Tattoo Eraser?

Tattoo

At some point, the psychedelic kitten may not seem so cool…

 

If PhD student Alex Falkenham is successful, removing tattoos may be easier than getting them in the first place. The Dalhousie University (in Nova Scotia, Canada) PhD candidate has been developing a cream to remove tattoos.

How are Tattoos Permanent?

Tattoos have a history which spans millenia. The introduction of pigmented inks into the deeper skin (the dermis) has been done in virtually every culture in every part of the world. Why a tattoo is permanent is a cool description of the body’s immune response to trauma. When the ink is injected through the epidermis (outer skin) and into the dermis, the body responds to the trauma by initiating the inflammatory cascade. This means that the white blood cells responsible for fighting infections, initiating wound healing, and repairing tissues are called to the scene of the tattoo. One of the most important cells are macrophages. These are larger white blood cells which act as a central contractor in the wound directing other cells to do their jobs. Macrophages also have the ability to eat (or phagocytose) the ink pigments. Some of these macrophages carry the ink away to the lymph nodes but many also remain in the skin, lying dormant and keeping the tattoo visible through the transparent epidermis. Over time the tattoo may fade as the dormant cells leave or die, but for the most part the tattoo is permanent.

How do you get rid of “I ♥ Kelly?”

Removal of tattoos has traditionally been done in two ways – cut out the skin with the tattoo, or use different lasers to break up the pigment. Cutting them out is simple enough, but this will leave a permanent scar and is not a great remedy for most tattoos due to size or location. Lasers work by targeting the absorption spectrum of the pigment in the tattoo. By delivering this frequency of light, the pigment fragments and is removed by the immune system.  This process is the most common but is time consuming, often taking multiple sessions, and costly. In the US last year, over $75 million dollars were spent removing tattoos.

Tattoo Removal Made Easy

What if you could simply rub a cream on a tattoo and watch it disappear? Sound too good to be true? Well, if Alex Falkenham’s approach works, a $4 cream may be just around the corner. Mr. Falkenham’s idea is to clear out the pigment laden macrophages in the skin by a clever use of compounds known as bisphosphonate liposomes. “Of course!” you say, “how could I have missed this?”

His details aren’t clear, but here’s my understanding of how this works:

Bisphosphonates are neat little chemicals containing two (bis) phosphate groups and are used commonly to deactivate osteoclasts to prevent bone loss. Osteoclasts are cells which break down the calcium structure of bone. Bisphosphonates work by being eaten by these osteoclasts and either suppress cell activity or trigger cell death (apoptosis). Thus, people will take bisphosphonates to prevent osteoporosis. What does this have to do with tattoos? Macrophages are very similar to osteoclasts. When a macrophage encounters a bisphosphonate, it phagocystoses (eats) the bisphosphonate and often undergoes apoptosis (cell death). The cell wall breaks down and a new macrophage will come along and clean up the mess left over. If you deliver bisphosphonates to the macrophages in the skin which contain the tattoo pigment, you can kill the cell, release the pigment, and have another macrophage come along and remove the pigment to the lymphatic system and out of the skin. Voila! No more tattoo! But how do you deliver the bisphosphonate to the macrophages you wish to destroy? Use a liposomal carrier. Liposomes are lipid structures in which you can place the bisphophonate chemical. Lipids do a good job of penetrating the skin (which is why you see so many “lipid formulations” for skin products). When these liposomes are encountered by the macrophages in the skin they are consumed and the bisphosphonate can have its effect on the cell. Destruction of the cell will release the pigment and another macrophage can come along, consume the pigment, and carry it away to the lymphatic tree.

Falkenham states this a little more simply:

When new macrophages come to remove the liposome from cells that once contained pigment, they also take the pigment with them to the lymph nodes, resulting in a fading tattoo.”

Although the specifics are hazy, the bottom line is re-engaging the macrophages to remove the pigment rather than having them stay dormant in the area of the tattoo. Falkenham notes that this technique is quite specific to the pigment containing macrophages and should not affect the normal skin cells in the vicinity. Unlike lasers which can have significant collateral damage, this is a targeted therapy to the pigment containing cells.

What does it all mean?

The research regarding this new method of tattoo removal is in the early stages. There is no research paper, no human trials, and minimal data. Up to now, he has been working on tattoos on pig ears. Regardless, if the results are as promising as he states, we may finally have a cheap solution to an often drunken and remorseful problem.

Burnout

The Strain of Modern Medicine

Burnout:

the condition of someone who has become very physically and emotionally tired after doing a difficult job for a long time. : a person who suffers burnout.    –Free Merriam-Webster online dictionary

 

 

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Burnout affects more doctors than you think

A Long Road Ahead

Medicine is hard. It’s a hard profession to get into – requiring excellence in the classroom, a mastery at passing standardized exams, and filling the remaining time with enough community service to get yourself a “leg up” on the other applicants. Once in medical school, classes are eight hours a day with weekly exams and evening studying for the first two years where you are expected to learn pretty much everything about the human body, disease, and treatment. The third and fourth years are the clinical rotations where that knowledge base is put into practice in the hospitals, operating rooms, and office settings. At some point during the third year, you are expected to choose a career path in medicine. Will you be a radiologist, internist, dermatologist, surgeon? If a surgeon, what kind? Plastic surgeon? Cardiac surgeon? Neurosurgeon? Once the decision is made, you spend months during the fourth year applying then interviewing at residency programs all over the country. Then, in the spring you “match.” This is the process where you rank the programs you interviewed at according to where you want to train. The programs who interviewed you do the same. A big computer in some underground government installation takes both lists and then spits out where you will spend the next 3-7 years of your life. It can be a bit stressful.

I did all that in the late 1990’s and early 2000’s. And although I remember the stress, I can’t recall many of the specifics. That’s because after you get through medical school, you go into residency. A statement which sums up residency pretty well was given to me by a neurosurgeon during one of my intern rotations – he said, “Residency is a giant sh*t sandwich, and everyday you take a bigger bite.” Quaint? Not really, but seemed most days to be on point. Residency is where professional responsibility is established. The patients become your patients. The outcomes are often predicated on your decisions. However, there is always the underlying safety net that your Attending physician is ultimately responsible. The hours are long, the criticism is high, and the inherent hierarchy is omnipresent. But, when you get through it, it is a badge of honor you wear for the rest of your life. And let’s face it – the goal of all this hard work is just around the corner! You get to finally start your own practice and do what you wanted to do a decade ago.

But That Must Have Been The Hard Part, Right?

So why is burnout so common among physicians? These are people who slogged through the rigors of medical school and the purgatory of residency and should be enjoying the careers they worked so hard to achieve? Instead, articles such as this, and this, and this are more and more common. A few months ago, myself and thousands of other physicians filled out a survey from Medscape.com regarding our personal perceptions of lifestyle and burnout. The results are quite fascinating and give insight into the reasons for burnout that we see in healthcare today. The survey went to physicians in all different specialties. Here’s the link to the Medscape results (note – you may need to have a Medscape account, but it’s free and spam free) and writeup by Carol Peckham in the Medscape Plastic Surgeon Lifestyle Report 2015.

Because this is a Plastic Surgery blog, I am primarily interested in the findings regarding plastic surgeons. And why not? If you watch the popular media, plastic surgeons must be some of the happiest physicians out there! Their patients are healthy, cosmetic, and pay lots of money for procedures to look beautiful, right?. If you read this blog or know a plastic surgeon, you’ll know that there’s much more to plastic surgery than Botox®, liposuction, and breast implants. And plastic surgeons are also not immune to government regulation, insurance sleight of hand, and the constant increase in demands on their time.

So let’s go through the survey and see what the tea leaves say shall we?

What do Plastic Surgeons say about Burnout?

To start, Medscape defines burnout for the purposes of this study as, “loss of enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment.”

45% of Plastic Surgeons  say they suffer from burnout. This is an astounding number, but in the survey this was in the bottom half of the results. The so-called “frontline” of medicine specialties – critical care physicians, internists, general surgeons, ER docs, and family physicians were all 50% or greater! However, the degree of burnout (on a 1-7 scale with 7 stating that you are going to retire due to burnout) was 4.5. That’s third highest amount all specialties.

The most common reason for burnout as cited by plastic surgeons are:

  • increased bureaucracy
  • the impact of the affordable care act
  • income issues, and increased computerization.

The least common causes are:

  • compassion fatigue
  • employer difficulties
  • keeping up with research
  • inability to provide appropriate care

In concordance with most other (if not all) specialities, female plastic surgeons suffered more from burnout than male plastic surgeons (52% to 42%). In regards to age, plastic surgeons in the “prime years” of their practices (age 46-55) had the highest rate of burnout at 57% while older plastic surgeons age 66 or greater had the least at 17%. Of interest is the 32% of young plastic surgeons 35 or younger (essentially right out of residency/fellowship) felt they were burned out. Residency hangover perhaps?

Some survey results are in the obvious category – plastic surgeons who took more vacation time, volunteered more, and were financially more secure reported lower levels of burnout. Plastic surgeons who felt more burnout reported a lower overall quality of personal health.

Of interest are the results that spiritual or religious beliefs showed no association with burnout, but attendance at religious services did. In other words, being catholic makes no difference but those who attended church described less burnout than those who didn’t. Read into this what you will. Neither did physician weight, exercise, or alcohol consumption. Also, physicians who came to the US as adults showed a much lower rate of burnout than those who were either born in the US or came to the US as children. The study spent a considerable amount of resources looking into physical attitudes towards marijuana use and legalization which fits into the “Lifestyle” title I guess, but does not contribute to the question of burnout per-say.

What does it all mean?

The data is well collated and presented by Carol Peckham in the article on Medscape and she does a nice job reviewing the information. I’ll give my perspective on the data as a 40-year-old plastic surgeon going through the ever-changing climate of medicine. First off, I think the causes of burnout are spot-on. The recent broad stroke changes in medicine by government mandate and the Affordable Care Act has complicated medicine. The federal government, through Medicare and Medicaid reimbursement, has chosen a reward and penalty system to force medical practices to modernize their offices through electronic medical records and universal sharing of information. While the switch from paper charts to electronic charts (EMRs) makes sense, asking a plastic surgery practice to submit the same “quality measures” as a family practitioners makes no sense. This is bureaucracy at its best – establish the rule without regard to implementation leading to confusion on the physician end as to how to go forth. The EMR my office uses is different from the hospital and different from most practices in the area. Syncing patient health information across multiple platforms leads to concerns for privacy, stability, and the ability to efficiently run a practice. Doctors end up spending more time with the computer than the patient and clicking boxes to satisfy government requirements rather than providing care.  In the government’s desire to improve quality measurements they have succeeded in making medicine less personal, turned doctors into drones, and increased the cost of providing care. For plastic surgeons, most of this is irrelevant to the daily practice of what we do. It’s simply more paperwork, more regulation to follow, and rather than incentivizing quality, you incentivize plastic surgeons to fewer Medicare and Medicaid patients. Add in the requirement that patients can access their medical records from your office creates a HIPAA nightmare and internet privacy concerns. Do you take the penalty or take the responsibility of data breaches by putting patient information on the internet? If Sony, Target, and Home Depot can’t prevent hackers from stealing information, how do you expect your family doc to protect your information? As a physician, you have to rely on the third-party software company to create secure access but the actual responsibility falls on the physician. If there is a data breach, I’m betting your malpractice insurance doesn’t cover you for the HIPAA violations that would ensue. Yep, very little control but all the responsibility. Can you feel the frustration of physicians yet?

Let’s talk finances! Most physicians make a decent wage and plastic surgeons are no exception. For those plastic surgeons with a thriving cosmetic practice, the above regulation has little impact. They can simply opt out of any requirements because the financial viability of their practice is not linked to Medicare reimbursement. One key survey question which was not asked was the burnout rates in regards to percentage of cosmetic versus reconstructive surgery. I would imagine that primarily reconstructive surgeons have a much higher degree of burnout than those with strictly cosmetic practices, but it would have been nice to see the data. Financial reimbursement is a main driver of burnout. The cost to provide care increases – medical supplies, office overhead, and employee salaries all go up. What doesn’t go up? Insurance reimbursement. The Affordable Care Act has created multiple “plans” with big insurances that may be affordable from a monthly payment standpoint, but have deductibles that can top $25,000! So while you think you have coverage, if you need an operation it can bankrupt you. If you are looking at these affordable care plans, it’s not because you have $25,000 lying around. It’s not affordable in any sense other than the premium. That puts the doctor in a contrary position – you want to provide care, but the patient can’t afford it. Pro bono work is prevalent in medicine, but there is a limit to the amount a practice can absorb. And we haven’t even mentioned the Sustainable Growth Rate reductions which are omnipresent – a proposed 24% reduction in Medicare/Medicaid reimbursement to physicians which comes up for vote about once a year. The cost to provide healthcare to seniors has increased 20% since 2001, but physician reimbursement has gone up 4%. The bottom line is this – Financial concerns are a daily problem for doctors and a strong source of burnout. Add in the impending ICD-10 diagnostic coding initiative and you have a recipe for disaster.

Why does physician burnout matter? Because it directly impacts patient care more than anything else. More burnout means less physicians. Already the primary care fields are struggling to meet the demand in our country. But with the current climate in medicine, I hear more and more doctors telling students not to go into medicine. That it’s not worth the hassle. That taking care of patients is the smallest part of your job and that the paperwork is never-ending. That patients are more litigious, less trusting, and the medicine has become a product that can be measured rather than a profession to be practiced. This will have a serious impact on the future of medicine. Patients are already seeing increased in deductibles, decreases in coverage, and denials for service. Add in the false promises that they can keep their doctors and you have dissatisfaction on all sides of healthcare. Unfortunately, the answer for some physicians are concierge practices where only those who can pay get in to see the doctor. Is this really the way we want healthcare to go in this country?

So what’s the solution? If I knew, I’d write a book. When I answered the Medscape survey, I stated that I did not feel burned out. In fact, I love my job. I love caring for my patients and I love the practice of plastic surgery. That being said, I have made decisions in my practice to keep burnout at bay. For instance, when the stress of always being on call at multiple hospitals started affecting my family life – I dropped call and my privileges from those hospitals. I took a big hit financially, but we changed our lifestyle and now I focus only on the portions of plastic surgery I want to practice. Striving for balance between work and family can be a great way to limit the stress of the job. Taking more vacation time, even if it means not going in the office on a random Tuesday can recharge the batteries. Many of us are control freaks and delegating responsibility can offload a lot of stress. But perhaps the most important thing we can do is remember our younger self that knew nothing about the day-to-day stress of medicine and regain that passion that set us on the course of medicine in the first place.