Cold Iron Truth

Unlikely mentors


 

Mentorship is a hot topic. Mentors are generally perceived as knowledgeable, kind, generous souls who will guide mentees through tough challenges and be your pal. I suggest to you that while such encounters are marvelous, and to be sought out, some of the most important lessons are taught by members of the opposite cast.

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The presiding secretary of the Ohio state medical board was a brigadier general, still active reserve, tall with a bristling countenance. I was president of the Ohio Dermatological Association and was accompanied by Mark Bechtel, MD, who was our chair of state legislation. We had been invited to discuss possible office surgery regulations with the medical board. We were secure in our personal knowledge that local anesthesia was very safe, and that there had not been any deaths related to local anesthesia administered by dermatologists in Ohio (or anywhere else). We expected to tell the medical board there was nothing to worry about, and we could all go home. This was 17 years ago.

It quickly became apparent that there had been an extensive prior dialogue between the medical board and representatives of the American College of Surgeons and the American Society of Anesthesiologists. They sat at the head table with the secretary of the medical board.

“In our experience, there are really some dangerous procedures going on in the office setting under local anesthesia, and this area desperately needs regulation,” the anesthesiologist’s representative said. The surgeon’s representative chimed in: “From what I’ve heard, office surgery is a ticking time bomb and needs regulation, and as soon as possible.” This prattle went on and on, with the medical board secretary sympathetically nodding his head. I raised my hand and was ignored – and ignored. It became apparent that this was a show trial, and our opinion was not really wanted, just our attendance noted in the minutes. Finally, I stood up and protested, and pointed out that all of this “testimony” was conjecture and personal opinion, and that there was no factual basis for their claims. The president stiffened, stood up, and started barking orders.He told me to “sit down and not speak unless I was called on.” I sat down and shut up. And I was never called on. Mark Bechtel put a calming hand on my arm. Goodness, I had not been treated like that since junior high.

I soon realized that dermatologists were not at all important to the medical board, and that the medical board had no idea about our safety and efficiency and really did not care.

Following the meeting, I was told by Larry Lanier (the American Academy of Dermatology state legislative liaison at the time) that Ohio was to be the test state to restrict local anesthesia and tumescent anesthesia nationwide. He explained that some widely reported liposuction-related deaths in Florida had given the medical board the “justification” to act. He went on to explain that yes, there were no data either way, but we had better hire a lobbyist and hope for the best.

Dr. Brett M. Coldiron, a dermatologist and Mohs surgeon in Cincinnati.

Dr. Brett M. Coldiron

I was stunned by what I now call (in this case, rough) “mentorship” by the medical board secretary. I understood I could meekly go along – or get angry. I chose the latter, and it has greatly changed my career.

Now, this was not a hot, red, foam-at-the-mouth mad, but a slow burn, the kind that sustains, not consumes.

I went home and did a literature review and was disheartened to find absolutely nothing in the literature on the safety record of dermatologists in the office setting or on the safety of office surgery in general under local anesthesia. We had nothing to back us up.

I looked up the liposuction deaths in Florida and discovered the procedures were all done under general anesthesia or deep sedation by surgeons of one type or another. I also discovered that Florida had enacted mandatory reporting, and the reports could be had for copying costs. I ordered all available, 9 months of data.

We dermatologists passed a special assessment and hired a lobbyist who told us we were too late to have any impact on the impending restrictions. We took a resolution opposing the medical board rules – which would have eliminated using any sedation in the office, even haloperidol and tumescent anesthesia – to the state medical society and got it passed despite the medical board secretary (who was a former president of the society) testifying against us. The Florida data showed no deaths or injuries from using local anesthesia in the office by anyone, and I succeeded in getting a letter addressing that data published expeditiously in the Journal of the American Medical Association (JAMA 2001;285[20]:2582).

The president of the American Society for Dermatologic Surgery at that time, Stephen Mandy, MD, came to town and testified against the proposed restrictions along with about 60 physicians, including dermatologists, plastic surgeons, and other physicians who perform office-based surgery who we had rallied to join us from across the state. So many colleagues joined us, in fact, that some of us had to sit on the floor during the proceedings.

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