S05E88 The Wild West of Cosmetic Surgery

This episode of 'Three Plastic Surgeons and a Fourth' features a discussion among plastic surgeon hosts Dr. Salvatore Pacella @sandiegoplasticsurgeon, Dr. Lawrence Tong @yorkvilleplasticsurgery, and Dr. Sam Rhee @bergencosmetic about the dangers of unregulated cosmetic surgery practices. The conversation is sparked by a tragic incident reported by the LA Times involving a pediatrician performing liposuction, which led to a patient's death. 

The doctors emphasize the importance of board certification and proper training in ensuring patient safety, critiquing the 'Wild West' of cosmetic surgery where professionals outside of plastic surgery venture into aesthetic procedures for profitability. 

The episode sheds light on the significant differences between board-certified plastic surgeons and those who label themselves as cosmetic surgeons without adequate training or accreditation, urging patients to thoroughly vet their surgeons' qualifications.

The episode critically examines regulatory failures, the commercial allure driving non-specialists to perform cosmetic procedures, and suggests ways for patients to ensure they're choosing qualified surgeons.

Dr. Sam Jejurikar @samjejurikar @3plasticsurgerypodcast #podcast #plasticsurgery #cosmeticsurgery #plasticsurgeon #beauty #boardcertified #aesthetic 3plasticsurgeonsandamicrophone ⁠#bergencosmetic ⁠#bestplasticsurgeon #beforeafter #aesthetics #realpatientrealresult #boardcertifiedplasticsurgeon #njplasticsurgeon #njplasticsurgery #nyplasticsurgeon #nyplasticsurgery   

#HealthcareSafety #PatientAdvocacy #MedicalEthics #SurgicalSafety #CosmeticSurgeryAwareness #SafetyFirst #RegulateCosmeticSurgery #MedicalAwareness #WildWestMedicine #UnregulatedSurgery #MedicalHorrorStories #SurgicalHorrorStories #EthicsInMedicine

Transcript

S05E88 The Wild West of Cosmetic Surgery

 [00:00:00]  

Dr. Sam Rhee: Welcome everyone to another episode of Three Plastic Surgeons and a Fourth. Today we have Dr. Salvatore Pacella in La Jolla, California. His Instagram handle is at San Diego Plastic Surgeon. And then we also have Dr. Lawrence Dong, who, uh, is in Toronto, Ontario, Canada. And his Instagram handle is Yorkville Plastic Surgery. 

That's correct. Awesome. And then my Instagram handle is at Bergen Cosmetic and I'm in Paramus, New Jersey. And our fourth, who is still on his way back from a, uh, medical surgical trip overseas in Bangladesh is Dr. Sam Jejurikar. And his Instagram handle is, uh, at Sam Jejurikar and he's in Dallas, Texas. So we have a pretty Yes. 

I hope he gets back soon so he can join us. Bye. Um, we have a pretty, uh, [00:01:00] fantastic, like, uh, attention grabbing topic today. It's about, um, and it was spot, it was spurred by an LA Times article, uh, about a week or two ago, and the headline read as such, she died after liposuction by a pediatrician, doctors warn of cosmetic surgeries. 

Wild West. So, uh, before we get into it, Larry, if you could read our disclaimer for us.  

Dr. Lawrence Tong: No problem. Uh, this show is not a substitute for professional medical advice, diagnosis, or treatment. This show is for information purposes only. Treatment and results may vary upon the circumstances, situation, and medical judgment of after appropriate discussion. 

Always seek the advice of your surgeon or other qualified health provider with any questions you may have regarding medical care. Never disregard professional medical advice or delay seeking advice because of something on this show.  

Dr. Sam Rhee: So let me, uh, open by just, uh, reading the first couple sentences of this, uh, article. 

It was written by [00:02:00] Emily, uh, Reyes, and it opens with the following sentences. Inside a clinic wedged next to a smoke shop in a South Los Angeles strip mall, Dr. Mohamed Yagi operated on a 28 year old woman who had traveled from Las Vegas to have fat trimmed from her arms and stomach. He had been offering liposuction for roughly seven years when he started making that, those incisions that day on October, 2020, but he was trained as a pediatrician. 

When the woman stopped breathing less than an hour into the surgery at La Clinica de Los Angeles, paramedics were summoned and the mother of four died days later at Good Samaritan Hospital, unable to recover from the loss of oxygen to her brain. So as board certified plastic surgeons, when you see this type of sensational and tragic, totally tragic incident occurring, And we see this not infrequently. 

[00:03:00] What are your thoughts, um, as a surgeon?  

Dr. Salvatore Pacella: Um, I'll start here. So I think, I think before we get into my feelings and thoughts on this, which I think are pretty obvious, we have to understand why exactly this can occur. And it is 100 percent legal to occur this way. Um, so when you become a plastic surgeon or a cardiothoracic surgeon or a pediatrician, you basically have to have a medical license, but that medical license just simply allows you to practice medicine. 

and or surgery. It has nothing at all to do with the type of medicine or the type of surgery you do. Okay. And so most of us that are interested in training to the highest capacity after medical school, we'll do a residency like the three of us did at the University of Michigan. We even went on to do fellowships. 

Okay. And from there, In order for us to [00:04:00] practice in a hospital setting, we have to be privileged by a community hospital or some sort of other accredited hospital facility, okay? So why this type of thing doesn't occur in, say, cardiac surgery? Technically speaking, it is 100 percent legal for me to go And do a triple bypass if I chose to do so. 

If I knew how to do it and I wanted to do it, it is 100 percent legal for me to do so. However, no hospital in the right mind would actually ever give me privileges to do this because I haven't been trained in that. Okay. And the wild west that they're talking about in this article is that. Because most cosmetic or aesthetic surgery is done in an outpatient setting, meaning in an office accredited operating room, or some other back office, or some other procedure room, and so there are no rules. 

There's no accreditation agency that applies to those. Most of us that that work out of those facilities, [00:05:00] are board certified and follow an accreditation process. The tragedy, the absolute tragedy of this story is that it was 100 percent legal for this pediatrician to do that. And in my opinion, that's, that's dreadfully wrong. 

It's horrific.  

Dr. Lawrence Tong: I agree with you. Um, where I practice in, in Toronto and, um, it's a little bit different. In, uh, 2007, there was a liposuction death in Toronto and it was a situation where a family physician performed liposuction on a 32 year old female real estate agent and she passed away from that tragically as well. 

As a result of that, there were changes made By the, um, the licensing board of Ontario and, uh, the changes now in, in my province, and I think most provinces in Canada actually, are that if you are, um, going to be, uh, performing procedures or any type of [00:06:00] medicine out of your scope of, of training. That is a no no. 

So that is something that's different, um, here, uh, where I practice compared to the United States. And I, I think that was a positive, um, you know, move, um, on, on the, uh, regulations here. But, uh, yeah, it is a no no. It is tragic that this can still legally happen, um, in the United States.  

Dr. Sam Rhee: Yeah, and the, the thing about this is, is that not, and we should really talk about regulation and, and how that's, worked or not worked in the United States. 

But this particular physician, like if you were a patient and you're like, Oh my God, how did she die? Or, or what went wrong? Um, he clearly, um, did not take appropriate care of this patient. Obviously, uh, when the state investigated this woman's death, he. proceeded with sedation [00:07:00] where he should have known that the patient should not have recently consumed food or water, which she did, which increases the risk of aspiration where the food or water gets into your lungs and then you have difficulty breathing. 

She also had uncontrolled diabetes, so she had major medical issues for which he did not screen for and Uh, in response to this tragedy, the doctor wrote a refund check for 6, 500 back to the patient, which of course was insufficient. And the family sued the physician for malpractice, reached a settlement. 

And then the California Medical Board at that point accused the physician for incompetence, and then he finally, four years later, has surrendered his license at this time. Um, In California, licensed physicians may practice in any area of medicine, as Sal said, if they [00:08:00] do so in a competent manner that complies with the law. 

What is it in California that allows, and this is not only occurring in California, but any state, where, where this, this happens?  

Dr. Salvatore Pacella: Well, let me, let me ask you, let me ask you to a question a slightly different way.  

Dr. Sam Rhee: Yeah.  

Dr. Salvatore Pacella: Why would a pediatrician want to do liposuction? What, what possible reason would they have to get away from the practice and going into another completely different, line of medicine whatsoever. 

What, why would someone do that?  

Dr. Sam Rhee: Money.  

Dr. Salvatore Pacella: One reason. That's right.  

Dr. Sam Rhee: So he did start in a family practice clinic with an emphasis on pediatrics. And then in 2009, he, he began offering aesthetic services, starting with sclerotherapy. And then he kept working his way up to more complicated cases, including breast augmentation and liposuction.[00:09:00]  

So. As Larry said, why would someone who initially started in family medicine work their way up into, uh, these aesthetic services? It's because it's lucrative.  

Dr. Salvatore Pacella: Absolutely, 100%. And that's, that's the tragedy of this, is because there's no insurance basis to this, there's no insurance watchdog, there's no sort of Um, you know, when I, when I do surgery in a hospital setting, I have to report every single complication that I have to the hospital, to a peer reviewed board called Morbidity and Mortality. 

So if I have a complication, well guess what? Because I'm part of a group, I have to answer for that complication. Okay. Is there something I did wrong? Is there something that I missed? Is there some other problem with the operation that I performed? And, and that hospital accreditation, that hospital privileging has some barriers of protection for patients. 

In the, in the outpatient world, this [00:10:00] doesn't exist. It's absolutely tragic. Um, now let me, let me ask you guys another question here. Okay. What would be the difference between someone who is, calls themself a plastic surgeon? And someone who calls himself a cosmetic surgeon.  

Dr. Lawrence Tong: So that's, uh, that's a great question. 

And, uh, basically it comes down to, uh, the type of training you've had. Um, and what I mean by that is to become, um, a plastic surgeon, you have to go through an accredited plastic surgery training program, which means there are certain, uh, criteria, um, that is involved. So that your training is sufficient, not just to do cosmetic procedures. 

Cosmetic procedures are part of plastic surgery training, but plastic surgery training also encompasses things like hand surgery, congenital anomalies, cancer reconstruction, um, A whole, you know, wound reconstruction, a whole gamut [00:11:00] and range of, um, procedures and theory that we learn so that we can become, uh, plastic surgeons. 

And after we become, uh, plastic surgeons, we still have to, um, You know, do a, do a board examination, which is basically a rigorous type of examination to make sure that we're fit to practice in terms of our ethics, um, and our knowledge. And then once you've passed that, then you can call yourself a plastic surgeon. 

Dr. Salvatore Pacella: One, one question for you. Let me interrupt you right there, Larry. Um, in order for you to pass that exam, so let me, let me ask it a different way. Does every plastic surgeon pass that exam? Does every plastic surgeon choose to become board certified? What if you're not board certified? 

Dr. Lawrence Tong: I can answer, um, at the current state in Canada, if you don't pass that exam, the equivalent Canadian examination, you don't practice, you don't practice in plastic surgeon, [00:12:00] in plastic surgery. But when I was in the United States and I was practicing, um, before I left, You could still practice if you were not board certified. 

Dr. Salvatore Pacella: And, uh, Sam, in Jersey, what's your answer to that question in the United States?  

Dr. Sam Rhee: Well, in order to get privileges at a hospital, you need to be board eligible or board certified. And that means as a plastic surgeon, like plastic surgery is one of the recognized 24, one of the 24 recognized specialties from the American Board of Medical Specialties. 

And this is the leading nationally recognized organization which serves the public In order to maintain appropriate standards, and it's what the hospitals use, uh, for the basis of their privileging. Um, I had a certain amount of time, uh, after I completed my residency to become board certified, uh, to obtain privileging at hospitals. 

And they expected me to become board certified after an appropriate amount of [00:13:00] time. If I did not, uh, Um, I would have lost my privileging.  

Dr. Salvatore Pacella: Well, so the sad state of affairs in California and across the rest of the country is, in order to be, you, what you just said qualifies you as a board certified plastic surgeon to have privileges in a hospital. 

Meaning, if I am at, in my outpatient surgery center and something happens, somebody has a heart attack or some sort of cardiac injury or, you know, uncontrolled diabetes, I can then send that patient to the hospital and still maintain myself as their doctor, as far as surgery goes, because I have privileges at that hospital. 

It's a reciprocity agreement that I have. That I can, I have privileges at hospital, so I can manage anything from small to large, or I could get the patient to the right person. Okay. Those, those of us that are not board certified cannot do that. Okay. And so the sad, sad state of affairs in California is that there are [00:14:00] many, many plastic surgeons out there who are not board certified, who are, who have done the training, but for whatever reason, didn't pass the exam or didn't choose to sit for the exam, that's still practice. 

And guess what? They can't admit patients to the hospital if there's a problem, okay? Now, let me ask you another question here. You mentioned about the 24, uh, specialties that are accredited by something called the American Board of Medical Specialties. Is cosmetic surgery accredited by the American Board, not plastic surgery? 

Cosmetic surgery. Is that accredited by the American Board of Medical Specialists?  

Dr. Sam Rhee: No, they're accredited by other freestanding organizations.  

Dr. Salvatore Pacella: Right. And so did you guys read the article from the New York Times about who was quoted in that article?  

Dr. Sam Rhee: No, tell me.  

Dr. Salvatore Pacella: Ms. Reyes, if you're out there, from the New York Times,  

Dr. Sam Rhee: or  

Dr. Salvatore Pacella: LA Times, you got it [00:15:00] wrong, okay? 

You quoted the President of the American Board of Cosmetic Surgery as an authority on this subject. Guess what? Doesn't work. Not accredited by the American Board of Medical Specialties.  

Dr. Lawrence Tong: Well, I think that actually gets to an important part, is that consumers, or patients, sometimes don't know the difference. 

And so, um, I think it's incumbent on, um, on us to sort of try to educate, uh, the public about, you know, when you go and seek cosmetic surgery, do your due diligence so you know whoever's doing your surgery is actually qualified to do the surgery. Now, I'm not saying that if you go to Board Certified Plastic Surgeon, you're never going to have any problems and there's no problem risks and you're not going to have complications. 

But I think that, um, you know, just like Sal had mentioned [00:16:00] before, you don't want me or Sal to do your triple bypass surgery. So, you know, you should know who's doing your surgery and you should have somebody who's been trained and has had years of experience and has gone through the rigors of testing, uh, to be doing your surgery. 

So I think that's important.  

Dr. Salvatore Pacella: I've got a, I've got a little story for you guys and the listeners and other plastic surgeons out there that I'd like to share. Um, so, um, I sat for my boards in 2009. I finished my residency in 2000 or my fellowship in 2008. So I passed the written exam in 2007. I had to sit out for a year to collect cases and then subsequently get submitted to the, to the board, just like you two did. 

And so the, the process of becoming board certified is an exhaustive and stressful and all encompassing process that you go through for a year. It's always in the back of your mind. And in order to become board certified, what the, the [00:17:00] board asks you to do is they ask you to submit all of your cases for a year. 

And then they cherry pick five cases that you have to write in a, in a book format. And then you get the, you get the privilege of getting I would say massacred about your decision making for each of these cases. Okay. So it's very, very stressful, but, but at the end of the day, I would say relatively fair. 

Okay. So now this board certification exam, when I took it was in November and all of us who were sitting for this, several 1000 of us, or several 100 of us, probably I should say, um, We sat in a hotel room or in a, in a hotel setting, and then you went to each room to, to, to get tested by each of these physicians, usually two in a room. 

And so you see all these, so we're at this resort in, outside of Phoenix, and you see all these people in suits going in and out of hotel rooms, okay? And I got done for the day, and I was all stressed out, so I decided to go sit by the pool. And I was chatting with a [00:18:00] couple. And they said to me, Hey, were you involved with this? 

What are all these suits here? Well, who's, what's going on here? And I said, Oh, this is, uh, the certification exam for the American board of plastic surgery. And they said, Oh, Oh, that's cool. I didn't know they had that. Okay, great. I said, well, let me ask you a question. Um, if you were having a surgery procedure, a plastic surgery procedure, would you go to somebody that is board certified by the American board of plastic surgery? 

Or by the American Board of Cosmetic Surgery. And what do you think their answer was?  

Dr. Sam Rhee: Cosmetic surgery.  

Dr. Salvatore Pacella: Absolutely. 100%. They said, they said, I, I would choose the cosmetic surgeon because that's what we're doing, right? So we, we, at the end of the, of the conference or at the end of the testing session, we had a, a meeting with the director. 

Uh, to get some feedback about the testing process. And we, and I was not the only person sitting there at the time. [00:19:00] So we decided to share this story for the, the president of the American board at that time. Okay. And I explained the story. Somebody explained the story. I can't remember who, it was me or not. 

And the, the question that the audience had to the American board president was, are we doing, from the board standpoint, what we're doing? to maintain safety for the general community and advertise that this is what's important for people to do or to get board certified and for patients to seek board certified plastic surgeons. 

And guess what his answer was?  

Dr. Lawrence Tong: Tell me. I'm assuming you weren't happy with it.  

Dr. Salvatore Pacella: Nothing. He said, that is not the job of our organization. Our job is not to market or to educate. It's to make certain that the surgeons that have the stamp of approval are safe surgeons. So we do a very, and the [00:20:00] moral behind the story is, Although we're sitting here in this podcast preaching about board certification, and every single board certified plastic surgeon is, is preaching to the general public, and these, these terrible things come out in the media, we are doing absolutely very little to educate the public on board certification, other than saying, this, you should get a board certified plastic surgeon. 

But we're doing a very poor job of it. And it's, it's tragic because these things are going to continue to happen. This  

Dr. Sam Rhee: is 100 percent true and I agree with you because of a couple things. One is, the article states that 12 percent of people out there practicing or performing aesthetic procedures are not certified in cosmetics. 

Uh, anything. Like, they are, um, they are, well, they called it practicing outside their scope of expertise. So that includes gynecologists, [00:21:00] urologists, anesthesiologists. These are all people that are marketing themselves as cosmetic surgeons out there. And yet, uh, Us as plastic surgeons, I cannot recall in the past, um, like, I don't know ever if anyone asked if I was board certified in plastic surgery when they came into my office. 

They don't know and they don't care. Um, and when they go see other providers, I'm pretty sure they're not asking if they're board certified or looking for that in plastic surgery. And if I answered no, but I am board certified in cosmetic surgery, I'm pretty sure that would have been enough. for them to say, like you said, like those people you asked, oh good, you're, um, you're well qualified in my book. 

And this is really a problem, uh, in our specialty. I know a lot of us who are, uh, who do a lot of aesthetic surgery as plastic surgeons find this to be the case. [00:22:00] It disappoints us in terms of our organization in terms of they put us through the ringer. We are true. I remember the oral. I mean, that was only the second part of the board certification. 

The first part, which you didn't mention is the written exam, which is in its. of itself pretty challenging. And then getting grilled on all of your clinical cases. That was the oral, uh, board exam, which was brutal. As you said, it was a massacre. I, I, I think that was possibly one of the most stressful experiences in my life, but it was, it was required for us to feel. 

Uh, comfortable and well, like we were certainly extremely well trained, uh, coming out, um, and they had to make sure that we were. Um, so what can California or all these other states do in order to help? Because clearly if our own organization isn't helping, what can outside organizations do to help protect [00:23:00] patients? 

Dr. Salvatore Pacella: Um, so one further piece of information, Larry, I'm very happy to hear that in Canada, if you're not board certified, you don't practice. Guess what? South of the border, in Tijuana, okay? If you're not board certified by the Mexican Board of Plastic Surgery, you don't, you can't practice either. You go to jail. 

All right. Really? Um, yep. I, I, uh, my good friend, Amanda Gossman, who's, uh, the UCSD chair here in San Diego. She's, she's very close with the, uh, uh, the academic folks on the other side of the border. And, uh, that's the rule there. And so we're pinched between two societies who have it exactly correctly. And we, in California, or the rest of the country, cannot. 

So, unless there is some law that is passed at the state legislature, or federal law that sort of guarantees that you have to be trained appropriately in the procedures that you perform, then this will [00:24:00] continue to happen. There is, it is, it is absolutely the wild west.  

Dr. Sam Rhee: They mentioned in this article a number of other similar incidents. 

There were over 600 complaints in the past 10 years in California in alleging negligence in cosmetic surgery. Even this particular provider had a problem in 2018 where he administered IV sedation in a facility without proper accreditation, and the patient suffered seizures and landed in the ICU at LA County USC Medical Center. 

There was a woman in Bakersfield who died from another, um, a GYN, uh, surgeon who, uh, His patient died after getting liposuction and a tummy tuck. Um, these, this is continuing and will continue to continue until we, as you said, force these regulatory bodies to not act [00:25:00] after the fact. None of this is preventative. 

It's all sort of punitive after these Physicians who are in no way, shape, or form qualified to perform these procedures are hurting and, and killing patients. And I'm not sure what else to do.  

Dr. Salvatore Pacella: So, so let me, let me, let me posit this too. So you would think that a majority of the Californians out there, and I, and I'm picking on California because, you know, I, I cannot walk outside my house. 

on the sidewalk without the potential for being ticketed. California is one of the most regulated states in the, in the union. Okay. So you would think that the, the citizens of California would say, well, this is clearly obvious. We need to do this. Clearly obvious. It's the safest thing for patients. Well, why doesn't it happen? 

And here's why it doesn't happen is because there are folks on the other side of the board [00:26:00] that claim suppression. They claim, um, restraint of trade, you know, well, there's no law that says I can't do this. There's no law that says I can't inject Botox or, or do this or do this operation. I'm a surgeon. 

I'm a surgeon by the American College of, uh, Ops, Ops, uh, Why, you know, this is a female operation. Why can't I do it? You know, and so this is why you're not Having any legislation.  

Dr. Sam Rhee: I don't really see a solution here because I agree. I think the pushback that we're getting from other specialties, because this is a literally like, uh, 18 billion dollar plus a year industry and. 

Constantly seeing over time more, and especially with the way medicine has changed, more and more providers, uh, interested in aesthetic care, aesthetic medicine. Um, I don't think this trend is going to change. I actually think it's going to continue to worsen and [00:27:00] it's, it's going to take some sort of, The way things always work in the United States, some horrible, like tremendous disaster to occur, something really high profile before the outcry is such that changes are made. 

But until then, um, the political, like you said, the political state is that, um, people are going to fight it, uh, not for, Patient safety, but like you said, for the money and for the, uh, amount of money that's available to them in this, uh, particular special, uh, specialization that is going to continue to drive things. 

And, uh,  

Dr. Salvatore Pacella: Now, now, now Florida is a little test case in this. Um, you know, so the state of Florida had a huge, huge problem six years ago with the amount of patients that were dying from doing BBLs, Brazilian butt lifts, right? And some of them died from board certified plastic [00:28:00] surgeons, but a whole lot of them died from non board certified plastic surgeons. 

And the Florida Society of Plastic Surgeons lobbied the state legislature and they came up with a set of rules. And the set of rules did not include those performing BBLs be board certified. That was not in the rules. was in the rules with specific parameters around the particular type of surgery. No more than two a day. 

You have to use an ultrasound. You can only do a certain amount of a volume. So there were, and that's a, that's a step in the right direction, but it doesn't solve the problem of non board certified or non qualified surgeons performing these operations.  

Dr. Lawrence Tong: Yeah. I just like to comment on, um, sometimes when, uh, non surgeons want to start performing surgery, they'll just go to a short course, maybe even a [00:29:00] weekend course, and then they'll start doing surgery. 

Uh, you know, we trained for six years before we were eligible to do something like that. Uh, and we trained in all forms of surgery, uh, in the plastic surgery umbrella, including cosmetic surgery. So there, there is definitely is a difference, um, in not just the title. of what kind of, you know, physician you are, but, uh, in the experience. 

And I, I think that's very important to realize that, um, the, the experience and the, and the, the training can be very, very, very different for, for different, uh, for different physicians.  

Dr. Sam Rhee: I think if you're a patient right now, you can't wait for these regulatory bodies to protect, protect us. I think if you're a patient, like Larry said, you have to look at how many years of experience that particular surgeon has. 

You have to look and see if they are [00:30:00] trained and board certified in plastic surgery. I'm not going to fight it with these other specialties about all this other stuff, but I would say as a patient, that to me would be very important. It's literally, like, it doesn't mean that you're not going to It doesn't guarantee you a perfect circumstance, but it would be literally like going to an Uber driver and choosing someone who didn't have a driver's license. 

Like, having a driver's license doesn't mean your Uber experience is going to be perfect, but I can guarantee you if that Uber driver does not have a driver's license, your chances are way higher that you're going to have a problem on that ride than not. So, um, I would say as a patient, that would be one, one thing you can do right now. 

is to do a little bit of due diligence. Doesn't matter if 15 of your friends said, Oh, they're awesome, this, that, or the other thing. Like, look it up for yourself and see. Um, there are so many good providers out there that do have the qualifications, the experience, and the training. Like, you [00:31:00] know, Take a little bit of time to, to make sure that, uh, that they at least have those minimum qualifications, I would say. 

Wise words. Good advice.  

Dr. Lawrence Tong: Um, I was interested, Sal, you said you made five books for your board exams. How many did you do, Sam?  

Dr. Sam Rhee: Well, to be honest, one of my books got, uh, messed up because the patient left and I, I couldn't track. Track them down in order to get follow up. Um, I was in Newark at the time at UMDNJ and, and I, I had a fair number of trauma patients and stuff. 

So I told the board, like, I couldn't get follow up on the patient. They skipped out, like they're gone and they're like, okay, well, here are three more books that you have to do. So I ended up like prepping, uh, like. Eight, seven or eight, eight, yeah, eight in order to, um, to get ready. And, and that was, that was a hard lesson, hard lesson there. 

How about you? I [00:32:00] might be  

Dr. Lawrence Tong: dating myself, but I think when I did it, I think I did 10 or 12 books.  

Dr. Salvatore Pacella: Oh my. It  

Dr. Lawrence Tong: was a lot , so I was surprised to hear. I, it definitely was not five. Did you, did you  

Dr. Salvatore Pacella: sit, did you sit for the American board or the Canadian board?  

Dr. Lawrence Tong: Yes, I, I sat for both.  

Dr. Sam Rhee: Yeah. Larry, uh, was practicing in, in, uh, the US for quite some time. 

That's right. In Detroit, right? Or outside of  

Dr. Salvatore Pacella: Detroit. Yeah, that's right. Yeah. Be before he moved to Toronto. So was the, was the Canadian board more challenging, would you say, or  

Dr. Lawrence Tong: the Canadian board? The written part was very challenging, because it wasn't multiple choice as it is on paper. Well, as it was when I took it, I don't know if it's still the same, but it was a lot of written, so it's not like the answer was there. 

If you didn't know the answer, you didn't know the answer. So, and you had to, uh, you had to get a fairly high, high score to make it to the next step, but we didn't have to make books. That's the difference. But the, for the viewers, the books are important because as you are practicing [00:33:00] during that first year, year and a half, you have to be uber careful about everything that you do because any of those patients that you've taken care of, you have to document everything properly, um, take photographs, have, um, all the proper, uh, paperwork because when you submit that list, the board can just say, okay. 

These are the ten cases that you have to do your books about, or five if you're, you know, younger than I was. Um, and, and if you don't have that, then, uh, you could run into difficulties just that, like Sam said, you had to do a few more extra books. So I think actually going through that process gets you accustomed to doing things the right way. 

Dr. Salvatore Pacella: Yeah,  

Dr. Lawrence Tong: it did. You know, I  

Dr. Salvatore Pacella: would say I, in my entire professional life and being in practice in 15 years, I've never. I've never broken down emotionally or cried ever, except for one time. And that was when I finished my boards. [00:34:00] I, I was so emotionally spent and exhausted and physically beaten up just from not sleeping and emotionally. 

And I just went back to my hotel room and I just, I think I cried for about 20 minutes. It's just like, you know.  

Dr. Sam Rhee: I celebrated like nobody, like, like it was 1999. I'll tell you that. I don't, I don't think I remember the next 12 hours after I got, uh, after I passed, like, I didn't  

Dr. Salvatore Pacella: even do that. I just like, I, I just was so lost. 

I had so much loss of energy. I just slept for two days. So,  

Dr. Lawrence Tong: so Sam, you didn't cry.  

Dr. Sam Rhee: Uh, I, I, I don't remember. I was, uh, Blotto at that point, so I might have cried, I might have laughed, I might have, who knows, I might have lost all control, but it was, uh, it was, I was just, it was, you know, like Sal says, when you, it's such a sense of relief that sometimes you just have to, like, literally Like, just, it's, you're an empty shell at that point, [00:35:00] no matter what. 

I was just gonna say, Asians  

Dr. Lawrence Tong: don't cry. It's not a K drama. Well, here's,  

Dr. Salvatore Pacella: here's the, uh, here's the best part of it is, uh, you know, a couple weeks later when you get your letter, and it says, Congratulations, you, you passed the American Heart Association Surgery. Um, and so you look at the letter, And then you nod and you just throw it on your desk and into a file somewhere. 

And that's it.  

Dr. Sam Rhee: That's it. And no patient will ever ask about it.  

Dr. Salvatore Pacella: It's completely anticlimactic.  

Dr. Sam Rhee: Yeah. Anyway, thank you so much, guys. I really appreciate it. And, um, until next time.