery packages without physician consultation and without knowledge of the medical implications to their health and well-being. Medical tourism companies and destination health care facilities, often owned and operated by non-physicians, benefit from maximizing profits without the necessary medical knowledge, legal responsibilities, and unfortunately, moral compunctions either.

All in all, elective plastic surgery is a drastic measure to undergo in order to change your appearance. So if you do it, you should have all the support from family and friends that you can get to help you get through it. Being home in a comfortable and familiar environment is also instrumental in proper healing. Going away to a foreign country to get this done just doesn’t make a whole lot of sense. And that’s the bottom line.


Sun Protection 

“But I love the sun!” ….is a phrase I hear in my office all too often - especially this time of year. My usual reply: “well, the sun doesn’t love you…” Skin cancer rates are on the rise. During the recent past, doctors have become increasingly aware of the increase in the rates of skin cancer in the United States, and have stressed the importance of the need for protection from ultraviolet (UV) radiation. The harm caused by UV includes premature aging (such as wrinkling and age spots), skin cancer, and permanent, sometimes blinding, damage to eyes. Doctors everywhere agree that education is critical to stopping the epidemic of sun related diseases - especially skin cancer. As to the actual physiological effects of UV radiation on the skin, I’ll spare the scintillating details. Suffice it to say that the sun ages our skin undoubtedly more than any other environmental factor. So, just in time for the summer, let’s come with and implement a sun safety program.

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