Tag Archives: hospital

Surgical checklists

Checklists do not work for surgery


A few years ago a a book came out that made a big splash called ” The checklist manifesto” by Dr. Atul Gawande.

The premise of the book was that having checklist will decrease errors in surgery. The prime example given was that of airline pilots who run a checklist before every flight.

Everyone started to make checklists for everything- and to a great extent they do work. The work for airline pilots, fr inventory and distribution of products etc. They do not work for surgery, as a recent study in the New England Journal of Medicine has shown.

“There may be value in the use of surgical safety checklists, such as enhanced communication and teamwork, and the promotion of a hospital culture in which safety is a high priority; however, these potential benefits did not translate into meaningful improvements in the outcomes we analyzed,” they reported.

… and all this despite the fact that this study, was conducted in over 90 hospitals in Canada with over 91% compliance, and covering 200,000 surgical procedures. No difference in mortality or complications occurred as a result of use of checklists.

Surgical checklists

One of the themes of “The checklist manifesto” was that checklists would prevent complications and standardize protocols. Other research has shown that in a hierarchical grouping of people, such as with airline pilots where the captain is all knowing, members of the group will rarely question decisions of the group “leader”.

In many hospitals, the  group”leader” (surgeon) in the operating room still cuts the wrong leg off or operates on the wrong side of the brain because other group members ( anesthesiologists, nurses and techs) do not question the decision and authority of the surgeon.

Still, why do checklists not work in the operating room or in medicine? I don’t know! They should!


Cosmetic Surgery Scheduled at 7 am?

Early morning cosmetic surgery


It’s 7 a.m. and I am waiting for my cosmetic plastic surgery patient to arrive at the surgery center for a gynecomastia surgery and a tummy tuck procedure. a cosmetic surgery scheduled weeks ago.  He may still be sleeping, but hopefully he is just late because of traffic.

I have written about pre-operative preparation for cosmetic plastic surgery in the past;



Why surgery starts early

There are several reasons why surgery of all types, including cosmetic surgery, traditionally starts early in the morning. These include medical reasons and non-medical ones.


Medical reasons for early morning cosmetic surgery

1. Hormonal cycle

Perhaps the most important medical reason for starting surgery early in the morning is the body’s normal cycle of contra-stress hormones.

Cortisol is the major anti-stress hormone in our bodies. It has a “diurnal” rhythm of its levels. It is at its lowest level at around midnight and rises sharply to its maximum between 6 a.m. and 9 a.m. It falls during the afternoon.

High cortisol levels protect the body against stress, psychological or physical. In the early morning, the associated high cortisol levels provide a little extra protection against surgery stress. Other hormones also play a similar role in stress reduction, but cortisol is the most important.


2. Blood sugar levels

Before any surgery requiring general anesthesia, cosmetic plastic surgery patients are required to fast for eight hours. This is important in preventing having any food in the stomach and decreases the risk of aspiration of stomach contents into the lungs—a condition that can be fatal!

The fast makes sure that your blood sugar levels are low in the morning. If surgery takes place later in the day, it’s like not eating breakfast. The low and decreasing blood sugar levels cause fainting, weakness and headaches, in addition to adding extra physical stress to the body.

3. Hydration

Having an early surgery means there is less chance for your body to become dehydrated. Not drinking water is part of the fasting process. Dehydration has obvious physical consequences and sets off its own series of stress responses that are not good for cosmetic surgery patients.


Non-medical reasons


1. Cosmetic plastic surgeons

Starting early in the day with cosmetic surgery allows the cosmetic plastic surgeon to have some time to see post-operative and pre-operative patients in the afternoon. Some plastic surgeons will operate all day long on certain days, but in general I like to break my days up and not operate for more than five hours a day.

Also, surgery is unpredictable in terms of timing. Though most plastic surgeons know how long their surgery takes, unforeseen circumstances like extra bleeding can occur and cause delays. This can have a domino effect and cause a string of delays extending into the evening.


2. Hospital staff

The workday at hospitals also starts early for nurses and staff. Hospitals are busy places, and the full day is needed to get all the work done; much medical care continues straight into the night! However, as in any workplace, hospitals are not fully staffed at night. The minimum number of staff required to take care of emergencies is usually what’s available. Most of the staff is at home, sleeping like normal humans! At 7:30 a.m., most hospital staff and nurses are at work.


3. Surgery complications

As with any other form of surgery, sometimes a complication arises after cosmetic plastic surgery. The complication of the surgery may require the patient to be taken back to the operating room.  Starting early in the morning means there is more time to deal with this possibility with the full complement of hospital nursing and support staff. It’s safer!

These are some of the reasons why cosmetic plastic surgery is started early in the morning. It’s  better for the cosmetic patient, better for the plastic surgeon and better for all the nurses and hospital staff.



Morad Tavallali, M.D., FACS

Plastic Surgeons Keep on Learning

Continuing education for plastic surgeons


The human mind is amazing. Even though we know intellectually that we should be doing something, our minds will direct us to procrastinate and put things off to the very last minute. Some say this is because we need that pressure to perform well; others say those types of people are just disorganized. I’m supposed to be taking an online plastic surgery test right now. I have until the end of the week to finish it, but instead I am writing this blog post because…

I have written about other aspects of plastic surgery education and training in the past. See here:





Board-certified plastic surgeon

Medical education is a long and Plastic Surgeons keep on learning , arduous process not for the faint of heart. After college, medical school and residency, the fully qualified plastic surgeon will start the process of board certification. A board-certified plastic surgeon is one who has completed a written exam the year of graduation from the residency program and then passed an oral examination where other surgeons review ten of the plastic surgeon’s patient cases after the first two years of surgical practice. The fail rate is about 30%! Surgeons do have a chance to retake it, however.

Board certification in plastic surgery is valid for only ten years. After that, plastic surgeons must retake a written exam and present a synopsis of their surgical cases to the Board for re-certification. I became board-certified in plastic surgery in 1995. I re-certified in 2005, and I will have to take an exam once more in 2015.  A hefty fee, a lot of busy work for my staff and an afternoon in front of a computer will “re-certify” me. That is a poor judge of what type of plastic surgeon I am and whether I am practicing sound and competent cosmetic plastic surgery.

By 2025, I’ll either be retired or dead. If I am still working, I’ll just have to become “not board-certified.” I’m not going to take it again! Most other medical specialties also require re-certification. Here is a link to the American Board of Medical Specialties site for comparison:


Continuing medical education for plastic surgeons

Board certification and re-certification in plastic surgery are distinct and separate requirements for plastic surgeons over and above the usual continuing medical education mandated for privileges at hospitals or medical licenses from states and governments.

All doctors are required to show at least 150 hours of continuing medical education (CME) every two years. Lawyers and other professionals also have similar continuing learning obligations (such as CLE: continuing legal education).

“Education” is achieved by attending conferences, listening to lectures and taking online courses or exams such as the one I am taking this week. This one is provided by the American Board of Plastic Surgery and is taken by all residents in plastic surgery and those practitioners that want to keep up with areas of plastic surgery they no longer practice. For example, I was just answering questions on hand surgery, though I stopped performing hand surgery ten years ago.

Continuing education is essential in any field. I want the guy who fixes my car to know the latest technology available and how to use it. That is good and should continue.

As far as I know, no other profession is required to re-certify again every so many years.  Many organizations call “re-certification” the process of acquiring continuing education credits. Doctors have to take a “professional entrance exam” again!

If we are going to ask plastic surgeons and other doctors to re-certify their knowledge every ten years despite the fact that they are practicing (plastic surgery) every day, why do we not have every other professional group do the same? Imagine the uproar if lawyers had to take their Bar exams every ten years! or architects or pharmacists or dentists or… Why don’t they?  By the way, did you know that only 1% of dentists are “board-certified”? See this link: http://www.abgd.org/boardcertified.php

So what does all this mean?

I know plastic surgeons are special but surely we are not that special.

Now back to that exam.

 Morad Tavallali, M.D., FACS