Barb: A Nova Scotia woman has reached a settlement with the province over a human rights complaint that was launched after she was denied breast reduction surgery. Melody Harding made a complaint against the province and the Department of Health in August 2017, after she was told she would not receive coverage under the province’s health insurance plan for the procedure, because here body mass index was above the threshold required.
Barb: She maintained that the policy was discriminatory. And according to the settlement the provinces agreed to remove a requirement that a person have a body mass index of 27 or less, to be considered for breast reduction surgery. It will instead assess the medical need for the procedure on a case by case basis.
Barb: Joining us to talk about this, he’s a great friend of the show, Dr. Stephen Mulholland, founder of SpaMedica. One of Canada’s top cosmetic plastic surgeons.
Barb: Welcome back to the show. Great to have you on.
Dr. Mulholland: Thanks for having me, Barb.
Barb: Thank you for doing this. So what is your reaction to this story, first of all?
Dr. Mulholland: I’m a bit surprised, because I trained in plastic surgery way back in the 80s. And back then, there were limits placed upon how much breast tissue needed to be removed in order to qualify for reduction versus, say, a cosmetic lift procedure. And you submit photos. And the Ministry of Health would make the adjudication.
Dr. Mulholland: But very quickly, over about ten years, by the time we got to the 90s, the health insurance plan here in Ontario moved to a doctor/patient based assessment. Doctors sent in a medical report that the patient is suffering from symptoms. No matter what their BMI. No matter how big they are. No matter big they think the breast might be, or relationship of the breast size to the patient.
Dr. Mulholland: If the patient suffers from shoulder pain, back pain, inflammation of the skin under the crease of the breast, which can get quite sweaty, or cervical neck pain. And in the doctor’s opinion it’s related to, plastic surgeon’s opinion it’s related to, enlargement of the breast, generally Ministry of Health will approve it. The procedure is done. And there’s no other criteria required.
Dr. Mulholland: Everything else does get into a slippery slope of discrimination based upon size, or breast size. And women can have enlarged breast symptoms even if they’re tiny.
Dr. Mulholland: So I’m quite surprised that Halifax would still have those kind of criteria. Most of the provinces have moved to a patient/physician assessment and form submission process.
Barb: So then what would that threshold indicate? What does that mean? Does it mean that she’s overweight? And that’s why they won’t do it? Or what is the formula?
Dr. Mulholland: In the past, and again, it’s of historical interest for Ontario listeners, British Columbia listeners, Alberta listeners, I believe there might be a prairie province or two, and some of in the Eastern area of Canada, that do have criteria, and it’s interesting, this is the opposite criteria, for most provinces you have to have a minimum amount of breast tissue removed, or estimated to be removed, and it can sometimes be eight or nine hundred grams in order to qualify.
Dr. Mulholland: This poor lady was disqualified because she was too big. Well, of course, if you’re too big you often have what’s called mammary hyperplasia, or big breasts, which is why you’re having the reduction in the first place. So some jurisdictions put that you have to have made an attempt to lose weight. And kind of be punitive. And if you can’t lose weight, and your breasts don’t shrink, tough, you can’t have the surgery.
Dr. Mulholland: Again, I think that’s a bit archaic. In this day and age would be considered some charter violation for sure.
Barb: Are there some surgeries that you perform that you have to turn people away from because of health issues?
Dr. Mulholland: Yeah. Quite often. I do only cosmetic plastic surgery. And if patients have unrealistic expectations. So let’s say they think that the procedure’s going to save a failing marriage, or get a raise in their job, or it’s going to get them off of an anti-depressant, that’s clearly just bad expectations. And you have to say no.
Dr. Mulholland: Then medical conditions, unstable cardiac disease, respiratory disease, inflammatory or rheumatoid arthritis, there’s any number of metabolic diseases that are inflammatory and respiratory cardiac diseases that would be counter-indication. And then sometimes patients are just frail and elderly, and not good candidates for surgery.
Dr. Mulholland: So it actually is, most plastic surgeons that do aesthetic surgery would say no more than they would say yes, which surprises some people.
Barb: Oh, really?
Dr. Mulholland: Oh, yeah. For sure.
Dr. Mulholland: I see more consults that I don’t operate than I do.
Barb: And that, I guess, is where you find a situation where people, if they are determined enough, will go to see enough surgeons in the hope that somebody will agree to do it, even though they’re probably in good health to do that type of surgery.
Dr. Mulholland: And that is unfortunately a big problem in the United States. In Canada we’re quite fortunate, particularly in Ontario, where to do plastic surgery you have to be a plastic surgeon. And most are quite competent, if not really quite talented. And they’re good at selecting patients. And they don’t feel economic pressure, because everyone is doing pretty well.
Dr. Mulholland: In the United States, I practiced in California for ten years, a patient will get turned down, let’s say, at a top echelon surgeon, and they’ll just going and going around until they find somebody who will say, “You know, yes. You maybe recently off psychiatric medication and homicidal maniac, but yes, we’ll do that cosmetic surgery on you.”
Dr. Mulholland: So unfortunately if patients shop around enough, they will find someone that does inappropriate surgery, whether it’s plastic surgery or even orthopedic, general, or obstetric surgery.
Dr. Mulholland: So it’s always patient beware. If you keep looking long enough, you’ll find someone that does the wrong thing for you.
Barb: What kind of testing do people have to go through before they are able to have surgery done?
Dr. Mulholland: That’s a good question. In the hospital now, in managed care, they do less and less and less pre-op screening tests. Generally you don’t require chest x-ray anymore. Generally some hospitals, at certain ages, don’t even require blood tests. If you seem healthy-
Dr. Mulholland: Yeah. It’s really become … I think more an economic issue of appropriate screening. You screen a thousand patients to find one problem. But if you’re the patient with the one problem, you’re glad that they found it. But Minister of the Healthcare System works on evidence based medicine and economics.
Dr. Mulholland: In plastic surgery, where the stakes are a bit higher. People are not unwell, they’re generally having elective surgery to look better. We do have a bit higher standard, or set the bar a bit higher. Meaning that we would do a cardiogram, some blood tests, a urinalysis, because it’s worth finding one in a thousand cosmetic surgery patients that shouldn’t do that elective surgery they don’t need anyway, if they’ve got a significant problem.
Dr. Mulholland: If they have any health issue at all, particularly for example in my practice, most practices, if they have uncontrolled diabetes, uncontrolled high blood pressure, angina from cardiac disease, or they’ve got asthma, or chronic obstructed lung disease from smoking. Those are the top five reasons they could not undergo a plastic surgery procedure.
Barb: I don’t know if you know the answer to this, but in terms of weight loss surgery, do people have to be at a certain weight before they would even qualify? And I mean can they be too heavy to qualify?
Dr. Mulholland: Excellent question. In general, patients that are over, let’s say, between 32 and 36 BMI, or they are four or five hundred pounds, are at huge, huge risk for gastric bypass surgery. And so most bariatric surgery centers, in Canada, that tend to be in teaching hospitals, will limit the BMI of a patient, not for discriminatory reasons, but health reasons, statistical increases in risk, at 32, 33, maybe 34 at the top, BMI. Preferably under 30, 27 to 30. Someone’s lost 100, 120 pounds, has some extra skin now. Then they can undergo their bariatric surgery, lost the remainder of the weight.
Dr. Mulholland: Or if they’re starting out with the gastric bypass or gastric sleeve, they can have the bariatric surgery, lose the weight, and then have their loose skin surgery. But, yeah, there typically is a maximum weight, past which comorbidities like pneumonias, and DVTs, which are clots inside your veins go up astronomically, if you’re just too heavy.
Barb: Quick question before we let you go. Someone on the text board asks if you would do plastic surgery on someone with an eating disorder.
Dr. Mulholland: An eating disorder. You know, I used to like hamburgers and french fries, which is not really a big disorder. So eating disorder, I’m presuming eating not just unhealthy, but truly have a restrictive disorder, means they’re anorexic, and they look in the mirror, and they’re dangerously thin, yet they can only see someone who is overweight. And that’s a psychiatric condition. That would be an absolute counter-indication for plastic surgery. A more psychiatric management issue.
Dr. Mulholland: And then bulimia. And that’s harder to catch. Someone who constantly will binge and vomit to get rid of the caloric intake before. They can soon, they can often run into anemia is an intrinsic factor, iron deficiencies, and it can be quite unhealthy. And so bulimics are harder to … Because they don’t admit it generally. You look for yellow staining of the fingers, which is a bile change in the fingertips. And someone who’s constantly concerned about keeping weight, or making weight, but again they tend to be unhealthy. So it’s rare that a bulimic would admit their eating disorder. But in general, most plastic surgeons are really good, 30 minute trained psychiatrists trying to weed out who’s psychologically a candidate, who’s realistic, who has medical counter-indications, who has psychiatric or psychological, or personality trait counter-indications.
Dr. Mulholland: At the end of the day, sometimes as they say, you might operate on one out of five, or six, or seven consults.
Barb: Dr. Stephen Mulholland, thank you for this.
Dr. Mulholland: Thank you so much, Barb.
Barb: Okay. We’ll see you soon.
Barb: Dr. Stephen Mulholland is going to be in studio taking your calls in a couple of weeks.