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Joshua Goldman

Bio Integrated Plastic and Reconstructive Surgery PGY-6; Medical Innovation*Evidence Based Medicine*Quality, Patient-Centered Care. Views are my own.

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Complex anatomy provides a platform for complex pathology, which necessitates complex excision begetting complex reconstruction. . A single cell mutates. It finds a way to avoid the body’s natural, protective mechanisms against over-proliferation. That cell makes itself at home, and divides, unchecked, until its biological needs overcome its intrinsic stores. Now, a mass, it finds a way to induce vascular ingrowth to supply the nutrients that allow it to flourish, without discretion, at the expense of surrounding tissue. It calcifies, scars, bleeds, ulcerates, and destroys. By the time primary growth plateaus it has hijacked speech, swallow, facial animation, mastication, and made respiration difficult. In other words, it has stolen verbal and non-verbal communication, satiety of hunger, thirst, breath, and social and emotional security; the very things that provide and sustain humanity. And when it presents, the questions begin. . Has it spread? Probably. Can it be obliterated? Potentially. Can there be a longterm cure? Unlikely. Can we prolong life? Almost certainly. Can we improve quality of life? Almost certainly. Can it be removed? Mostly. Can it be reconstructed? Yes. . My entire medical education, whether I knew it or not, boils down to a statement many of my mentors nonchalantly make to extirpative surgeons. It’s astounding in its simplicity: “Any hole you make, I can fix.” . And “fix” is a loaded term because for a Reconstructive Surgeon it applies to form AND function. It means drawing on centuries of experience, innovation, and principles to repair obliterated structure, to reproduce lost purpose, and to do so with the goal of an aesthetically pleasing outcome. . Photo Credit: From Unsplash. Hannah Gibbs.

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image by Joshua Goldman (@goldstandardplasticsurgery) with caption : "Congrats to all the graduating Chief residents!!! Like @jason_mraz says, “you are A-W-E-S-O-M-E.”
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Thanks to all my and" - 1803110685125569641
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Congrats to all the graduating Chief residents!!! Like @jason_mraz says, “you are A-W-E-S-O-M-E.” . Thanks to all my and @kdaws309 family for coming to share the moment. Thanks to all my faculty and mentors over the years for making me the surgeon and person I am today. . 12 years primary education, 4 years undergrad, 1 year clinical research coordinating, 4 years medical school, 6 years integrated plastic and reconstructive surgery. Graduating 26th grade!! . As my dad and Frank Sinatra say, “the best is yet to come”! . . 🙌 ❤️

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image by Joshua Goldman (@goldstandardplasticsurgery) with caption : "As physicians, we make decisions every day that affect people’s lives in such a direct and profound manner that medicine" - 1800060320457055814
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As physicians, we make decisions every day that affect people’s lives in such a direct and profound manner that medicine is held in a vastly different regard than other professions. . As people, choices and priorities dictate our direction, and, once we arrive at a particular destination, reflection on those choices often prescribes the distinction between pride and regret. . Should I have? Would I have? Could I have? . This piece abstractly discusses choice. I wrote it after reading on moral luck and thinking about its relation to circumstance and situationalism. These are fundamental tendrils of the discussion on morality and its relation to responsibility and free will versus determinism. . Link to short piece in profile. Written for Creative Cafe’s contest prompt “I Choose.” Or copy and paste: https://medium.com/@joshua.goldman/the-way-straight-ahead-7b4504b3ebae . Photo by Lora Ninova on Unsplash (cropped) . . . . .

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“Multi-platinum, and tour of the world, and all of this[…] I always saw it. Even when I was a kid I was like, ‘That’s where I’ma go.’ […] It’s jus...It didn’t happen that fast.” – G-Eazy, Rapture S1/E4- G-EAZY: Worldwide Amplified” on Netflix . Our society focuses on the fast fix, the get-rich quick plan, learn a language in 10 days, efficiency apps, life hacks, fifteen minute abs. The truth is, greatness takes time. It just doesn’t happen that fast. Even the ones who make it look easy leave decades of practice, sacrifice, blood, sweat, and tears, indefatigable drive, and a skosh of luck in the wake of their campaign to reach the top. . For med school graduation, my mom bought me a beautiful gold and silver Cross pen and a Bosca leather prescription pad that’s smoother than chocolate pudding. Six years later and a few days ago, the American Society of Plastic Surgeons sent a congratulatory letter and a gold and silver Cross pen in anticipation of the completion of residency. The symmetry of two writing utensils book-ending my residency is overwhelming. I am genuinely humbled by and grateful to both watchdog organizations. . I had this plan from age 5. At age 7, I knew where I wanted to go to college; it was the only school I applied to when it came time. By 12, I was attending a health careers magnet high school. At 18, I was officially Premed. By 21, I was without-a-doubt going to be a hematologist-oncologist. By 23, I was without-a-doubt going to be an OB/Gyn specializing in REI. At 27, I matched into Integrated Plastic and Reconstructive Surgery; it was the only specialty I applied to when it came time. At 32, I matched into fellowship in Microsurgery. . Chase anything you have the passion to do, only a dream 'til it happens to you - @g_eazy, “Opportunity Cost” . Less than two weeks to graduation, and I’m still training, still learning, still growing. I kept my eyes up, so I could always see the prize, and, in the moments it seemed too far away, I reminded myself “it just doesn’t happen that fast, keep chasing.” . . Thanks to @plasticsurgeryasps and @allerganplc. @boscaleather @crosspens

image by Joshua Goldman (@goldstandardplasticsurgery) with caption : "[3/3]
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Memorial Day, my family was hit by a drunk driver on the highway; it’s still surreal to say out loud. Fortunatel" - 1791303410715178082
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[3/3] . Memorial Day, my family was hit by a drunk driver on the highway; it’s still surreal to say out loud. Fortunately, we had the best possible ending to a frightening scenario: dents and scratches on the car, baby slept through the entire episode, and both parents unscathed. Still, a deluge of fear washed over me as my mind drifted to the worst. . In the OR, rigorous preparation gives way to layered contingency plans backed by well-established algorithms. That doesn’t work for life’s infinite eventualities. For fatherhood, I had mentally prepared for inevitabilities like diaper rash, teething, potty training, confusing math homework, puberty, and heartache. Suddenly, confronted by the reality of environmental factors, the crushing realization set in that I had not intellectually materialized concerns like Russian Hackers, Climate Change, Harvey Weinstein’s and Larry Nassar’s, Cyber-bullying, AR-15’s, and Drunk Drivers (the stranger-than-fiction dangers plaguing modern society). In an all-too-pointed metaphor, I could feel my functional anxiety careening into a new lane. Given my disposition, continuing on in a fear-driven model for achievement would consume me. . Before, the question, “will what I do matter?” focused on my effect on the world, my capacity to advance my field and create meaningful differences in patients’ lives. The question lived and thrived in a microverse largely under my control. I embraced my anxiety-inducing fear of failure, because it sharpened my senses, pushed me harder, allowed me to work late against exhaustion, train despite physical pain, sacrifice without question, and the return on investment was all but assured. But now, the question focuses on my inability to make a valuable difference in a world easily shaken by externalities. . How do I stay motivated and driven if what I do might not matter? Can hope be the carrot where fear used to be the stick in life, fatherhood, and in medicine? . Fear gave me anxiety about the future, hope makes me anxious for it. It’s time to manifest change by letting go of limits and embracing growth. . What drives you, fear or hope? Or something else altogether? .

image by Joshua Goldman (@goldstandardplasticsurgery) with caption : "[2/3]
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“The one necessary thing. A person must have one or the other. either a disposition which is easygoing by nature" - 1791295993096743909
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[2/3] . “The one necessary thing. A person must have one or the other. either a disposition which is easygoing by nature, or else a disposition eased by art and knowledge.” Friedrich Nietzsche, ‘Human, All Too Human,” Aphorism # 486 . Since childhood, the anxious and rational parts of my brain produced a voice that constantly questioned, “Will you be the best, or will you fail?” Their philosophical counterpart, constantly requiring intricate examination, chimed in with its own concern: “Will what you do matter?” For the last decade and a half that logical voice has specifically asked, “Will you be a good enough surgeon, or will you fail patients?” After 6 years of training, I feel confident enough to reply, “Yes, and yes, but I will do everything I can to avoid failure. I will continue to learn more, to work harder. The philosophical quandary is quelled by morsels of patient appreciation and the profound reward of positive impact will only presumably grow as an attending. Still, there is more to be done, and much more to achieve. . The last nine months of my residency contained a new twist and some of the most anxiety-inducing and heartbreaking moments of my life. They concluded with a healthy, excessively cute, tiny human being, who shares with his mom, all of my love. Just before his birth, a much more aggressive voice appeared in the front of my mind, anxiously demanding the answer to a question I had barely allotted prior consideration, “Will I be the best Dad, or will I fail him?” . It’s followed once again by, “Will what I do matter?,” but the tone is different. The prior voice appears to have been preoccupied with superficial concerns of achievement and people-pleasing; it suddenly seems caught up in the mystification of health, the mythification of medicine, and the deification of doctors. . For life, that won’t work, so in the immortal words of Sam Cooke, “It’s been a long time coming, but I know, a change is gonna come.” . @medelita_gram @freudandfashion @mike.natter @shanny_do @jess.g.johnson @speakoutmedicine

image by Joshua Goldman (@goldstandardplasticsurgery) with caption : "[1/3]
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My entire academic life, I’ve worn my functional anxiety as a badge of honor. In grade school, they called it “b" - 1791287832382192123
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[1/3] . My entire academic life, I’ve worn my functional anxiety as a badge of honor. In grade school, they called it “being such an over-achiever.” It made me a straight-“A” student, a nationally competitive gymnast, and got me to Stanford. How many sacrifices made to rote learning and muscle memory? How many hours spent worrying over performance and grades? Nevermind, keep going, work harder, theres more to be done, and much more to achieve. . In medical school, it was called “attention to detail”, “dedication,” and “patience for minutia.” It put me at the top of my class and earned me a coveted spot in Integrated Plastic and Reconstructive Surgery. How much time alone in the library, travel foregone, relationships ignored, opportunities missed? How many hours spent staring at the ceiling thinking about tomorrows’ exams, reassessing knowledge while nerves turned my stomach? Nevermind, keep going, work harder, theres more to be done, and much more to achieve. . In clinical medicine, it’s described with nouns like “vigilance” and “thoroughness.” Nobody, praying over family in the ICU, takes pause to accuse their physician of being hyper-vigilant or overly thorough. It made me a competent clinician, comfortable with the highest level of acuity. How many long shifts and sleep lost checking orders? How many hours perseverating over todays’ labs, tomorrows’ treatment plans, and the lives affected? Nevermind, keep going, work harder, theres more to be done, and much more to achieve. . In the OR, as long as you learn to manage time, “trust your markings,” take the idiom, “the enemy of good…” to heart, your anxiety is rebranded under the charitable euphemism, “perfectionist.” No patient ever complained their plastic surgeon was too perfect. How many nights spent reviewing anatomy, pouring over old books and new notes, scouring the internet for expert videos and journal articles? How much OR time prioritized over breakfast with your wife, lunch with a friend, dinner with a parent, dessert next to your sleeping baby. Nevermind, keep going, work harder, theres more to be done, and much more to achieve.

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Did you think “Dr. Boutte is Board Certified” meant that she was boarded in Plastic Surgery by the gold standard in plastic surgery certification, the American Board of Plastic Surgery (ABPS)? Wrong. The ABPS is the only certifying organization approved by the American Board of Medical Specialties to perform ALL types of aesthetic surgery. Other well-respected specialty boards also include specific cosmetic areas. . . To further confuse matters, many copy-cat societies exist that confuse the layperson, patients, and even some physicians. She notes that she is a member of American Academy of Cosmetic Surgery, and American Society of Cosmetic Physicians. Similar physicians might also claim board certification by the American Board of Cosmetic Surgery (a board that is not recognized by ABMS). Board Certified Plastic Surgeons are certified by ABPS and are generally members of the American Society of Plastic Surgeons and/or the American Society for Aesthetic Plastic Surgery. . . This story is of a physician who was not properly trained to the standards of plastic surgery societies and held herself out to be equivalent, as many in “cosmetics” do. Additionally, she performed surgery at unaccredited facilities. Usually, this is a cost-cutting measure; one, I would bet, is not, at its core, to save the patient money. This is not about good guys and bad guys. This is about physicians lulling patients into a false sense of safety with unaccredited certificates. This is about patient care and, above all, patient safety. . . I’ll repeat: This isn’t going to a Mexican Restaurant with an Italian Chef. This is taking your car’s engine to a mechanic, who trained in air conditioner repair and did a weekend course on vehicular detailing. We don’t allow mall security guards to call themselves SWAT. Why would we do that for physicians? . . Full article on the subject coming soon. . . @plasticsurgeryasps @theaestheticsocietyasaps -surgeons . Find a . 💯

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Anybody in the United States with a medical license can perform “cosmetic surgery.” Admittedly confusing, given that there is essentially no scope-of-practice laws, advertising oneself as a “Cosmetic Surgeon” does NOT mean the physician garnered specific, intensive training to perform specific surgeries and certainly does not mean they meet the rigorous standards required to become a “Plastic Surgeon.” . . You might be asking, “why would patients go to a dermatologist for their cosmetic procedures that involve more than the skin?” The terms cosmetic, aesthetic, and plastic are loaded, and used interchangeably, but to physicians who know better, the semantics are of no consequence; what matters is training and experience. Predatory physicians hoping to capitalize on the lucrative nature of aesthetic surgery use the obscure language to confuse patients and referrers. . . Did you think “ Female Cosmetic Surgeon in the Southeast” meant the same thing as ‘ Plastic Surgeon,” or that she had undergone a rigorous, objective determination that concluded she was the best to perform specific surgeries or procedures? Wrong. This is a subjective claim backed by nothing. . . Her practice website is no longer accessible (maybe it was taken down or traffic is just too high), but before that happened I took a screen shot of Dr. Boutte’s “qualifications.” You’ll notice that she attended prestigious universities and programs for her undergraduate and graduate studies as well as her training in dermatology. She is, per the site, board certified in SKIN SURGERY and DERMATOLOGY. These training and board certificates would certainly indicate that she is a competent SKIN surgeon (NOT any-part-of the-body-at-any-depth surgeon) and DERMATOLOGIST (not cosmetic surgeon, not plastic surgeon). . (Ctd…Part IV) @plasticsurgeryasps @theaestheticsocietyasaps . Find a . 💯

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It’s the end of Week 3 with , Are you pondering what we’re pondering? Do the math! That’s right! Time to eat, sleep, and poop until we TAKE OVER THE WORLD...or at least Week 4. NARF! . . Diagnosis: Excessive Cuteness (it’s a preal problem). Rx: one million kisses, PRN ❤️; infinity refills. . . . Can you tell we chose the titles of each other’s textbooks? . @hobbylobby @cartoonnetworkofficial

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Swipe left for some facts about board certification from http://www.pamf.org/cosmeticsurgery/cosmeticfacts/surgeon.html.

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Swipe left for original post by @roc_prs_residency. Glad to see residencies using their social media platform to educate patients and advocate on their behalf.

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Still considering the nature of sacrifice and the responsibility of choice. Sacrifice, in one way or another, is requisite on the path to greatness, but not necessarily to obtaining success, which is nebulous, and broadly speaking, self-defined. Nobody climbs Meru, makes CEO, is promoted to tenure, champions olympic gold, or is called “best” without sacrifice. But people do hike, make middle management, start academic careers as professor, stay fit, champion a half marathon here and there, and are called “good” while giving up far less than their “best” counterparts. . Choosing one thing over another, stepping out of bed instead of hitting snooze, running when you could walk, practicing rather than partying, studying rather than binging Netflix, and owning the choice to do so, balances sacrifice. The value of the choice is only realized once its ends are achieved, or you, as is more often the case, assign the journey, the chosen struggle, its own intrinsic worth. . Striving to be the best at something, to be great, can matter. Being good at many things, leaving time to choose comfort over struggle, can also matter. Even finding satisfaction in the status quo, realizing better is sometimes the enemy of good, finding self-content in a society that idolizes “wanting more,” “hustling,” and “side gigs,” can matter. . Is the life you are leading, your aspirations, and the sacrifices you’ve chosen empirically better than the road more traveled? Or would you be better off with the pancakes? . Photo Credits: 1. Yoori Koo on Unsplash 2. Anthony DELANOIX on Unsplash 3. Jelleke Vanooteghem on Unsplash 4. Linda Söndergaard on Unsplash 5. Yakynina Anastasia on Unsplash (text and filter added by Joshua J Goldman, MD)

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“Is helping others less valuable to you? Not worth your effort?” - Marcus Aurelius, “Meditations” . Athletes sacrifice their bodies for love of the game and competition, to be the best. The sports enthusiast knows that, and pays homage. People in the military are willing to give up their lives (in the most literal sense) in the name of country and freedom, to protect the people and ideals they love. Those not in the military, enjoying those freedoms, know that, and sometimes pay homage. Physicians sacrifice in so many ways, and patients, generally, don’t know that, or feel it worthy of homage. . Nobody knows how many Step I questions you did, so you could prescribe antibiotics for sinusitis at 2 am. Few can commiserate with innumerable hours spent alone, at a desk, in the library, trying to memorize a mnemonic, so you could memorize a fact, you might never use, for a patient with a problem that may never walk through your door; just in case they do. Inevitably, it will go unnoticed that you missed your grandfather and his twin’s 80th birthday, your sister’s graduation, and lost touch with friends who used to want to travel with you to do one more case to prepare for the time you sew a dog-bitten child’s face instead of eating dinner, or a hand needs to be reattached, over 12 hours, after operating for the previous 12. . But, at the core of sacrifice, is choice. And I alone am responsible to myself for those choices and the way they affect those around me (patients and otherwise). The profoundly personal question becomes: Each choice, will I look back on it with regret as a mistake, a part of life traded for the wrong reasons? Or, will I know my sacrifice made a difference, and will the difference be worthwhile in providing serenity for someone seeking how best to live? . The foundation of this distinction is my expectations of myself, my nature, my efforts, and the value I place on “helping others.” The hindsight perspective built on that foundation depends heavily on a reality of mixed rewards, reactions, and the appropriateness of those expectations.

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Week 2: Avett C-137. I TURNED MYSELF INTO A BABY, MORTY. Somebody better catch me, Morty. IM BABY RICK!!!! . The parents who got schwifty, we’re still here, still selling fake doors. . Adventures dot come for a hundred years. . We made it through week 2 without cronenberging up the whole place. One week older, one week wiser. On to the next dimension, on to the next adventure. . . . . . @rickandmorty @hobbylobby @cartoonnetworkofficial @chalkolachalkmarkers

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The speech always starts the same: Can you see yourself doing anything else? . Medicine, with few exceptions, isn’t a career. It’s not even a lifestyle. It’s your life. It’s my life and I love it. But I built a world, and fostered a world view, that allows (sometimes forces) me to maintain outside interests and achieve personal as well as professional goals. I was born into and developed a support system to be the foundation for those achievements; one that allows soft, forgiving falls for the many failures on the way to success. And, maybe most of all, I had a lot of luck, at many junctures. Good fortune isn’t always by design, but law of averages generally produces some if you search long and hard enough. . Choose medicine because healthcare is your passion. Maintain other interests because, while medicine may be your life, very few people are so one-dimensional that medicine alone will sate their soul. . Choose the rabbit hole for love of the adventure, and enjoy the present no matter how trying; it will, at many times, be trying. Make yourself aware, at least cursorily, of the obstacles ahead and the potential rewards beyond them. Take the red pill with cautious optimism and reckless pragmatism. . . . . . . . 💯

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New post is up, and published on Doximity’s Op-Med. https://opmed.doximity.com/its-not-just-another-physician-suicide-it-s-suicide-17a1b09aa33b (Link in profile.) . In case you were unaware, DoctorsArePeople, but we treat their committing suicide like collateral damage, or worse, sweep it under the rug. The statistics are appalling. An estimated 300–400 physicians die by suicide in the U.S. per year, which equates to a 1.41 times greater risk, for males, and 2.27 times greater risk, for females, than the general population. But, perhaps more important than the statistics, is remembering that these physicians were PEOPLE with patients, friends, and family who loved and cared about them. . The point: Doctors are PEOPLE, the system is flawed if not broken, and it’s time to do something. . Don’t let these tragedies become another “headline from last week” in a sea of one-upping atrocities in the news. Don’t contribute through complacency. Share your stories. Keep the conversation going. Doctors, remind society that you are People. Patients, it’s your responsibility too. Remind others that your doctors are People. Take care of the People who take care of you. . . . . . @doximity @pamelawiblemd @tedmedcommunity . Thanks to @medelita_gram @freudandfashion @mike.natter @shanny_do @jess.g.johnson for the campaign. . Photo by nikko macaspac on Unsplash; Text added by Joshua J. Goldman, MD

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Happy Mother’s Day to these two superheroes. One made me who I am and the other who I will be. Both are the strongest, most hardworking, loving people I know. Powerful, caring, a and an , they shaped and continue to inspire my high expectations of, and respect for, women and people in general. At just over eleven days old and just over eleven thousand days old, they are the best we two monkeys could ask for. So grateful and fortunate to have them in my and Avett’s lives. . . . . . . @kdaws309