Unsupervised Physician Extenders Are a Key Malpractice Concern

Dr. Goldberg was recently interviewed by Denise Napoli of Skin & Allergy News magazine. Here is the published May, 2010 article in its entirety.

--------------------------------------------------------------

Improper use of "physician extenders," a lack of informed consent, and patient dissatisfaction are some of the top reasons why patients sue, and all are easily preventable, according to Dr. David J. Goldberg.

The first - the use of unsupervised or improperly trained physician assistants, nurse practitioners, or other physician extenders - hits home for many dermatologists. According to the American Academy of Dermatology, in 2010, 36% of physicians will use NPs and PAs in their practice, up from 30% in 2007 and 20% in 2002, Dr. Goldberg said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation in Santa Monica, Calif. "NPs and PAs who work for core physicians are clearly the most qualified nonphysicians to perform these procedures," said Dr. Goldberg, director of dermatologic laser research at Mount Sinai School of Medicine, New York. Many have received cosmetic training through the Aesthetic Extender Symposium (www.aestheticextendersymposium.com), he said.

However, there are still risks. A 2006 American Society for Dermatologic Surgery survey found that 51% of ASDS members reported seeing nonphysician, nonsupervised physician-extender complications in their practice, with the two most common being misdiagnosed skin cancer and scarring following dermatologic procedures.

"If the [physician extender] is sued, so will be the provider who is affiliated with the PE," said Dr. Goldberg, who also is on the faculty of Fordham University School of Law in New York.

Poorly informed or uninformed consent is another moneymaker for medical malpractice lawyers in the field of dermatology, according to Dr. Goldberg. "Because dermatologists tend to see large numbers of patients, there is a tendency to be overwhelmed by the paperwork associated with quality informed consent," he said.

One procedure to be especially careful about is botulinum toxin type A injections - there were 2,464,123 in 2008, according to the American Society for Aesthetic Plastic Surgery. The black box warning on Botox reads "swallowing and breathing difficulties can be life threatening and there have been reports of death."

Dr. Goldberg encouraged physicians to instruct patients to read the warning on botulinum toxin "each and every time" they receive it. He also encouraged discussion about these risks and the procedure's other rare but potential side effects, including generalized muscle weakness, diplopia, ptosis, dysphagia, dysphonia, dysarthria, and urinary incontinence.

He noted that many of these potential complications have never been reported with the cosmetic use of botulinum toxin.

Finally, Dr. Goldberg said that dermatologists can keep legal troubles at bay simply by keeping patients happy. He cited a 2006 retrospective chart study of all patients who received botulinum toxin injections over a 2-year period at a private dermatology clinic. The retention rate was 55%. However, the "institution of a 2-week posttreatment evaluation increased the retention rate from 55% to 67%," said Dr. Goldberg (Dermatol. Surg. 2006;32:212-5).

"Probably more important in keeping patients happy - and keeping them coming back - is to communicate with patients," he advised. "Treat each patient as if they are special. Pay total attention to their concerns. They will appreciate your one-on-one interaction with them."

Dr. Goldberg is a founding director of the Aesthetic Extended Symposium. SDEF and this news organization are owned by Elsevier.

Using Light-Activated Technologies for Battlefield Injuries

A recent research study by the Air Force Office of Scientific Research shows that conventional sutures as well as glues and staples used to repair wounds in the skin or to reconnect nerves, blood vessels, tendons and corneal incisions, can be replaced with Photochemical Tissue Bonding. According to Dr. Irene Kochevar (Massachusetts General Hospital Wellman Center researcher and Harvard Med School professor), "We have demonstrated that this technology is very helpful in medicine for the Air Force because it produces better healing and functional outcomes than the same wounds that were treated with conventional materials.”

Bonding (aka nanosutures) is achieved when a dye is applied to the wound, after which the wound is exposed to green light for a brief time. The dye absorbs the light and then proceeds to molecularly bond proteins on the surface of the tissues. "No glues, proteins or other materials are used that might stimulate an inflammatory response," said Kochevar. "An immediate, water-tight seal is formed between the tissue surfaces leading to reduced inflammation in the near term and better scar formation in the long term."

Researchers plan to continue to assess the efficacy of this new technology, particularly as to how it might be made even more effective in the field. If all goes well, they hope to create a shorter treatment time and an even stronger bond. "We are approaching this challenge by identifying the basic molecular mechanisms responsible for light-activated crosslinking," she said. "We believe that this information will show us how to improve the efficiency and effectiveness of the nanosuturing technology on the battlefield."

Valeant Pharma to Purchase Vital Science Corp

According to a Socaltech.com report, Valeant Pharmaceuticals (VRX.N) will purchase Vital Science Corp., a Toronto-based manufacturer of over-the-counter dermatology products in the 2^nd quarter of 2010. They have recently acquired two other dermatology firms, both in Brazil. One of the firms, a private Brazilian company focusing on branded generics and OTC products, reported annual sales in the 49 million Brazilian reals range (about 26.7 million dollars US) with an average compounded growth of 15% per year. Purchase price for this company is reported to be approximately 56 million US$ and will be consummated in the 2^nd quarter of 2010.

"This latest transaction, along with Valeant's acquisition of Instituto Terapeutico Delta Ltda last month, will be our second acquisition in Brazil this year," stated J. Michael Pearson, chairman and chief executive officer. "We see strong synergies between these two acquisitions and our current operations in Brazil and believe that the combination of all three businesses will provide Valeant with expanded opportunities for growth in Brazil and enhance our Latin American franchise. This new business operation has had product sales that have grown in excess of 30% over the last year, while also achieving operating margins greater than 20%. Incorporating our new, state-of-the-art manufacturing plant in Indaiatuba will also provide us the ability to achieve significant growth and synergies across all three businesses."

The company has been on a shopping spree over the past few years, with purchases in 2009 of EMO-FARM, Mexico’s Tecnofarma S.A. de C.V. (Tecnofarma); Private Formula Holdings International Pty Limited (PFI) in Australia; Canadian skincare firm, Laboratoire Dr. Renaud and another US company. Last May, Valeant bought trademarks, inventory and intellectual property for dermatology products that were sold in New Zealand and Australia.

Valeant Pharmaceuticals International (Valeant) is a multinational specialty pharmaceutical company that develops, manufactures and markets pharmaceutical products. Their specialty pharmaceutical and over-the-counter (OTC) products are marketed under brand names and sold in the US, Canada, Australia and New Zealand. Valeant also has branded generic and OTC operations in Europe and Latin America, which focus on pharmaceutical products that are bioequivalent to original products and are marketed under company brand names. The Company’s product portfolio consists of 380 products with approximately 2,000 stock keeping units. The Company’s products are sold through three segments: Specialty Pharmaceuticals, Branded Generics/Europe and Branded Generics/Latin America.

Part III of III from the ASLMS Meeting in Phoenix

Dr. Goldberg and I attended the ASLMS meeting in phoenix last weekend. This is my favorite meeting of the year as we see new products and evaluation of existing products. The clear winners this year in terms of number of presentations and buzz were Zeltiq and Ulthera—devices that we have blogged about before, and which we have in our offices. The scientific studies on Zeltiq were very clear - excellent results and efficacy of 20-30% per treatment. That is what we have been seeing in our Boca office - very satisfied patients with consistent results. The Ulthera data mostly came from Asia, where they have had the device for some time. Results with the older protocol were good but newer data from a number of physicians showed that the newer protocols of dual layers and increased numbers of "lines" placed, leads to better, more consistent results.

We had 2 posters from the Boca office at ASLMS. The first was on healing times after fractional resurfacing and microlaserpeel with the Sciton TRL (tunable resurfacing laser). See attached. We showed that healing times are affected by a number of variables, including depth of microlaserpeel, depth of fractional treatment and density of the treatment. This gave us the data for use in our practice to be able to treat patients more effectively and with limited downtime.

The second poster we presented was about face lifting and laser resurfacing. See attached. We showed the safety and efficacy of treating patients with the Sciton TRL system. The key to successful treatment was to perform deep resurfacing on the non-undermined areas and to use the lighter fractional settings on the undermined flap.

Dr. Jason Pozner

Part II of III from the ASLMS Meeting in Phoenix

At the 30^th annual American Society for Lasers in Medicine and Surgery (ASLMS) meeting in Phoenix. Arizona last weekend, I presented a variety of talks. These included: 1) Pearls and Problems in the Laser Treatment of Unwanted Hair and Pigmented Lesions; 2) My Approach to Laser Facial Rejuvenation; 3) Problems with Laser Treatment in Medspas; 4) The Use of the Cutera Pearl Fractionated Er:YSGG laser for wrinkles around the mouth; and 5) a 10 Year Look at Laser Treatments of Tattoos in our Offices.

The highlights of my talks focused on the novel laser treatment concepts including the use of 1) the new Syneron eMatrix fractionated radiofrequency device for acne scars; 2) treatment of resistant melasma with multiple sessions of Q-switched Nd:YAG laser treatment; 3) the increasing incidence of complications seen at poor quality, low priced medspas; 4) the success we can now have in treating wrinkles around the mouth and 5) the future of newer lasers for more effective treatment of tattoos.

Last weekend we were in Phoenix. This week, Dr. Pozner and I are both lecturing at the American Society for Aesthetic Plastic Surgery (ASAPS) meeting in Washington, DC. Stay tuned!

Dr. David J. Goldberg

Dr. Charles Townes, recipient of Special Recognition Award at ASLMS Meeting

Last week we attended the ASLMS (American Society for Laser Medicine & Surgery) meeting in Phoenix. One of the highlights of the meeting, besides celebrating the 50th anniversary of the operation of the laser, was the Special Recognition Award given to Dr. Charles Townes, an American Nobel Prize-winning physicist and educator. We were excited to see this award presented, as Townes is known worldwide as the “Father of Lasers,” having developed laser technology to the benefit of millions, both in military and medical uses.

Townes, born in 1915 in South Carolina, graduated summa cum laude from Furman University at the tender age of 19. He completed a master’s degree in physics at Duke and a PhD from Cal Tech with a thesis about isotope separation and nuclear spins. Keep in mind that this was back in 1939, when these technologies were in their infancy. As an early member of the Bell Telephone Laboratories, his work in radar bombing systems and microwave technology, which led to his appointment to the faculty at Columbia University, led to uses of ammonia gas in masers (microwave amplification through radiation), which ultimately produced laser technologies. He and his research assistants were the first to detect complex molecules in the galaxy, as well as the measurement of the mass in the black hole in our galaxy’s center. With the assistance of Arthur Schawlow, he wrote Microwave Spectroscopy, which was published in 1955. During his tenure at Bell Labs, Dr. Townes was asked to help with the development of a radar system for WWII aircraft. Although Dr. Townes did not serve in the military, he and his team contributed to the war efforts by creating more accurate and precise radar systems, though none of them were ever mass-produced by the military. Some of the new systems developed were used as prototypes in the early B-52 bombers.

Dr. Townes went on to become the VP and Director of Research for Washington DC-based Institute for Defense Analyses, a nonprofit group that advised the government. After 2 years in that position, he became Provost and Professor of Physics at MIT, specializing in research of quantum electronics and astronomy. In 1967, he became a professor at University of California, on the Berkeley campus.

We'll be posting more details from the event later this week! Don't miss our upcoming info about the ASAPS (American Society for Aesthetic Plastic Surgery) conference this weekend!

Dr. Jason Pozner and Dr. David Goldberg

Part I of III from the ASLMS Meeting in Phoenix

This past weekend Dr. Pozner and I attended the 30th annual American Society for Lasers in Medicine and Surgery (ASLMS) meeting in Phoenix. Arizona.

ASLMS is the one meeting where the latest in next generation energy based cosmetic treatments is always first presented. Attendees come from all over the world – although the volcano in Iceland, and its impact on flights to and from Europe, did deter some Europeans from coming. The meeting consisted of a wide variety of workshops, panel discussions and abstract sessions with the singular goal of learning what’s new, what’s old and what will be soon arriving in cosmetic laser treatments.

Although the economic recession has led to some pull back from laser manufacturers, there was great interest in the new approaches to the non-surgical treatment of the aging face and neck, body sculpturing, and fat removal. In addition, it was clear that improved cellulite and melasma treatments remain the next 2 great frontiers in the cosmetic treatment of the skin. In my next blog I will focus on my own particular lectures.

Dr. David Goldberg

Publishers of New Beauty Mag buy 2 more pubs

Our friends at Sandow Media, publishers of New Beauty magazine, on whose board Dr. Pozner serves, has completed the acquisition of Interior Design magazine and the Furniture Today group of publications.

These two pubs add powerful and influential brands to Sandow's group of publications as well as more than 100 new employees. This important deal doubles the size of Sandow Media and continues to position the firm as a leader in the media industry.

Our congrats to Sandow!