The Existence of Sub-Specialty Societies is Only Natural

by Paul S. Howard, MD, FACS

Every surgical specialty society spawns sub-specialty societies.  It has always been that way.  Subspecialty groups began their own societies when their specific issues, whether educational or otherwise, are not being met by the parent group.  This was certainly true of the ASAPS.  At the time of their origins, many leaders of the ASPRS could not even utter the words “aesthetic surgery” thought it a demeaning endeavor and offered few educational opportunities.  The aesthetic surgeons had trouble getting adequately trained and were an embarrassing after thought in most training programs which was reflected in the ASPRS leadership.

The ASAPS was borne in this environment and was successful because it filled a void.  Since then, the ASAPS slowly embraced aesthetic surgery and devoted to increasing educational opportunities thus creating what was to become a chasm between the two societies ultimately based in financial issues.  The ASAPS was perceived to be more “exclusive” due to higher fees and a smaller membership devoted exclusively to the practice of aesthetic surgery.

Several years ago when the ASPRS dropped “Reconstructive” from its name it appeared that the society had become schizophrenic trying to appease the aesthetic surgeons at the expense of the historical primary of reconstructive plastic surgeons.  From the outside looking in, it appears the ASPS is losing its identity in an awkward attempt to be all things to all people.  It is assured that underlying the ASPS posture are financial considerations.

The leadership of the ASAPS are rightfully concerned that the ASPS intends on ending the “duplication” of services which it has created over the years by engulfing the smaller, more exclusive ASAPS into their 9000 member polyglot. Again, in a seemingly awkward attempt to fill the coffers, the ASPS has opened their meetings to non-plastic surgical physicians to enjoy the benefit of our training and expertise as co-called “guest” physicians.  It seemed inevitable since we gave away our leadership in aesthetic surgery by giving ENTs, derms, ophthalmologist and whoever “core” physician status; a word and status that makes no intrinsic sense whatsoever.

There comes a time in all battles when there is no clear winner and both fighters should retreat into their respective corners as there simply cannot be a winner only losers.  A good model for the ASPS is that of the American College of Surgeons where specialties are given a voice and a token amount of time at the national meetings.  The ASPS needs to concentrate on the needs of their historical “core” membership and try not to damage our leadership in aesthetic surgery by training others to compete with us.


Dr. Paul Howard is a Board Certified Plastic Surgeon in Birmingham, Alabama.  He is husband of Pamela Howard, founder of



Posted in Misc | Tagged | Leave a comment

ASPS Identity Crisis 2.0

Millard Principle Number 12: Do Not Underestimate the Enemy

Plastic Surgery the Meeting 2015 could likely sink into the Boston Harbor making plastic surgery history.  Not that the ASPS pays any attention to my contributions to the industry in which we all thrive, but this year they appear to especially ignore their own membership that created their existence.  Certainly I am not the only person to notice this year’s ASPS meeting registration form allowing registration for any physician as long as they are willing to pay an extra $600 and provide a copy of their medical license.

By now, if you are a real ABPS board certified plastic surgeon you have paused in horror and reaching for that original meeting registration form to verify my statements.  It’s true.  The same organization that delivers vague videos about “White Coat Confusion” and often reports on the horrors of cosmetic surgery tourism in third world countries is now throwing your credentials and board certification into the Harbor.

Two years ago, leaders and members of the Aesthetic Society circulated my blog article addressing the identity confusion and disrespectful proposals of a rather ambitious desire to merge with the Aesthetic Society without proper discussions with the Aesthetic Society.  In summary of that article, I pointed out the failure of the ASPS to maintain the identity of real plastic surgeons as both reconstructive and cosmetic plastic surgeons since their de-valuing name change from the “ASPRS” to the “ASPS.”  That same year, while present with my ABPS surgeon/husband at the Aesthetic Society (ASAPS) meeting in New York City, several senior officials and members approached me to not only thank me for the article, but appreciated my point-of-view.

Fast forward to 2015 and we have witnessed no attempt by the ASPS to maintain the integrity of ABPS certification as they allow the cosmetic cowboys to attend and participate in your “meeting.” Might I add that the phrase “cosmetic cowboys” was originally penned by the British Plastic Surgeons who are the “guest” country at this year’s ASPS convention (The real plastic surgeons in the United Kingdom have the same problem as we do here in the US). Yes, you have been sold out.  Your trade secrets are now dispersed in the name of the “core” and the cosmetic cowboys get to play “pretend” with your board certification granted courtesy of your white-coat-confused ASPS.

So where are they going with this? Is ASPS membership expected to be all warm and fuzzy? This sneaky maneuver is clearly a desperate attempt by the ASPS posing as the  medical industry’s flower child to increase their numbers since that Aesthetic Society “merger” didn’t work out for them.  I suppose this is their Plan B and let’s hope a special meeting “session” won’t be created for the cosmetic cowboys in future ASPS meetings.  Obviously, I do believe this is where they are going. It’s no secret where their priorities are: generating revenue any way possible.  Rumors have circulated for years that their numbers are down after having experienced poor attendance at some previous meetings and they have more focus on the Medicare lobbyist efforts while losing vision of the true cosmetic bread-and-butter that affords their membership fees and meeting expenses.

Over a decade ago, they dropped the “R” and now the meeting is open to all with a valid medical license.  I have previously argued they failed to defend the cosmetic plastic surgeons by dropping the “R’ thus opening the door and generalizing all plastic surgeons.  It’s long overdue for real plastic surgeons to take a stand and let your voice be heard.  This is your industry and there is no confusion about your white-coat but the ASPS needs to be made aware of their diagnosis and treated accordingly.

In the recent newsletter published by the ASPS, the current president wrote that both the ASPS and the ASAPS provide “duplicate” material and even sub-title one section of the address as “We are one specialty.”  This address is a pathetic attempt to “calm the waters” between the ASPS and ASAPS with condescending statements regarding “one-word” duplicate services, reminding the reader the ASPS boasts “9000 members (world-wide)” to the mere “2000 members” the Aesthetic Society maintains as an “overlap.”  The numbers may be greater with the ASPS but let’s not forget their new open door policy creating an over-crowded dingy of white coats.  The ASAPS confirmed with me by telephone today, October 16, 2015, that they only allow real board certified plastic surgeons to their annual meetings.  Looks like their membership is about to increase.

In the ASPS President’s Message, he acknowledges the concerns membership have with the “incursion of other specialists, paraprofessionals and non-professionals into the field of plastic surgery.” Yet, in a separate article proclaiming the “bright” future of the ASPS, any ABPS surgeon would quickly notice that the ASPS is on a fast-tract to shed integrity in the name of “collaborative efforts” with those invading “other specialties” and opening the door to cosmetic cowboys who continue to diminish and slander the accredited plastic surgery residency programs nation-wide that produce ABPS surgeons who deserve to not have their credentials toyed with.

Dr. Ralph Millard would agree to a point with Principle Number 29: Gain Access to Other Specialties’ Problems.  Real board certified plastic surgeons already receive their problems.  I find it hard to believe The Chief would agree to allowing the problematic cosmetic cowboys access to a specialty originally built on integrity and currently being sabotaged in the name of “collaborative efforts.” But let’s not get ahead of ourselves with “duplicate” material.  With this “collaborative” attitude and new business plan, the ASPS is creating their iceberg in the water and moving straight for it.

Posted in Misc | 2 Comments

Lift Style Lift Un-lifted

The mass marketing company, Life Style Lift filed for bankruptcy protection earlier this year.  As a result, thousands of patients have been rumored to have been stranded having pre-paid for cosmetic services now seeking legal advice to recoup their money.  Their mass marketing business plan commoditized a cosmetic surgical procedure targeting the Greatest Generation’s desire to look as good as they feel.  Many of these buyers not only got scammed on the mass marketing, but the lure of positive results based on that marketing focus instead of quality and credentials of the surgeon. The internet has been littered with their derogatory reviews and scathing blog articles. Yet, these buyers ignored these Caveat Emptor warnings and chose to compromise their finances and faces for the Debby Boone ads in hopes of “lighting up” their lives.

Life Style Lift was a company centered on a mass marketing campaign.  They first began as a pay-for-the-referral marketing company where the physicians would pay per “sales lead.”  Eventually, the mass marketing grew into a larger scale scheme involving surgery centers and plans to build more.  The physicians were mostly NOT plastic surgeons, but doctors from a variety of specialty backgrounds with or without surgical experience. So where did they go wrong?  I’m being sarcastic with that question.

Not even founded by a Real Board Certified Plastic Surgeon, but a physician with the “D.O.” credential, the company did not focus on credentials for their selected physicians but rather a test of “compliance” to follow their orders according to their company business plan which included a very precise surgical procedure for the face which has been widely criticized for how it cut corners in patient care.  So where did they go wrong? Their one-size-fits-all facelift is just the beginning of their failure. Patients presented with mediocre results, poor after patient care, extensive bruising and swelling, and continued sales pressure to purchase additional procedures.

The Life Style Lift business plan was to mass market a face lift primarily through television advertisements.  Potential “customers” would call their call center that housed dozens of people answering the phones to collect as much information as possible. Those customers would then be directed to a consultation center to meet with a consultationist or maybe a physician who may or may not be the actual physician to perform their procedure.  A very heavy sales pressure would be placed on the potential face lift patient that included reserving a surgical date and making a financial commitment to either pay in full or pay a substantial deposit.  Their average facelift has been reported to have cost $6000, of which approximately only $1000 or less actually went to the physician performing the procedure.   The remaining of the money obviously went towards the operative facility, staff, and that mass marketing campaign that got you there.

Their facelift procedure was nothing new or ground-breaking either.  Based on a local anesthesia protocol, this anesthetic method for facial procedures has been around for decades and is actually more common than general anesthesia.  In fact, my own plastic surgeon husband has been performing facial procedures under local anesthesia for decades, but he is also a real board certified plastic surgeon. The Life Style Lift face lift procedure involved their strict business plan which pressured the operating physicians to complete up to 8 per day.  A business plan that cut corners on patient care including the exclusion of post-operative drains that help reduce swelling and bruising, shorter incisions or mal-positioned incisions that were not always in the best interest of the patient’s results.  Obviously, the Life Style Lift business plan focused more on their bottom dollar than the results itself.

Now in bankruptcy, the internet is littered with folks like me writing “I told you so” articles.  The Life Style Lift proved how a great marketing plan can deliver consumers to your business.  However, that business still needs to deliver what they are selling in order to grow and maintain that positive marketing brand. Perhaps it was greed that drove LSL to the ground.  It is known they had business plans to expand their surgery centers nationwide dependent of being fed by their television ads.  So where did they go wrong? Outside of their poor selection process of operative physicians failing to require they be board certified plastic surgeons, their facelift procedure itself was flawed and inhibited by their business plan to turn the patient in a hurry so as to move onto another one.  Their business plan failed to recognize the facelift patient as an actual patient, not another dollar.

Posted in General Plastic Surgery Information | Tagged , , , , , , | 1 Comment

What is the cost of Breast Augmentation?

Plastic Surgery marketing usually focuses on targeting the budget cosmetic surgery seeking patient with breast augmentation in the forefront.  You are probably reading this blog article with this primary question in mind. In this article I will explore the expenses associated with breast augmentation surgery and what you can expect financially before and after breast implant surgery.

First, let’s break down the different fees that make up the total cost of the surgery itself.  First there is the obvious cost for the implants themselves. There are several different manufacturers of saline and silicone breast implants.  Saline implants are cheaper than silicone.  However, saline implants have an average life-span of 10 years so you should expect to face another surgery down the road if you want those puppies to keep their shape.  Silicone implants are on average almost twice the price as saline.  Most surgeons charge between $800 to $1200 for the saline implants, and between $1500 to $2000 for silicone implants.  These prices do not include the cost of the operating room, anesthesia services, and the surgeon’s professional fees.  These charges rarely include any retail mark-up from the surgeon and should include taxes (sales taxes and the ACA tax).

The cost of the operating room is usually dependent on the location and the duration of time is takes for the surgeon to complete the procedure. Same is true for the anesthesia service fees.  On average, operating room fees vary from state to state and can be anywhere from $750 to $2000.  Then, the anesthesia fees are usually added in addition to the operating room fees.  Those fees are usually between $350 to $1000 depending on several factors such as demographic locations and surgical operating room site.

Last, the surgeon’s professional fees are usually added to the complete quote for breast augmentation surgery.  Surgeon fees vary according to their time and sometimes these fees vary according to incision site for the procedure and any special equipment that may not be included in the operating room fee.

According to the 2013 statistics by American Society of Plastic Surgeons, average cost of Breast Implant surgery was $3678.00.  As a break down example quote, you can expect to be quoted something like this:

Breast Implant Cost

Breast augmentation advertisements are plentiful on the internet and even highway billboards that often capture one’s attention with a very low price of $2500 or even less.  What the fine print even your best vision cannot see is the phrase, “plus nominal operative fee.”  With breast augmentation being one of the most shopped-around procedures in search of the most attractive price, these ads target those less informed shoppers and are baited with their low price.  Subsequently these shoppers are hooked in the physician’s office with the true cost which is thousands more.  Add a convenient financing plan with outrageous interest rates and the pressure to schedule usually will land you a scheduled surgery date before you leave the physician’s office.

Lastly, you will need to figure in any additional consultation fees that usually run about $100 per initial consultation and the costs of post-operative prescriptions such as pain medications, antibiotics, and possibly a muscle relaxer.  Some surgeons have been known to not include the patient’s post-operative garments (surgical bra and maybe a breast elastic band sometimes referred to as an “implant stabilizer”) so be sure to inquire if the cost of the garments is included in your surgical quote. Some surgeons may direct their patients to a particular retail store or on-line web site where you purchase the garments prior to your surgery date.

Another final expense may be the opportunity to purchase an extended warranty on the implants.  Most saline breast implant manufacturers offer an extended warranty you may purchase within 30-90 days following surgery.  This extended warranty is highly recommended and usually won’t set your wallet back too much with fees around $125.00.  I highly recommend you purchase any extended warranty offered to you by your implant manufacturer.  I have witnessed and assisted many patients over the years with their implant warranties after experiencing a “blow-out,” or deflation which can happen for no good reason.  It’s not a medical emergency, but the appearance will be a rude reminder of why you got implants to begin with. The implant manufacturer will replace your deflated implant usually within 10 years (from original surgery date), maybe longer depending on their specific extended warranty you may have purchased, and will even reimburse some of the costs associated with surgical fees.  They won’t give you the money up front, but reimburse the patient after the surgical remove and replacement of implants. The deflated implants are always shipped back to the manufacturer for their investigation and then a check will be sent to you (usually a few months after your surgery).

When scheduling consultations with plastic surgeons, be sure to ask if the consultation with be “private” or “group.” I know this sounds strange, but more and more stories are emerging of Bundled or Group consultations where several patients all inquiring about the same procedure are scheduled at the same time to deliver the same information in a conference room, then perhaps an individual private examination with a very brief meeting with the doctor or a doctor’s associate. If the group meeting doesn’t bother you, then best luck to you.  Otherwise, schedule at least three different consultations with three different surgeons so you can make a more informed decision.  In other words, don’t settle for less.

This article addresses expenses for Breast Augmentation only and does not include other surgical scenarios such as breast lift with implants. Such instances where a breast lift could be recommended in conjunction with breast implants, all of the above mentioned expenses can be expected to increase significantly anywhere from $500 to $5000+ depending on the recommendation.

Posted in General Plastic Surgery Information | Tagged , , , , , , , | 1 Comment

Ten Things You Should Never Say to a Plastic Surgeon’s Wife

Think being married to a plastic surgeon is all cookies and crème? Well, maybe, but certainly not all the time. We are like any other wives out there, with our own list of annoying things people say to us. However, Hollywood has managed to portray us as cosmetic surgery junkies with Michael Jackson-like visions for cosmetic results and daily lives living at the spa. There may be a few wives out there that match this description, but the truth is most of us are quite the opposite. I have compiled a list of my top ten things you should never say to a plastic surgeon’s wife, but keep in mind: I stopped at ten.

  • Must be nice being married to a plastic surgeon, you can get procedures whenever you want.

This statement screams of shallowness. I can’t speak for some plastic surgeon wives, but I can speak for the ones I know: we did not marry our husbands based on their profession.  Albeit it can be nice, but it isn’t as convenient as some may think. Their schedules are busy and taking the time to do procedures on their wives can be tricky.  First, some hospitals have rules against “operating on family members.” Like we are going to let our husband’s competition operate on us? Uh, no. Next, employees can get weird and think they deserve some “freebies” too. Like the wife should have to pay the employee price too? Uh, no. Then, there’s the after care: the plastic surgeon husband gets to be the care taker too! Bravo! There’s the added benefit!

  • I don’t believe in plastic surgery. You should live with what God gave you.

People who say this to plastic surgeons and their spouses are calling themselves out as truly ignorant. Those same people will be the first to call when they cut their finger, or need special attention to that potential skin cancer on their nose. All of a sudden how those scars are going to look will matter. Then appears the “cosmetic” argument.  Breast implants following mastectomy can be considered “cosmetic” in nature especially if the patient needs a revision years later.  Many plastic surgeons have also witnessed confidence transformations in their cosmetic surgery patients. Cosmetic surgery isn’t just about “altering” a person’s appearance, it can enhance much more than the image in the mirror.  I am also holding myself back from posting before and after photos of children born with deformities. Should those kids “live with what God gave them?” Uh, no.

  • I know your husband gets medical stuff for free, so when do I get my free implants?

This is one of the most annoying statements made to plastic surgeons, their spouses, and employees. The assumption that doctors get all their medical supplies for “free” and  just because they may have their own private in-office operative suite doesn’t mean it doesn’t come with a cost. Doctors get charged premium on everything. They get very little for free, even prescription samples. Skincare companies rarely give samples to physicians for their patients. Most of those samples you ask for before investing in the products are purchased by the physicians.  Hitting up the wife for some of those “freebies” can really touch a nerve. Surgeons reserve those few “freebies” for their wives, employees, and maybe even themselves.

  • Doesn’t it bother you that your husband touches other women’s breasts all day?

Doesn’t it bother you that your husband has his face in other women’s vaginas all day?  Really people? All physicians have what could be considered “uncomfortable” situations in their daily profession of medicine.  It’s the human body to them, their heads are not in the gutter and the wives are not that insecure about their marriages.

  • How many cosmetic procedures have you had?

Many a time do plastic surgeon wives get asked this question. Well, okay, honestly, too often is this question asked. So don’t be surprised if the answer you get is something along the line of, “You know, you should really go see my husband about those bags under your eyes.”

  • You really shouldn’t trust nurses around doctors.

Why? Doctors are not starring in a daily soap-opera filled with your fantasies. The truth is that nurses actually insulate doctors from those patients who may have a few fantasies of their own. The truth is: doctors get hit-on more by their patients than those nurses who work for them – Especially in the supposed glamorized world of plastic surgery.

  • You should really try this skincare line I sale. I think it would work for you.

Everyone is out to earn a little extra money these days, and some of those people seem to forget how that sales pitch can be more of an insult to a plastic surgeon’s wife.  Plastic surgeons take a lot of pride in their wives and their wives do take advantage of their skills and access to great skincare.  Next time you memorize that sales pitch you learn at the training seminar, think about how it applies to the receiver.  The sales pitch is not a one-size-fits-all.  Not to mention, you might be quizzed regarding the exact chemistry of your skincare line and how it works. The plastic surgeon wife might be more willing to point out the ineffectiveness of your retail-store product compared to the physician-only product line. Be prepared to learn more about your product than you actually learned at that training seminar. Otherwise, don’t try to sale skincare to a plastic surgeon’s wife unless you are Dr. Obagi himself.

  • When are you going to have a Botox party?

It’s not ethical for doctors to deliver medical care in a party environment. Medical records should be on hand to document the medical treatment, waivers should be signed, sterile supplies, and the consumption of alcoholic beverages is not recommended following such a treatment.  Assuming your friend can schedule a fun party for some free Botox is out of line. Botox is very expensive. So why do you think doctors would give away thousands of dollars for the wifie pooh’s friends? If your friendship is only valued by what you can get out of the plastic surgeon, then maybe you need to move to another circle.

  • Did your husband do many cosmetic procedures on you before he would marry you?

{{Insert Charlie Brown “UUGGGGHHHH”  – here}}  Hollywood has opened the eyes of the cosmetic industry to some favorable and unfavorable characters.  Sure, there are one or two hideous stories out there about a wannabe-plastic surgeon shining a light up his arse in some sort of pride over their claim of molding the perfect wife. We should truly feel sorry for the wife, but never assume plastic surgery marital bliss began with a pre-nup requiring cosmetic refinements.  Dr. Ralph Millard said it best, “Know the ideal beautiful normal.”

  • I hear doctors always marry ‘down’ in intellect, especially plastic surgeons due to their egos.

Did you know my husband did a brain transplant on me before he would marry me? Claimed I was too smart and that wives are not allowed to have higher IQ’s than their doctor husbands{{Sarcasm}}.  The truth be, all doctors favor intellectual engagement and like to have intellectual conversation over dinner.  Real Plastic Surgeons are among the highest educated in the medical field. The plastic surgery industry and surgical techniques are quite “plastikos” as well as other medical specialties, but theirs receives more Hollywood exposure and glamorization.  Their careers began with intense studies requiring both sides of their brain, so they tend to gravitate to spouses who can understand these demands. Don’t get me wrong, I’m not shining a light up my arse here declaring my outstanding IQ, but my astro-physics professor from college would gladly come to my defense as he is convinced I missed my calling to be an astro-physicist. I just hated differential equations.

Posted in General Plastic Surgery Information, Misc | Tagged , , , , , | 1 Comment

60 Years Ago this Month a Plastic Surgeon Made History

Sixty years ago a plastic surgeon made history when he successfully performed a kidney transplant. That plastic surgeon paved the way for many to experience second chances with the help of organ donors: deceased and living.

This last July, I gave my plastic surgeon husband my left kidney to save his life after a vaccine almost took him away from us all. I am happy to report both of us are doing GREAT! In addition to receiving my left kidney, he also inherited my sweet tooth and low blood pressure.  We have decided to stay out of work during this recovery and plan to return in 2015.  His recovery has been remarkable. And, it is true what they say that it is harder on the donor: the donor had to take care of the recipient!

My husband wrote a tribute to me in which he shared on his blog. He published this article on the eve of our surgery at UAB:

I would like to thank all of our plastic fantastic friends and family who have followed us through this process. The Plastic Surgery Community is solid gold!

Posted in Board Certification for Plastic Surgeons | 2 Comments

Plastic Surgeons: The latest target by Drug Seekers

Drug Seekers have always been one the biggest challenges to physicians of all specialties. Plastic Surgeons have never been immune to this demographic of patient, but the current environment of electronic prescribing and monitoring has placed new challenges for narcotic abusers and dealers. The State of Alabama Medical Board of Examiners has implemented tools to help physicians verify and monitor patient prescriptions via an on-line portal. Along with this helpful system, the medical board appears to be on a mission of intimidation to those physicians who might be classified has high prescribers. The last few newsletters published by the Alabama medical board contain educational articles regarding this practice and how to prevent being a target by these “patients.” However, the tools suggested are not enough to protect the physician from new tactics by desperate drug seekers.

Since the first of this year, Plastic Surgeons have noticed an increase of new patients that fit this persona. Since their usual “sources” aka primary care physicians, orthopedics, internal medicine and pain management clinics are under the gun by the medical board to help reduce narcotic abuse, addicts and dealers are choosing new targets. Plastic Surgeons long have a history of highly individualized care for these elective procedures that include more personal access to the surgeon and/or staff. Allow me to first outline a some examples experienced by our office and other physicians:

(1) New Patient presents for cosmetic surgery consultation. The patient schedules surgery and a pre-operative appointment at which time the patient will sign necessary paperwork, receive pre-operative instructions including prescriptions required for day of procedure. The patient pays by check. The check is returned for insufficient funds. The procedure is cancelled. Patient is contacted and claims to have changed their mind regarding the procedure. The prescription is not returned as requested.
(2) Patient has liposuction procedure. Two days following procedure, patient’s caretaker calls to request a refill of pain pills. The refill is denied pending patient’s appointment the following day. Caretaker attempts to bribe the nurse into calling in the refill.
(3) A new patient appears for consultation. After being placed in exam room, office staff can over-hear the cabinet doors opening and closing in said exam room. When they open the door, the patient is sitting in the chair. Only then do they realize why the patient is carrying an oversized handbag that appears to be empty. Apparently bottles of alcohol, peroxide, and ointment were not on their wish list. Patient never signs up for any procedure.
(4) A new patient arrives early for their consultation. Appearing frustrated, the new patient informs receptionist their cell phone is not operational and they request to borrow an office phone. The receptionist offers her mobile phone charger instead. Patient refuses the assistance of the charger and still insists on needing to use a “land-line” phone.
(5) A tummy tuck patient, who had requested multiple narcotic refills following surgery shows for a scheduled post-operative appointment. Having already been cut-off of narcotic refills and Tylenol recommended, the patient shows with her husband. While in the exam room, the husband becomes aggressive with the surgeon demanding a full script pad of signed blanks. The altercation became violent when surgeon refused. Office staff dialed 911. Suspects fled the scene before police arrived but not after threatening bodily harm to the doctor and his staff.
(6) A primary care physician is threatened by a drug seeking patient during a routine office visit. Patient threatens a multitude of threats including bodily harm, law suit, sexual harassment claim, and filing formal complaints with governing hospital and state medical board. He refuses. Patient follows thru with complaints with the hospital and medical board. The physician was forced to defend himself in a “she said he said” situation.
(7) A primary care physician is contacted by a local pharmacist requesting prescription verification. The pharmacist had been presented with narcotic script with a very high pill count. The prescription was a fraud and the pharmacist destroyed the script. Upon further investigation, the physician discovered numerous prescriptions had been written using a counterfeit prescription pad, forging his signature and even using his correct medical license number and DEA number.
(8) Several years ago, Plastic Surgeon’s wife (me) went to fill a prescription of Valium written for her by her husband just prior to having to put-down their beloved 16 year old dog. At the pharmacy, the pharmacist questioned the prescription and stated he had just filled a prescription earlier that day in the same name by the same doctor for narcotics. I demanded to see the prescription and even requested he contact my husband. I gave him my driver’s license to verify I was who I claimed to be and he gave me a description of the person who came earlier with the narcotic prescription. The description closely resembled an employee and the pharmacist refused to give me a copy of the prescription presented. He also refused to speak with my husband whose signature had been forged. In my investigation, I discovered a flaw in our practice software that allowed users to print prescriptions then delete the records. The software was fixed and the employee eventually fired after obtaining further proof of misconduct.

As you can see, physicians are at risk and drug-seeking patients have very little fear. Stories such as these are never ending. Physicians are now forced to protect their credentials from all angles. Documentation in medical records is at a whole new level when dealing with drug seekers, that’s if you have a medical record.

First of all, let’s examine the ways these drug seekers obtain your correct medical license numbers and DEA number: internet. The first guilty party is Angie’s List. Physicians do not create their own profiles on their service, but are allowed to monitor their profiles and can request to correct the information. The physician must email the web site administrators to request removal of their sensitive license numbers. Physicians of all specialties should hire an in-house web site administrator to not only handle your sensitive web site material, but now to help monitor the web for abuses of your protected license numbers and reputation. Out sourcing this position is not advised.

Second, remove any and all office land-lines from unprotected areas of your office. The “my cell phone died” trick is a ruse to use your phone to call a pharmacy. Pharmacies often use caller-ID as their prescription verification methods. Otherwise, anyone from any phone number could call in a prescription claiming to be your nurse, especially if they already have your license numbers from the internet or from a previously written prescription. Even if you only use electronic prescriptions, not all pharmacists will know this is your office policy.

Third, create a new document for your office employee manual. If a chapter regarding prescription fraud is not already present, it’s time to revise. Medical staffs are often targeted by drug-seekers, often buddying-up to them offering bribes or playing a pity story. It’s time for all physicians to have a camp-fire meeting about this sensitive subject making very clear they are all at risk should only one cross this line. Make sure your employees understand it’s your medical license at stake, which is your career and all of their jobs. When hiring new employees, verifying employment history is imperative. Also, if an employment history of “doctor-hopping” is present, skip and move on to the next candidate.

Assign only one staff member responsible for handling prescriptions: calling in refills, access to the old-school paper prescriptions pads, and password protected access in the computer system for electronic prescriptions and printing. Otherwise, this duty will be all yours. Request this person to also create a daily prescription log by the end of every day to be placed on your desk.

For the threatening situations mentioned among the examples, there are few suggestions to help avoid or to defend yourself. The internal medicine physician now carries a small recorder in his pocket at every patient encounter. In most states, this practice is legal as long as one of the parties involved is aware of the recording. Many commercial phone systems also have a “record” button. If your practice software will allow for audio or visual recording files, then consider this protection as part of your patient’s medical record. Otherwise, create an excel spreadsheet by date to save the recorded files. Transfer those files to a memory chip to store in a secure HIPAA compliant place. Otherwise, consult with an attorney regarding the laws of your state and any further advice they may be able to offer. Further steps to protect your practice would be to install a “bank teller” like security system, and hire an expert to educate staff how to handle these situations.

Advanced prescriptions have been a courtesy in the plastic surgery industry for decades especially when meds are required prior to the surgical procedure. With the new trend of in-office procedures becoming more popular, plastic surgeons will need to develop new steps to avoid becoming victim to the drug seeker in these scenarios. Since drug seekers have no problem signing bad checks, a new financial policy requiring a cashier’s check or money order could prove beneficial. Many practices have also fallen victim to the “charge-back” scenario for cosmetic procedures. To get around this, practices have created “convenience fees” up to 4% for credit card charges of surgical services. One practice went from paying out thousands every month in merchant fees down to less than $200 a month after placing this policy without losing one single patient. If this policy is not feasible for your practice, then consider not providing prescriptions in advanced. If some prescriptions are necessary prior to surgery, requiring a non-refundable cash deposit to hold the surgery date would be advised.

As you can see, physicians need to yet again add another area of protection to their practices making the practice of medicine more challenging. These drug seekers are under pressure with state medical boards placing more accountability on the physicians. As physicians crack down on the amount of narcotics they prescribe and/or become more aware of those drug seekers in their patient files, they will also become softer targets by said drug seekers due to their credential and reputation vulnerability. Be aware of any and all situations where you could be cornered by a drug seeker. Arming yourself and staff with protecting tactics such as audio recorders could prove vital should you fall prey to the desperate drug seeker.

Posted in Misc | Tagged , | Leave a comment

What you need to know before you go for your Breast Augmentation Consultation

Choose your surgeon wisely

Choosing a surgeon who is Board Certified by the American Board of Plastic Surgery should be your first requirement.  A recent survey conducted by found that patient satisfaction is 30% higher when patients chose a Real Board Certified Plastic Surgeon.  If you need more information about how to find a Real Board Certified Plastic Surgeon, read my article, or go to  Most surgeons will recommend you see at least three different surgeons before making a final decision. Some factors to think about when choosing the Plastic Surgeon:

How long have they been in practice?

Do they have before and after photos for you to view?

Is the office staff friendly?

Where is the procedure performed?

Does the surgeon spend adequate time with you?

Will the surgeon be seeing you for your post-operative care?

Know your correct current bra size

Most women are not currently How to measure chest for bra sizewearing their correct bra size.  In fact, most women currently wear the wrong bra size because they have not properly measured themselves.  Most women begin with the usual “34” sized bra then choose the cup size from there.  When measuring for a bra, place the measuring tape UNDERNEATH the breast, measuring only around the chest, not on top of the breast.  This is the biggest mistake that manages to get so many women in the wrong bra size.  The purpose of the bra is to provide support of the breast.  Most women fit themselves focusing on mere coverage of their breast under clothing.  The bra cannot provide support if it is loose around the back, causing the back of the bra to rise up, thus the breast sag in the front.

Once you have the correct chest measurement, then you choose your cup size.  This is where so many Americans get frustrated.  Women tend to think that a size “C” cup is the same for a chest measurement of 32, 34, 36, and so on.  Nope.  Nothing could be further from the truth.  In fact, a 34C is the same cup size as a 36B or a 32D.  Also, a DD size is also size E, and triple D (DDD) is also size F.  Europeans use common sense cup sizes of A, B, C, D, E, F, G, and so on.  Americans like to be complicated and use A, B, C, D, DD, DDD, and so on.

So when you go into your Plastic Surgeon’s office and tell them you desire to be a “C” cup, think again.  Most “C” cups are actually not as big as you think.  Below is a chart to give you a better idea:  a 32C has the same cup size as 34B, a 32E (DD) has the same cup size as 34D and so on.

Bra Cup Sizing Differences

Saline or Silicone?

Choice in implant substance is a very personal decision and must be chosen wisely.  Saline is salt-water.  Silicone is, well, silicone.  The lifetime of saline implants is on average 10 years, meaning the implants are likely to require replacement approximately after 10 years.  Saline implants also are known to “reduce” in size and lose volume over the years which can lead to implant deflation which is why the life expectancy is around 10 years.  Silicone is back on the market and is gaining momentum as the implant of choice for a few factors.  Some believe the silicone gel is more natural feeling than the saline, and the life expectancy of the silicone implants is greater than saline.  Silicone is more expensive and the FDA recommends patients monitor the implants by way of an MRI every few years which is not covered by insurance.  Both implants run the risk of deflation, or outer shell failure, but the saline is absorbed by the body.  On the other hand, silicone is not absorbed by the body but less likely to deflate due to the silicone gel not losing volume over time.  Loss of saline volume over time causes the shell of the implants to shrink, thus creating folds, or rippling, in the shell.  These folds break down the shell due to friction leading to deflations.

There are three FDA approved Implant Companies in the USA:

Allergan (Natrelle™ Breast Implants) – manufactures saline and silicone implants

Mentor– manufactures saline and silicone implants

Sientra– only manufactures silicone implants, AND only sells their implants to Real Board Certified Plastic Surgeons.

Breast implant warranties chart

Implant Incision Site

The incision site for breast augmentation will be dependent on many factors depending on your choice of surgeon and choice of implant type.  Saline implants are most commonly placed using the sub-mammary incision (under the breast), and this incision site is required for silicone breast implant placement as well.  Other incision options include in the arm-pit (trans-axillary), through the umbilicus (TUBA), and around the nipple (peri-areolar).  Not all surgeons are skilled at these other incision sites and those that are not often have clever excuses such as “it is dangerous.”  What they really mean to say is, ‘it is dangerous for me to do it that way because I am not skilled at doing it that way.’

Decide what size you think you would like to be then do your research

Trying to choose your desired breast size can be easier than you think.  Most women have a friend who has 350cc saline filled implants, they look great, and they claim to be a “C.”  Take note than 350cc implants do not equal “C” cup for everyone.  Some women get locked-in an idea of what breast size they want to be according to “CC’s.”  Get over it.   Not all women are created equal and certainly not our breasts.  Decide what cup size you are now, and what cup size you desire to be.  The best way to assist in your decision process is by purchasing a few bras at your local discount store, stuff them and play around with sizing until you get a better idea.

Trying to pre-determine your implant size according to what size implant your friend got, who is taller or shorter than you, or may have started out with more or less breast tissue, is just not smart.  Let your surgeon measure you and chose the implant size according to what cup size you request.

The East Coast or West Coast Look?

I know this sounds funny, but it is a real thing.  Women on the East Coast have a different idea of how the implanted breast should look than the women on the West Coast.  I’m an East Coast woman and like the full look that achieves an augmented appearance on the upper polar portion of the chest.  West Coast women like the fuller look in the lower cup portion of the breast.   The difference in the two looks is created by implant size, shape, and placement.   Breast implants come in three different projections:  low profile, moderate profile, and high profile.  High profile is often used to achieve the upper polar fullness, moderate profile is the most commonly used implant, and low profile is the least commonly used implant.

There is another “anatomical” implant shape on the market referred to as the “tear drop” shaped implant.  Not that popular since most breast implants are placed under the muscle for the most natural appearance.  This implant is a consideration when sub-muscular placement is not an option for some patients such as body builders.  Otherwise, any special shape is lost under the muscle.


Breast Augmentation is the most “shopped around” procedure.  Price is usually the very first factor in choosing a Plastic Surgeon for this procedure.  Unfortunately, choosing your surgeon according to price can land you in a bad facility.  Most surgeons who charge very low fees for surgical procedures are business minded people focused on turning their operating room at rapid rates, which means you will be one of maybe a dozen patients that day.  Make sure you choose this type of surgeon wisely if price is that important of a factor.

Post-Operative Care

The patient’s after care plan is something that should be well organized in advance of any surgical procedure and breast augmentation is no exception.  Many young women perceive this procedure as a “weekend recovery” and often make plans to return to work or go enter that bikini contest.  Breast Augmentation involves the placement of a foreign object (implant) inside the body.  This procedure can involve a painful recovery easily resolved with pain medication.  The incision site must be protected until the doctor instructs otherwise, and physical activity will be limited if not prohibited by your surgeon for a period of time.  Most patients describe the pain discomfort as “an elephant sitting on my chest.”  Most Plastic Surgeons recommend taking a week off of work or other physical activities.  You should also make arrangements to have someone stay with you for the first day or two, and even drive you to and from your post-operative appointments the first week.

Posted in General Plastic Surgery Information | Tagged , , | 3 Comments

2018: Your Doctor is a Plastic Surgeon

For over 12 years I have worked for my husband in his Plastic Surgery Practice in Birmingham, Alabama.  I began by managing his Cleft Lip/Palate Clinic  which included fighting with insurance companies to cover the medically necessary services for these special children born with facial deformities.  For ten years I fought tooth and nail to get insurance companies to “approve” surgery for children born with facial deformities.  Did you hear me?  I had to fight to get these surgeries “approved.” Often times, the insurance companies would “authorize” the surgery only to have the claim denied after the surgery had been performed.  We would then have to follow the insurance company’s protocol of filing a “letter of appeal” only to get that brushed under their mat hoping the surgeon’s office staff would forget thus allowing for the time to run out for the claim.  After numerous phones calls, faxes of medical records, sitting on hold listening to how wonderful they are, the claim would eventually be mailed as “paid” only no check would be enclosed and the “Patient Responsibility” would list the full amount of the claim minus the insurance company’s “contractual not-allowed.”  The patient’s family would call and the insurance company would tell them the doctor’s office didn’t submit a “clean claim,” and when we called the insurance company they gave us the run around.  It was a classic pit-the-patient-against-the-doctor scam.  It worked.  The last time this happened to my husband, he never got paid.   The patient’s family was convinced by the insurance company that his office “didn’t file a clean claim.”  The insurance company claimed the “elective surgical procedure” had been approved under a clause of the patient’s insurance policy where they were financially responsible.

This is how it has been and will be for doctors and insurance companies.  Somehow the people of the USA think Obamacare will guarantee them healthcare.  Not so fast.  Allow me to shed light on where this is going and why I say:  2018- Your Doctor is a Plastic Surgeon.

Patients always gripe about their “co-pay” and “patient responsibility” with their doctors.  First thing everyone needs to understand is that physicians have a contract with these insurance companies they are providers for that requires them to collect co-pays and patient responsibilities from the patients at the time of service.  Patients are required to pay these fees as outlined in their contracts they have with their insurance providers.  These co-pays are part of the payment, if not all, the physicians agree to accept from the insurance companies. Since the passing of Obamacare, insurance rates have skyrocketed, including the out-of-pocket expenses for patients, and additional taxes are burdening basic medical supplies at the expense of the physician and/or medical facility.  What this means for physicians is that their private practice costs have also skyrocketed, reimbursement remains a challenge and un-fixed, and their patients are no longer able to afford their co-pays.  Given the insurance payment challenges physicians have been up against for decades,  physicians have been “crossing the specialty line” for many years changing their specialties from general surgery, family practice, dermatology, OB-GYN, to “cosmetic surgery.”  This is where I stepped in 2010 with exposing these rogues with fly-by-night liposuction training in Vegas then showing up Monday morning with a hang-over and a sign that reads “Now offering lipo.”  These rogues are ever increasing as the true insurance regulations are ignored by Obamacare resulting in fewer primary care physicians and more “cosmetic surgeons.”

It’s common knowledge in the Plastic Surgery Industry that a majority of the plastic-surgery-gone-wrong stories plastered in our media are due to the procedure being performed by one of the rogues who are not board certified by the American Board of Plastic Surgery.  As outlined on, these rogues have created their own board certifications as a pathetic attempt to justify their lack of formal education for the specialty they practice.  This deception has been recognized by states such as Florida with a “Truth in Medical Marketing Act.”  Even my OB-GYN offers Botox and artificial fillers as a “French Fry” business to supplement his income.  This is what my husband refers to as a “perfect storm” in the Plastic Surgery Industry meaning both a storm surge of Plastic Surgeons, and also a lack of other medical health providers offering real medical services other than cash paying cosmetic services to squeeze out pathetic insurance reimbursements.  Imagine going to your cardiologist for bypass surgery and the doctor asking you “would you like lipo with that?”

Bottom line is that physicians are being squeezed more and more by insurance companies as they place more of the financial burden on the patients.  The cost of physicians to file insurance claims and fight for these payments is merely an additional practice expense to the already squeezed private practice physician.  Even the Society for Hospital Medicine recommends physicians could “provide Botox services at cosmetic parties in the evenings” as a way to supplement their income.  The storm surge of cosmetic surgeons had already been on the rise prior to Obamacare, and now post-Obamacare sans real insurance reform gives Americans “the perfect storm.”  The American Academy of Cosmetic Surgeons (home of these physicians whom are not board certified by the American Board of Plastic Surgery) states on their website they had the “highest attendance in the Academy’s history with more than 900 medical professionals” for their 2013 annual meeting.  The internet is littered with articles discussing the decrease in physicians for the years to come.  Physicians from coast to coast are faced with early retirement or seeking alternative ways to generate income outside the exam room.  Many predict the only place to find medical care will be the major universities thus foreseeing overcrowded waiting rooms and longer waiting times with less time to speak to the physician.  And, you think it is lean now.  Just wait, or go see your Real Board Certified Plastic Surgeon for that head cold.

From time to time, state medical boards are faced with the task of regulating these rogue physicians in response to the plentiful complaints of damaging cosmetic surgery results performed by these rogues.  Recently, the Medical Board of the State of Alabama made such an attempt to regulate in-office liposuction procedures in the name of “patient safety.”  While it’s all a great idea, it doesn’t address the root of the problem.  These medical boards can legislate how the procedure is performed as far as anesthesia safety is concerned, but they cannot address the permanent contour deformities and tissue loss these patients are given as a result of their cosmetic physician not really knowing how to do the procedure.  These are things real plastic surgeons learn in their plastic surgery residencies.

Surveys conducted by Athena Health and Sermo show “79 percent of physicians are less optimistic about the future of medicine, 66 percent indicated that they would consider dropping out of government health programs, and 53 percent would consider opting out of insurance altogether” (Daniel Palestrant, M.D., “Why Physicians Oppose the Health Care Reform Bill,” Sermo, April 8, 2010).  It’s that last number of 53% which strikes my attention.  What would these doctors do?  Will they only accept cash for medically necessary services or are they considering crossing over to the rogue cosmetic surgery side?  Considering the high insurance premiums, co-pays, and deductibles, is it financially feasible for a patient to pay cash to see their doctor for sinusitis?  Doctors already know the answer to that question is ‘no.’ No, Mr. Obama, patients are not likely to keep their doctor.  Instead their doctor will be glad to see them for a facelift or liposuction.

Recent reports of restaurant chains and movie theatres decreasing employee hours so as to avoid health benefit programs should be more than alarming to patients and physicians alike.  Physicians need patients and patients need physicians.  These employees will be at the mercy of a government based health plan, with fewer doctors willing to accept them as a patient. “If 66% of physicians are considering dropping out of government health plans, if only half actually do we would have an incredible shortage of doctors to see Medicare and Medicaid patients. The last resort is your local university training program, but don’t expect to see an attending physician,” states my husband, Dr. Paul Howard who spent years on the faculty at the University of Alabama Birmingham as an attending physician.  A recent report by The Texas Medical Association shows two alarming grafts of the decline of physicians accepting Medicaid and Medicare.  Texas physicians are dropping out of these government insurance plans steadily since 2000.  This is only the beginning.  The real Medicare deal hasn’t even hit yet.

Obamacare only addresses the Medicare system for physician payment.  Private insurance companies already have a long history of cat-and-mouse with their providers as mentioned at the beginning of this article.  With no real health insurance reform protecting physicians, they will continue to drop out of accepting not only government insurance plans, but private ones as well and the “cosmetic surgeon” trend will continue with the likes of me on their coat tails calling them out for the rogues they are.   This will leave us with the Real Board Certified Plastic Surgeons who most have already adapted to the poor insurance reimbursements and are actually qualified to practice according to their board certification.  Let it also be known that most Real Plastic Surgeons completed a general surgery residency before going on plastic surgery residencies, making them quite qualified to help out with those head colds.  By 2018, Obamacare will be at its finest and the number of physicians opting-out of accepting insurance plans can only predict to be devastating, and they will all be labeling themselves as either a Plastic or Cosmetic Surgeon.  Secure your Real Board Certified Plastic Surgeon today.

©Pamela Howard



Posted in General Plastic Surgery Information | Tagged , , | Leave a comment

ASPS – ASAPS Unification by Pamela Howard

A recent proposal is on the table calling for the “unification” of the American Society of Plastic Surgeon and the American Society for Aesthetic Plastic Surgery.  Those in favor cite “economic” reasons as well as the “creation” of a more “aesthetic” unification.  Must I be the one to point out it was the ASPS who decided to remove the “R” over 10 years ago?  It seems we have an organization with an ongoing identity crisis.

I vividly recall hearing about the name change from the American Society of Plastic & Reconstructive Surgeons to the American Society of Plastic Surgeons when I was first employed into this industry. Having been employed into a Reconstructive sector of my husband’s practice, I remember my reaction to the news as a negative one.  “Simplification” was the answer, even my husband understood both sides of that argument.  This blonde-brain didn’t.  I recognized instantly the narrow road it would create for an industry built on both the reconstructive and the cosmetic.  So the “Ann Coulter” of the Plastic Surgery Industry here (that would be me) is happy to say “I told you so” as I explain why this was such a bad idea and why the unification proposal doesn’t help our position in the real world of Plastic Surgery.

First of all, removing the “R” was a big slap to this industry.  It clearly opened the door for the “rogues” to step in and claim the “cosmetic specialty” for themselves as they refer to plastic surgeons, such has my husband, as “general plastic surgeons” and they plaster all over their websites phrases such as “plastic surgeons are only trained in wound care and reconstructive surgery.”   Your “simplification” ideas of the past have not worked out for the reputation of your very members.  To simplify this paragraph for those of you who are merely scanning; Plastic surgeons are now considered “general plastic surgeons” which is the old “reconstructive surgeon.”  Anything “cosmetic” got reassigned to those physicians (I do not refer to them as “surgeons” for the obvious reasons) who have gone rogue.  Also, marketing and branding is more complicated by the capitulation in the “core” physician agreement.

Now more than ever this Industry is faced with a “so easy a cave man can do it” mentality created by the cosmetic rogues.  Real Board Certified Plastic Surgeons are faced with the daunting challenge of marketing themselves against these rogues stressing the importance of “board certification.”  This is where I stepped in with my a few years back.  We all know that anyone can claim to be “board certified,” but the general public doesn’t understand that statement can be deceptive.  We do, the ASPS does, the ASAPS does, but where are all of the financial efforts focused?  Medicare?  We also know that the bread-and-butter of this industry is in cosmetic cases and that Congress could care less about the reimbursement of a cleft lip repair or BCC removal.  With ideas such as the removal of the “R” and now a unification proposal on the table, I cannot help but think the ASPS is in some sort of bubble and has no clue about this industry.  Maybe some of you cats would like to work with me for a day in Birmingham, Alabama.   I dare you.

Don’t get me wrong, Medicare and Medicaid reimbursement is very important to any physician. I have direct experience in filing these claims.  I also know, the reputation of my husband’s industry is extremely important to putting food on my table.  Our news is bombarded with “plastic surgery gone wrong” stories that often fail to mention, or merely stress, the importance of finding a “real” board certified plastic surgeon, and I wonder where is the ASPS?  Ok, so they issue a press release, or they may manage to get some news time, but why does it appear they are focusing their efforts more on Washington than the integrity of this industry with the general public?  You want more respect with Washington?  Here’s a novel idea:  start with the respect of this industry with the general public.  Better yet, restore the “R” and leave the ASAPS alone.  The “American Society of Plastic & Aesthetic Surgery” would only be more confusing to the public we market to.

I have more respect for the ASAPS because they were the first to respond to my efforts.  I knew I got their attention.  This plastic-surgeon’s-wife-from-Alabama made waves with Plastic Surgeons world-wide.  The ASAPS took notice and recognized the void I attempted to fill.  They were the first to step-up to the plate with social media and help tackle this growing problem with “the rogues.”

So, who put this proposal on the table?  The ASPS?  Why would it benefit the ASAPS to unite with another organization with a history of identity confusion?  I have heard a few arguments for both sides.  The ones citing economic reasons I must disagree with first.  The ASPS divided plastic surgeons in a pathetic attempt to unify the specialty during a time when division was already rampid.  They folded, caved in, and changed their name, and obviously opened a door for the cosmetic rogues to step in and create “white coat confusion.”  The reason being we never trademarked our “Plastic Surgery” moniker.  Has anyone seen a marketing effort by a Real Plastic Surgeon that touts their “core” physician status?  Then, we have the core curriculum ambiguity which created even more marketing confusion.  So I ask you “economic reason” supporters, why seek to save a little money when the reputation of the industry in which you thrive is at stake?  If either group is having problems maintaining membership or meeting attendance, they should look within rather than trade on false assumptions.


Posted in Misc | Leave a comment