Unveiling the Hidden Discrepancies Between Medicare Physician Reimbursement Rates and Inflation Across Different Surgical Specialties.

OBJECTIVE: This study aimed to analyze the trends of Medicare physician reimbursement from 2011 to 2021 and compare the rates across different surgical specialties. BACKGROUND: Knowledge of Medicare is essential because of its significant contribution in physician reimbursements. Previous studies across surgical specialties have demonstrated that Medicare, despite keeping up with inflation in some areas, has remained flat when accounting for physician reimbursement. STUDY DESIGN: The Physician/Supplier Procedure Summary data for the calendar year 2021 were queried to extract the top 50% of Current Procedural Terminology codes based on case volume. The Physician Fee Schedule look-up tool was accessed, and the physician reimbursement fee was abstracted. Weighted mean reimbursement was adjusted for inflation. Growth rate and compound annual growth rate were calculated. Projection of future inflation and reimbursement rates were also calculated using the US Bureau of Labor Statistics. RESULTS: After adjusting for inflation, the weighted mean reimbursement across surgical specialties decreased by -22.5%. The largest reimbursement decrease was within the field of general surgery (-33.3%), followed by otolaryngology (-31.5%), vascular surgery (-23.3%), and plastic surgery (-22.8%). There was a significant decrease in median case volume across all specialties between 2011 and 2021 (P < 0.001). CONCLUSIONS: This study demonstrated that, when adjusted for inflation, over the study period, there has been a consistent decrease in reimbursement for all specialties analyzed. Awareness of the current downward trends in Medicare physician reimbursement should be a priority for all surgeons, as means of advocating for compensation and to maintain surgical care feasible and accessible to all patients.

Analyzing the Visibility of Gender-Affirming Surgery Education on US Plastic Surgery Residency Program Web Sites.

BACKGROUND: As the demand for gender affirmation grows, teaching gender-affirming surgery (GAS) in plastic and reconstructive surgery (PRS) programs has become increasingly important. Residency applicants interested in GAS often use program web sites to explore potential training opportunities. Our study aimed to quantify the GAS training opportunities promoted on residency program web sites and determine the characteristics of programs likely to promote GAS training. METHODS: An assessment of 88 integrated PRS residency programs' web sites was conducted between 2021 and 2022. Plastic and reconstructive surgery residency and institutional webpages were queried for geographical location, training opportunities in GAS through residency or fellowship, and the number of faculty performing GAS. Descriptive statistics and multivariable regressions were used to describe and identify factors associated with increased GAS residency training opportunities. RESULTS: Twenty-six percent of PRS residencies mentioned training opportunities for GAS on their web sites. Gender-affirming surgery fellowships were offered at 7% of institutions, and an additional 7% were available via adjunct academic programs. Programs with faculty practicing GAS were 54% more likely to mention GAS on their residency page (odds ratio, 1.54; 95% confidence interval, 1.14-2.21; P = 0.009). CONCLUSIONS: Few PRS residency programs mention GAS on their web sites. As GAS becomes a more robust component of plastic surgery, appropriate information about the extent of GAS training should be available for applicants. Determining how local, state, and federal policies impact programs' abilities to highlight GAS should be investigated in future studies.

Exploring the 6-year Trend in Dedicated Research Years among Integrated Plastic and Reconstructive Surgery Residents.

Background: The plastic and reconstructive surgery (PRS) match has become more competitive with an emphasis on research productivity. With the transition of the US Medical Licensing Examination step 1 examination to pass-fail grading, alternative evaluation metrics for residency applications are needed. Our study provides a landscape of the incidence of research years amongst integrated PRS residents and the potential impacts of gender and race. Methods: A retrospective study was conducted for all integrated PRS residents who matched between 2017 and 2022, using publicly available sources including residency websites, PubMed, Doximity, and social media. Demographics, educational background, and participation in a dedicated PRS research year were recorded. Results: Among 993 residents across 85 accredited integrated PRS programs, 15.7% (156 of 993) took a research year, with a significant increase over 6 years (R 2 = 0.73, P = 0.019). The majority were men at 51.9%, and White at 53.5%, with underrepresented in medicine residents comprising 13.5%. A total of 73.1% came from a medical school with a home program, and 52.6% matched into a top 20 residency program. No significant difference was seen in the racial/ethnic or gender representation of residents who took a research year compared with all PRS applicants and active PRS residents. Conclusions: Research years before applying to residency are becoming more common among integrated PRS residents. Research years are especially common with students who do not have a home program and may help them gain skills and access to mentorship that improves the likelihood of matching.

Addressing the Rhino in the Room: ChatGPT Creates "Novel" Patent Ideas for Rhinoplasty.

Background: OpenAI's ChatGPT can generate novel ideas for a number of applications. The aim of this study was to prompt the chatbot to generate possible innovations in aesthetic surgery relating to rhinoplasty. Methods: ChatGPT was prompted to develop rhinoplasty patents. The resulting outputs were tabulated and categorized based on technology domain and anatomic location. A Google Patents search was conducted to find uses of the term "rhinoplasty" between 2021 and 2023. Patents not pertaining to rhinoplasty were excluded. Filed patents were compared with those generated by ChatGPT to determine predictive power. Results: A total of 40 patents resulted from ChatGPT and 42 Google Patents from 2021 to 2023 were included. Patents generated without a detailed description command were related to preoperative planning (35%), intraoperative tools (30%), functional evaluation (15%), and 3D printing and implants (10%). Patents with a detailed description command resulted in the majority being postoperative tools (40%), followed by intraoperative tools (30%), 3D printing and implants (10%), and nonsurgical (10%) categories. The anatomic locations included the airway, dorsum, septum, and nasal tip. ChatGPT's predictive power yielded 45% for the detailed prompting, which was higher than the prompt without the detail command. Conclusions: ChatGPT has reasonable potential to generate ideas for innovations in plastic surgery with the assistance of an experienced surgeon-innovator. With new artificial intelligence generations and updates, chatbots will continue to improve. Determining whether these technologies can assist in the later portions of the patent process beyond idea generation will be crucial.

The law code of ChatGPT and artificial intelligence-how to shield plastic surgeons and reconstructive surgeons against Justitia's sword.

Large Language Models (LLMs) like ChatGPT 4 (OpenAI), Claude 2 (Anthropic), and Llama 2 (Meta AI) have emerged as novel technologies to integrate artificial intelligence (AI) into everyday work. LLMs in particular, and AI in general, carry infinite potential to streamline clinical workflows, outsource resource-intensive tasks, and disburden the healthcare system. While a plethora of trials is elucidating the untapped capabilities of this technology, the sheer pace of scientific progress also takes its toll. Legal guidelines hold a key role in regulating upcoming technologies, safeguarding patients, and determining individual and institutional liabilities. To date, there is a paucity of research work delineating the legal regulations of Language Models and AI for clinical scenarios in plastic and reconstructive surgery. This knowledge gap poses the risk of lawsuits and penalties against plastic surgeons. Thus, we aim to provide the first overview of legal guidelines and pitfalls of LLMs and AI for plastic surgeons. Our analysis encompasses models like ChatGPT, Claude 2, and Llama 2, among others, regardless of their closed or open-source nature. Ultimately, this line of research may help clarify the legal responsibilities of plastic surgeons and seamlessly integrate such cutting-edge technologies into the field of PRS.

A Systematic Review and Meta-Analysis of Synthetic Mesh Outcomes in Alloplastic Breast Reconstruction.

Background: Mesh implants are frequently employed in alloplastic breast reconstruction. Notably, no mesh to date has FDA approval for this indication. Several synthetic meshes have been introduced with heterogeneous properties and outcomes. Objectives: This study aims to systematically review synthetic mesh use in alloplastic breast reconstruction, describe rates of short-term complications, and analyze these outcomes in reports comparing synthetic and biologic meshes. The authors hypothesized data from comparative and noncomparative studies would show no significant differences between synthetic and biological meshes. Methods: The authors conducted a systematic literature review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Thirty-one studies reporting the use of synthetic mesh and clinical outcomes were included. Eight studies directly comparing synthetic mesh and biological mesh were meta-analyzed for relative risk (RR). Nineteen noncomparative studies were analyzed for meta-rates. Outcomes, including seroma, infection, reoperation, and explant, were assessed on a per-breast basis. Resultant models were challenged for sensitivity and bias. Results: Meta-analysis of comparative studies demonstrated no difference in the risk of infection with synthetic mesh (RR = 0.53; 95% CI [0.26-1.10]), but a reduced risk of reoperation (RR = 0.54; 95% CI [0.33-0.89]) or explant (RR = 0.43; 95% CI [0.21-0.87]). Meta-analysis of noncomparative studies demonstrated rates of seroma = 3%; 95% CI [1%-6%], infection = 4%; 95% CI [3%-6%], reoperation = 10%; 95% CI [7%-13%], and explant = 3%; 95% CI [2%-5%]). Conclusions: Studies comparing synthetic and biologic meshes demonstrated noninferiority of synthetic in all outcomes assessed. Noncomparative studies demonstrated rates of seroma, infection, reoperation, and explant similar to literature values for biological mesh.

Class in Session: Analysis of GPT-4-created Plastic Surgery In-service Examination Questions.

Background: The Plastic Surgery In-Service Training Examination (PSITE) remains a critical milestone in residency training. Successful preparation requires extensive studying during an individual's residency. This study focuses on the capacity of Generative Pre-trained Transformer 4 (GPT-4) to generate PSITE practice questions. Methods: GPT-4 was prompted to generate multiple choice questions for each PSITE section and provide answer choices with detailed rationale. Question composition via readability metrics were analyzed, along with quality. Descriptive statistics compared GPT-4 and the 2022 PSITE. Results: The overall median Flesch-Kincaid reading ease for GPT-4-generated questions was 43.90 (versus 50.35 PSITE, P = 0.036). GPT-4 provided questions that contained significantly fewer mean sentences (1 versus 4), words (16 versus 56), and percentage of complex words (3 versus 13) than 2022 PSITE questions (P < 0.001). When evaluating GPT-4 generated questions for each examination section, the highest median Flesch-Kincaid reading ease was on the core surgical principles section (median: 63.30, interquartile range [54.45-68.28]) and the lowest was on the craniomaxillofacial section (median: 36.25, interquartile range [12.57-58.40]). Most readability metrics were higher for the 2022 PSITE compared with GPT-4 generated questions. Overall question quality was poor for the chatbot. Conclusions: Our study found that GPT-4 can be adapted to generate practice questions for the 2022 PSITE, but its questions are of poor quality. The program can offer general explanations for both the correct and incorrect answer options but was observed to generate false information and poor-quality explanations. Although trainees should navigate with caution as the technology develops, GPT-4 has the potential to serve as an effective educational adjunct under the supervision of trained plastic surgeons.

Surgical management of breast fat necrosis: Multi-institutional data analysis of early outcomes and risk factors for complications.

BACKGROUND: Breast fat necrosis (BFN) is a non-cancerous condition affecting the adipose tissue. Despite incidence rates of up to 25% after breast surgery, little is known about risk factors and postoperative outcomes following the surgical treatment of BFN. METHODS: The National Surgical Quality Improvement Program of the American College of Surgeons (2008-2021) was queried to identify female patients diagnosed with and surgically treated for BFN. Outcomes of interest included 30-day surgical and medical complications, reoperation, and readmission. We performed confounder-adjusted multivariable analyses to determine risk factors. RESULTS: The study population included 1179 female patients (mean age: 55.8 ± 13.8 years), of whom 96% (n = 1130) underwent direct excision and 4.2% (n = 49) received debridement of necrotic tissue. The majority of cases were operated on by general surgeons (n = 867; 74%) in the outpatient setting (n = 1107; 94%). Overall, 74 patients (6.3%) experienced postoperative adverse events, most of which were surgical complications (n = 43; 3.7%). Twenty-one (1.8%) women had to return to operating room, while readmission was reported in 18 (1.5%) cases. Adverse events were significantly more likely to occur in patients with chronic heart failure (p = 0.002) and higher wound classes (p = 0.033). CONCLUSION: Complication rates following the surgical management of BFN were found to be relatively high and seen to correlate with the setting. We identified chronic heart failure and wound contamination as risk factors for complication occurrence. These evidence-based insights may sensitize surgeons to critically balance patients' eligibility for BFN surgery and refine perioperative algorithms.

Bard Versus the 2022 American Society of Plastic Surgeons In-Service Examination: Performance on the Examination in Its Intern Year.

Background: Bard is a conversational generative artificial intelligence (AI) platform released by Google (Mountain View, CA) to the public in May 2023. Objectives: This study investigates the performance of Bard on the American Society of Plastic Surgeons (ASPS) In-Service Examination to compare it to residents' performance nationally. We hypothesized that Bard would perform best on the comprehensive and core surgical principles portions of the examination. Methods: Google's 2023 Bard was used to answer questions from the 2022 ASPS In-Service Examination. Each question was asked as written with the stem and multiple-choice options. The 2022 ASPS Norm Table was utilized to compare Bard's performance to that of subgroups of plastic surgery residents. Results: A total of 231 questions were included. Bard answered 143 questions correctly corresponding to an accuracy of 62%. The highest-performing section was the comprehensive portion (73%). When compared with integrated residents nationally, Bard scored in the 74th percentile for post-graduate year (PGY)-1, 34th percentile for PGY-2, 20th percentile for PGY-3, 8th percentile for PGY-4, 1st percentile for PGY-5, and 2nd percentile for PGY-6. Conclusions: Bard outperformed more than half of the first-year integrated residents (74th percentile). Its best sections were the comprehensive and core surgical principle portions of the examination. Further analysis of the chatbot's incorrect questions might help improve the overall quality of the examination's questions.

Tweeting for Success: The Role of Twitter in Enhancing SCImago Journal Rank for Specialty Surgical Journals.

Background The cornerstone of surgical education and practice is the surgical journal, but the ability to disperse the vital information within their pages had previously been limited. The use of Twitter by surgical journals has increased in recent years and has allowed these journals to reach a wider audience than they previously could. In this article, we discuss the role Twitter engagement has on a journal's impact factor, visibility, and prestige. Methods The authors compiled a list of journals using the SciMago Journal and Country rank platform. Included journals' Twitter profiles were then assessed using Twitonomy, an online platform that collects and processes data regarding individual Twitter profiles. Statistical analysis was conducted to determine the relationship between Twitter use and SCImago Journal Rank (SJR). Results Simple linear regression and multiple linear regression models determined that the only variables that had a statistically significant impact on all journals were the age of the Twitter account (p=0.003) and the percentage of retweets (p=0.001). When it comes to specialty-specific journals, further analysis showed that the only significant factor regarding its impact on SJR was the percentage of retweets (p=0.007). Conclusions Surgical journals' regular use of Twitter is important in the dissemination of important information to a wide audience. This article shows that the most important variable to determine the impact and visibility of a surgical journal is the percentage of retweets. Further research should be performed to better understand how to use Twitter and other social media platforms to reach a larger audience.

Journeying Through the Hurdles of Gender-Affirming Care Insurance: A Literature Analysis.

Gender-affirming surgery (GAS) has been proven to be successful in the treatment of gender dysphoria. The benefits of providing insurance coverage for transition-related surgeries far surpass the costs of suffering from persistent gender dysphoria, including many positive health outcomes such as decreased rates of substance use, psychiatric illness, and suicide. Despite being deemed a medical necessity, discrepancies in access to treatment and insurance coverage for GAS persist. The purpose of this review is to understand the impact of limited insurance coverage on the well-being of transgender patients. A comprehensive search was conducted utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in SCOPUS and PubMed databases using the terms "insurance" AND "gender affirming surgery." Articles in non-English languages were excluded. Data related to variations in insurance coverage for GAS in the United States were collected. Of the 67 articles reviewed, 29 met the inclusion criteria. When compared to the general population, individuals who identify as transgender have higher rates of being uninsured as of 2020, with only 30 states in the United States providing insurance coverage for transgender and gender non-binary people. Of the 30 states, only 18 provide coverage for GAS, with chondrolaryngoplasty having the highest prevalence of coverage. As evidenced in our review, the persistence of complex insurance regulations impedes transgender individuals' access to equitable care. Overall, this literature review elucidates the variability in insurance coverage as it relates to gender-affirming care. Furthermore, this review highlights the need for additional health policy reforms, in addition to improving physician awareness regarding the hurdles of navigating the insurance world as a transgender patient.

Racial Disparities in Postoperative Breast Reconstruction Outcomes: A National Analysis.

BACKGROUND: Studies have shown that Black patients are more likely to experience complications following breast reconstruction compared to other racial groups. Most of these studies have been conducted on patient populations focusing on either autologous or implant-based reconstruction without possible predictive indicators for complication disparities for all types of reconstruction procedures. The aim of this study is to elucidate disparities among patient demographics by identifying predictors of complications and postoperative outcomes among different racial/ethnic patients undergoing breast reconstruction utilizing multi-state, multi-institution, and national level data. METHODS: Patients in the Optum Clinformatics Data Mart that underwent all billable forms of breast reconstruction were identified via CPT codes. Demographics, medical history, and postoperative outcome data were collected by querying relevant reports of CPT, ICD-9, and ICD-10 codes. Outcomes analysis was limited to the 90-day global postoperative period. A multivariable logistic-regression analysis was performed to ascertain the effects of age, patient reported ethnicity, coexisting conditions, and reconstruction type on the likelihood of any common postoperative complication occurring. Linearity of the continuous variables with respect to the logit of the dependent variable was confirmed. Odds ratios and corresponding 95% confidence intervals were calculated. RESULTS: From over 86 million longitudinal patient records, our study population included 104,714 encounters for 57,468 patients who had undergone breast reconstruction between January 2003 and June 2019. Black race (relative to White), autologous reconstruction, hypertension, type II diabetes mellitus, and tobacco use were independent predictors of increased likelihood of complication. Specifically, the odds ratios for complication occurrence for Black, Hispanic, and Asian ethnicity (relative to White) were 1.09, 1.03, and 0.77, respectively. Black patients had an overall breast reconstruction complication rate of 20.4%, while the corresponding rate for White, Hispanic, and Asian patients were 17.0%, 17.9%, and 13.2%, respectively. CONCLUSION: Our analysis of a national-level database shows that Black patients undergoing implant-based or autologous reconstruction have increased risk of complications, likely due to multifactorial components that play a role in the care of this patient population. While higher rates of comorbidities have been cited as a possible cause, providers must consider racial influences involving cultural context, historical mistrust in medicine, and physician/health institution factors that may drive this disparity of outcomes among our patients.

From Risk Assessment to Intervention: A Systematic Review of Thrombosis in Plastic Surgery.

Thromboembolism is a feared complication in plastic surgery and is linked to higher rates of morbidity and mortality. Despite extensive research, there is a lack of consistency between recommendations and clinical protocols to be implemented pre and post-surgery to reduce the incidence of thromboembolism. A systematic literature review was conducted using Pubmed and Scopus databases to determine the risk factors, screening methods, and existing treatment models for thromboembolism prevention. Articles in non-English languages were excluded. Analysis indicated that predominant risk factors include age (>35), elevated body mass index, coagulation disorders, smoking, estrogen therapies, genetic predisposition, vascular endothelium damage, stasis, and use of general anesthesia in patients with a history of cancer. Implementation of a proper prophylactic protocol is dependent on understanding the interplay between the aforementioned risk factors and the utilization of well-defined, evidence-based guidelines, such as the 2005 Caprini Risk Assessment Model and ultrasound surveillance. The literature review revealed that mechanical prophylaxis is the primary prevention method, followed by thromboprophylaxis for patients with higher Caprini scores. Plastic surgeons often underestimate the present risk stratification tools available for the prophylactic intervention of thromboembolism due to the fear of bleeding or hematoma complications postoperatively. In summary, this literature review emphasizes the importance of plastic surgeons selecting protocols that is inclusive of the patient's risk profile to yield a reduced risk of thromboembolism.

A SWOT Analysis of Hot Topics in Plastic Surgery Resident Education: Consensus From the ACAPS 10th Annual Winter Meeting.

Background: With the aim of facilitating a critical self-reflection on how to align plastic surgery education with making excellent plastic surgeons, a rotating small-group session followed by live interactive audience polling was used to perform a SWOT (strengths, weaknesses, opportunities, and threats) analysis at the 10th Annual American Council of Academic Plastic Surgeons Winter Meeting. Methods: The final day of the conference included a 3-hour session of rotating small groups followed by live interactive audience polls discussing the following six relevant educational topics: the Plastic Surgery Common Application and resident selection, aesthetic surgery education, leadership development and business education, embedded fellowships and focused training, mentorship, and faculty retention. Results: A total of 60 individuals participated in the activity. A SWOT analysis was successfully performed for each educational topic, and a minimum of four opportunities were identified per topic to help guide future endeavors. Examples of opportunities include releasing recommendations for the implementation of holistic review; developing formal guidelines for aesthetic surgery education in residency via collaboration between ACAPS, American Society of Plastic Surgeons, and The Aesthetic Society; creating extended focused elective rotations; integrating business education into formal curricula for all training levels; enforcing transparency regarding position expectations and offerings including salary, call schedule, and current challenges; and more. Conclusion: The results of this study will help guide future initiatives by the ACAPS to improve resident education and academic retention.