Calling for a Modern-Day Flexner Report
I was pleased to read the excellent article by Ralph Di Libero, MD, in the January issue about Abraham Flexner's work almost 100 years ago to standardize medical education. Flexner sought to eliminate the many so-called medical schools that didn't teach good science and evidence-based medicine.

In recent years, I've been dismayed by the influx of pseudo-science into the medical school curriculum. I'm also uncomfortable with the "informercial" and testimonials for products, funded by people who call themselves doctors. The advertised nostrums are usually sold over the counter and are alleged to cure almost everything without one shred of scientific evidence to support the claims. The FDA is working hard to control the claims made for bogus OTC products, though the agency never seems to catch up.

Regarding the complementary and alternative medicine being taught at our medical schools, I'm in favor of another Flexner Commission.

Melvin H. Kirschner, MD, MPH
Family Practice
Van Nuys


In Praise of Specialized Training
The January Medical World feature titled "Learning and Growing" was excellent. A keeper!

Its message about the value of providing ongoing training for medical office staff reminds me of the evolution in the training of and practice by physicians.

Across all specialties, there is the healthy trend toward increased sub-specialization. For example, orthopedics has subdivided itself into hand surgery, spine surgery and sports orthopedics. Likewise, ophthalmology long ago began training  retina, corneal, pediatric and neuro-ophthalmologists.

In the relatively young specialty of cosmetic surgery, what single practitioner can be "at the top of the totem pole" if he or she performs everything--from hair transplants, nose jobs and face lifts to eyelid surgeries, breast surgeries and calf implants? It's impossible to do everything well.

Today, my practice performs only six procedures. Other cosmetic procedures are referred to other sophisticated and specialized surgeons. For example, I no longer perform revision eyelid cosmetic surgery. If patients have had unsatisfactory work done elsewhere, they deserve to have it done right the second time. Therefore, patients are referred to ophthalmic plastic surgeons; they are the masters of eyelid reconstructive and cosmetic surgery. They have the most training and experience in this very narrow niche.

Another positive development flowing from having highly specialized surgeons handle specific procedures is that two or even three surgeons, operating sequentially, will perform best as a team. For example, the ophthalmic plastic surgeon does the eye work, the plastic surgeon does the breast procedures and tummy work and the facial cosmetic surgeon does the face and nose work. One anesthetic, one surgical session and one recovery. Economy of time and money.

Using a team of expert surgeons is the alternative to one surgeon doing everything in one operation. With the team approach, not only are the results more likely to be optimal, but there is no issue of surgeon fatigue. A tired surgeon is rarely a superstar.

Robert Kotler, MD, FACS
Cosmetic Facial Surgery
Beverly Hills