A recent study has found that repetitive Transcranial Magnetic Stimulation (rTMS) is effective in treating depression. The results showed that the majority of patients experienced a significant reduction in symptoms, with some even achieving complete remission.

Are you interested in Group Therapy? Groups offer a safe space for sharing ideas, helping others who are going through similar struggles and can promote social skills and group accountability. Click to read more.

The combination of TMS (Transcranial Magnetic Stimulation) treatments and Ketamine Infusions is gaining national attention as a powerful way to alleviate Treatment Resistant Depression. For more information or to schedule an assessment call or text us at 330-754-4844.

Plastic Surgery

We should try to feel good from the inside out, right? What if we start feeling and looking good from the outside in? Plastic surgeon Dr. Carp and his nurse anesthetist Nick Angelis, CRNA openly discuss the interplay between mental health and aesthetics. Who’s the appropriate patient? What’s the next step for those suffering with body dysmorphic disorders? They also talk about how health care has changed over the years and the importance of selecting qualified, dedicated providers regardless of specialty.

hello and welcome to the Ascend Health
show I’m your host Nick Angeles I’m a
nurse anesthetist and the owner of
Ascend Health Center and have with me
today Dr Steven karp from carp Cosmetic
Surgery Center
good afternoon
and this
is going to be really fun because I work
for Dr carp sometimes so you know maybe
I’ll get fired at the end of this maybe
I won’t who’s to say
no if you haven’t
by now you’re probably in pretty good
shape
yeah that’s a good point so uh you
own a plastic surgery place and the
intersection between plastic surgeon
mental health has always been
fascinating to me because on the one
hand it’s like well people aren’t
feeling good about themselves so they go
get plastic surgery but the other hand
you could say that well people are
finally feeling better about themselves
so they’re investing into themselves and
getting some plastic surgery
It’s a
combination of all of that and certainly
from our standpoint while we’re not
Mental Health Providers we do have to be
kind of on the alert in part of our
screening and consultation process to
look for people that yeah helping people
with their self-esteem is one thing but
may making sure we’re not offering
services to people that are expecting
something life-changing that isn’t from
their physical appearance and needs to
be addressed in other ways so basically
seeing people having an accurate
perception of who they are what they
look like what they’re going to
absolutely absolutely absolutely we you
know probably the the number one thing
that we look for is any signs of body
dysmorphic syndrome and an individual
that has that as a that’s really an
absolute contraindication to having any
sort of plastic surgery uh in general
right and I think we’ve talked too about
different lawsuits just because it’s a
fun conversation in the OR and sometimes
those do reveal like okay in this case
they should have done more to watch out
for this or in this case you know this
person was never qualified and you
shouldn’t expect them to have the
expertise to diagnose something like
that
well absolutely and you know every
specialty has its kind of standard of
care of what should be part of it what
you screen what you shouldn’t screen and
from the mental health side of it
certainly it’s something we look for
and I certainly have had patients that
I’ve I’ve told them you know before we
proceed I want you to see somebody
um you know operate on a lot of people
that that have are seeing some sort of
mental health provider psychiatrists
psychologists whatever it might be and
they’re under care and doesn’t mean that
they can’t have cosmetic surgery and
most of them can but in many cases I’ll
still ask that to get kind of a
clearance from their provider right and
I think that’s an important point that
just because you’re undergoing mental
health care doesn’t mean you’re excluded
it’s sort of like uh no when you see
some horrific crime on TV and then they
start talking about mental health issues
it’s like well that’s kind of insulting
to be people with mental health issues
because often it says nope that was an
evil person it’s not any more complex
than that
sure sure there’s not there
some sometimes the lines are very
ambiguous but sometimes they’re very
clear
so for sure okay so uh when is
plastic surgery you’ve always had of
what it’s a bad idea but is there
anything specific now usually when I
work with you we’ll have somebody who’s
came to three years ago was like well
that worked really well for me and then
they’ll come back another one or two
years
and you know look at a tummy tuck
where before they got a breast
augmentation sure there’s in in general
there’s almost an evolution in patients
that first when they’re younger do I
want to do it do I want to invest in it
I’m afraid to have surgery and then they
for whatever reason something finally
pushes him to do it you know we kind of
have a saying people probably pick up
the phone 10 times before they actually
make the call for plastic surgery but
once they do it and they get a comfort
level with the safety what the
experience is having them come back as
uh down the road as a repeat patient is
not at all in common and it doesn’t mean
you he’ll pay people say oh you become
addicted to it it’s not about that at
all obviously there was probably a very
very small percentage of people that
that is the case that probably do need
some sort of at least some sort of
mental health guidance but in general
just people become comfortable with it
and you know I always tell people you
know there’s really no difference
between making a decision to have
cosmetic surgery versus you know having
your hair done buying different clothes
it’s just a degree and you have to be
comfortable with it and understand what
those things can and can’t do right and
that’s something that you said too that
sometimes people spend a lot of money on
their nails or their hair but a lot of
times with some of the some of the
procedures you do actually makes a
bigger difference for a longer amount of
time too
no absolutely the the patients
that come in that are you know been
struggling with looking in the mirror
and when I say struggling I don’t mean
that they’re they don’t go out they’re
home ridden because they don’t want to
be seen but they finally make that
decision for whatever reason sometimes
it’s just financially they couldn’t do
it now they can but they make that
decision go through with it and then
afterwards probably the most common
thing I hear is why did I wait so long
so again what you’re saying is somebody
who’s like alone at home and really worried about
the way they look that’s probably not a
good step of like hey let’s just go get
plastic surgery and then everything will
be fixed but if people are already
starting to work on their appearance or
uh one thing isn’t it’s a little awkward
but uh in the business World it actually
helps a woman get promoted if she looks
better well there’s studies that that
come out every few months about and
again it’s an awkward topic
but absolutely nothing if not awkward yeah
but it’s absolutely it’s true and
it’s really not awkward because what
we’re seeing is uh as our population is
aging and and both men and women in
their 50s plus still having to work and
compete for jobs that’s one of the
reasons we’re seeing a rise in men
undergoing cosmetic procedures for that
exact reason
yeah and then I think I’ve
seen that several times at the clinic
where it’s like well I’m working with a
bunch of 30 year olds and I can’t look
out of place like right I have to look
like my mind is sharp and maybe it’s not
fair but I and I think there was one
patient who actually said, “look I can
spend this amount money on this type of
training or I can do this and they’ll
both equal the same results for my job”
well and that’s probably true for some
people in certain jobs absolutely yeah
but I think and this is something we
talk about on the show a lot what really
helps is just having a a knowledge of
what the truth is that a lot of times
especially mental health uh we’ll see a
lot of positive affirmations and a lot
of oh you’re doing such a great job and
sometimes what people really need is
just somebody to speak the truth to them
whether it’s good or bad just some
honesty as opposed to this sense of self
that’s so far off base
well that’s
absolutely true and one of the things
that I discuss with patients first of
all is and most importantly is yet just
that you have to really be honest and
upfront of what it is you can do for
them
and try to get a sense of
will that meet their expectations and be
clear to them that these are the goals
for for what we’re trying to achieve and
if that fits what you’re trying to do
then you’re a candidate but it really is
incumbent upon us to kind of pull some
of that information but then also give
it back to the patient and really the
way I look at it is without fluff and I
mean I know I have patience and have had
consults in my office patients come in
and kind of a little bit of a clash of
Personality simply because I’m very
direct with patients with saying this is
what you’re asking about this is what
your options are
or I don’t think there’s a good option I
don’t think you’re a great candidate and
sometimes patients don’t want to hear
that but I think it’s important worst
thing I think we can do is take patients
down the road that they’re never going
to be happy
right and that’s why I
thought this would be such a fun show is
because you’re one of the most direct
people I’ve met and you think of plastic
surgery as something like superficial
and aesthetic and oh they’re going to
make you look beautiful but instead it’s
like here’s what we can do here’s what
we can’t do you know so a lot of it
you’re saying is in the patient
education
absolutely if you don’t spend
the time with patients first finding out
what it is that they’re looking to do
what bothers them and then spend the
time going over what their options are
what to expect which includes risks
that’s where you end up with patients
that are unhappy and I’ll see that and I
hope it’s my patients don’t go elsewhere
for second consults or second opinion
and it happens to but I certainly see
patients in my office that have had
either consults or actually had surgery
they’re not un they’re not happy with it
and when I talk to them it’s I I the
impression I get is they weren’t given
all the information their expectations
were not real or the results couldn’t
meet their expectations and are they
surprised when you take that time to
walk them through that education I think
that there are more I wouldn’t say
surprise as much as it gives them a very
good experience and a level of
confidence that hey somebody’s spending
the time with me I’m not just a number
right and you know the way I’ve run my
practice really since day one I’m in
Solo practice it’s just me I have my
nursing staff is that that we have a
very small group of people that know how
I do things and so there’s never ideally
never any conflict of information given
to patients then contradict each other
but that they can sit and talk whether
it’s to me whether it’s to Jessica my
aesthetic coordinator one of my nurses
and feel comfortable at the information
they’re getting is is important number
one and honest and truthful right and
I’ve run that into those patients where
the last something and I’ll say well
let’s look at what this chart summary
says or let’s look at what this
paperwork says so that we we’re on the
same page
absolutely I’ve seen that a
lot in mental health where well the
nurse practitioner said this and then
you said that and a lot of times it’s
like well let’s make sure we’re on the
same page sure and let’s make sure we
all have the same expert and sometimes
it’s not that it’s different information
but how it’s said just comes across
different
right and in my days when I
would do most of my procedures in a
hospital setting you know our staff and
myself would spend time with the patient
discussing post-op care things like that
and and then they go to the hospital and
somebody at the hospital would say well
here’s information from us and now the
patient has no idea and of course it’s
not even no idea what to believe but who
to trust now right you know you would
hope that they trust your surgeon more
but sometimes they listen to somebody
else and and I’ve had situations where
that actually can get a patient uh have
some some problems because of that right
they’re not certain way who do I reach
out to is this the big issue is this not
and it’s really something that every
specialist should have of what’s our
expectations why what I started to send
is I’ll actually have a piece of paper
with the patient and together we’ll
write out what we expect because similar
to electronic consent forms there’s some
things that if they’re digital will go
through the motions it’s just what we
all do as people but for whatever reason
the physical writing down like are we
looking to have a complete remission of
depression are we looking to
you know dedicate an hour a week or get
by at my job or I want one or two less
antidepressants and it’s not something
that’s usual for Health Care people are
like oh I want to get better but I think
when we Define what exactly is that
we’re looking
sure sure and I’ll have
patients come in sit down and go and I
know on the schedule they made an
appointment let’s say for breast
augmentation and I walk in the room and
I’ll sit down and say so what is it that
you’re trying to address you know what
bothers you not so you’re here for
breast augmentation because I think
that’s a very different way of thinking
of things and when you do it that way
then they start saying things that maybe
they wouldn’t have brought up before
right the same thing with somebody that
comes in uh you know that’s older maybe
in addressing facial aging and they’ll
say well what do you think what would
you do and my answer is no it’s what
what bothers you prioritize what’s the
number one thing when you look in the
mirror that you see what’s number two
and what do you expect to see different
if you go through with any sort of
treatment right so previously on the
show we’re talking about group therapy
because we’re Shameless plug we’re going
to start that in a few weeks at Ascend
you’re all welcome to come it’s 50 each
time though so we’re starting group
therapy and what we realize is the way
it works is you actually have a sounding
board it’s not your family that
sometimes can be both the cause of your
distress and sometimes part of the
healing it’s actually people getting
together and being a sounding board okay
here’s what we want or here’s what we
think of the situation
so what you’re
saying is instead of just oh I don’t
like how this looks I need it fixed okay
well let’s address the deeper reason of
what is it and sometimes that probably
means that the patient doesn’t get
surgery because when they say it out
loud they’re like well that was dumb I’m
not doing this and that’s best for
everyone well also it it’s an
opportunity where because people get so
many misconceptions today with Instagram
all the social media of what can and
can’t be done and what to expect and
they’ll come and think well I just want
to look younger and I’ve had patients
that I want the procedure that you know
Kylie Jenner had and you look in and say
well I don’t know first of all what
specific procedure you’re talking about
number one but number two is
that might be fine for that person but
that doesn’t mean it applies to you so
what is it that really bothers you and
you got to start from there right so do
you see this like everyone craving to
just be younger like the way that in our
culture it’s not so much younger I don’t
think it’s being younger I think it’s
it’s looking better looking healthier
um now with again the the crazes that
we’ve had in the last five years with
social media which we’re actually
starting to see a little pullback on
some of that stuff you know all these
people that were over injecting their
lips their butts all these things we’re
starting to see little pullback because
people are starting to go wait a minute
that doesn’t look like me that doesn’t
look real you know and of course once
the celebrities start pushing it one way
or the other you see that Trend sure so
you’re saying too there’s there’s a
balance between like I had this
conference of how I look as opposed to
oh wait I look ridiculous
um so it’s really confidence versus
self-esteem versus mental health like
all those are kind of rolled up into one
absolutely and we shouldn’t be making
people look odd we should be enhancing
but we shouldn’t be taking something
that’s normal and making it look
abnormal you know there’s a difference
there’s a huge difference and in which
we’ve certainly seen that as plastic
surgery cosmetic surgery has become such
a kind of normal thing now where people
are not just pushing the envelope
they’re they’re Crossing that that line
completely and I’m not even talking you
know you could talk about like things
like Michael Jackson Etc but but just
the average person who is going out you
know might be you know some 20 or 30
year old who you know spends a lot of
money every three to six months on
injectable products and they keep doing
and keep doing it and to the point where
now they took a normal structure normal
lips whatever it might be that they want
to enhanced filled some and now they
don’t look right right yeah because
everything has a risk right whether it’s
mental health plastic surgery there’s
always a risk benefit and that’s kind of
what we’ve been saying about education
and informed consent of here’s what we
can do here’s the risks of it and is it
worth it sure so and that’s you know why
going to somebody that’s that’s well
trained and being well trained isn’t
just I learned how to do a technique
it’s understanding who it applies to
when it applies what are the risks what
are the complications how do you handle
the complications do you know how and
how do you avoid somebody going wow that
doesn’t look like me anymore right well
part of that is are they board certified
the way you are in plastic surgery the
way our psychiatrists at Ascend is and
Psychiatry neurology but what other ways
can patients tell like oh this is a
reputable place with experts or oops
they’re going to take my money
well the
first thing you know from a plastic
surgeon standpoint as you said I’m board
certified there’s there’s basically a
handful of boards that historically are
the ones that through the right training
process have said and then testing said
okay you are a certified physician in
this particular board Board of Medicine
Cardiology and plastic surgery being one
of those so do your homework make sure
they’re certified by the American Board
of plastic surgery there’s some other
boards out there that aren’t part of
that that you might hear about a board
of cosmetic surgery which is not part of
us so that’s where it starts number one
and then number two is you know find out
you know you know what’s their
experience in in a particular procedure
if they’re not a plastic surgeon you
know there’s a lot of other non-surd
plastic surgeon for example injectors
out there doing Botox uh Restylane all
the injectable products right you know
what’s your experience how did they
train where did they train for what
experience did they get if they have a
complication do they have the the right
tools drugs to manage the complication
will they even recognize the
complication and certainly you know the
the the way I kind of see this is if I
look at the things that I receive
literature that the amount of
information for programs talk to train
people I don’t want to just say surgeons
but nurse injectors family doctors ER
doctors anybody else doing this stuff
the programs that are going skyrocketing
in terms of teaching people how to
manage complications
says there’s a lot more complications
so so but you got to ask the right
questions
yeah that makes a lot of sense
because I get pamphlets in the mail all
the time and I’ve even had I think at
one point there was a chiropractor
trying to convince me to do like PRP
injections and I was like I don’t have a
personality for it I was like let’s go
to Dr Carp for someone like that and
that’s part of it too like are we
looking for you know my anesthesia
Styles let’s get
this compilation of drugs and together
we’ll make something that works for you
individually but that idea on someone’s
face is a terrible lighting
sure and and
we’re seeing what you know the best way
to describe is scope of practice
creeping meaning yeah you trained as a
plastic surgeon you do plastic surgery
you trained as a gynecologist you do
gynecologic surgery what we’re seeing is
people creeping away from that into the
aesthetic world with weekend courses
things like that and even the American
Medical Association now has it as kind
of one of their things that they’re
looking at and how to address and that
right there should tell you that this
creeping into other Specialties is
creating problems because the public
unless you do your homework it can be
hard to really ascertain she is at the
right person and especially if you’re a
Price Shopper because to me Healthcare
is not the place to be shopping for
price you go to the place so you feel
most comfortable and confident with
based on that person’s experience not
price right and that is one of the
interesting things about plastic surgery
is it being a self-pay model because uh
for all the ills that you just mentioned
at least you know what you’re getting
you know most other branches of
healthcare it’s like well I hope this
works out and patients aren’t really
ever thinking is this worth the money
I’m paying because they don’t know what
money they’ll end up paying you know you
can have explanations of benefits or
estimations but it’s still very vague of
what you’re getting for what you’re
paying well with the implementation of
the requirement for giving good faith
estimates that’s changing but it’s
certainly from the aesthetic side of it
for cosmetic plastic surgery we’ve been
doing that forever you get a
consultation here’s your bill here’s a
quote this is what you’re going to pay
and and it’s starting to happen where
we’re seeing it because it’s been
mandated by federal law right uh that’s
that’s happened so it’s mostly because
of my people anesthesia is is a big
reason of us purposely staying out of
contract so we could bill and it’s it’s
not uh it’s not a world where anyone’s
innocent
um sure it’s certainly one where it is
much better like here’s what I’m paying
and here’s what I’m getting like any
other economic decision but somehow
Healthcare has been regulated to like oh
my the doctor said I must have this and
that’s all there is to it instead of it
being like here’s what I get and here’s
how much I have to pay for it yeah well
and there’s obviously it’s a very
complicated right uh process there and
there’s so many other hands in the pot
from start to finish that you know
really when you look at for example the
cost somebody’s having any sort of
Medical Care the cost of the overall
health care dollars that are spent in
this country they’d actually go to the
physician is a very small percent right
you know when you start factoring all
the administrators drugs all these other
things what goes to the actual physician
providing the care is a very small
percentage of it right you see Pharmacy
care benefits and different programs
where they’re complete middlemen and
don’t do anything
but that is an
interesting topic of scope creep and
it’s fun too because it’s offensive for
everyone you know right me as a nurse
anesthetist or nurse practitioners well
but we were trained but at the same time
yes but do you have the expertise for
what the patient needs sure and there’s
certainly cases like the ER isn’t a
place to go get your expert opinion no
um in fact most of our patients we tell
them don’t go the ER call us first and
see if we can take care of whatever
mental health or physical health crisis
there is and then if we can’t then go to
the ER and and that’s true and
unfortunately what what I think has
happened is you know the days have come
and gone where you’d call your doctor
first for most situations you now that
if you call many times we’re closed if
it’s an emergency go to the ER or who
are you right right so I mean I always
tell have always told patients call me
first before you go anywhere so if
you’ve had surgery in your word you got
a prompt call me first because number
one in many cases there’s not much going
on that needs to be addressed and if
there is and I do think you need to be
go to the emergency room so we can see
it’s usually I’m going to be involved in
that making sure you if you need testing
you get the right testing you don’t just
get any testing and and and have money
spent that didn’t need to be spent and
and I think that’s critical because
first of all then it’s our job to be
taking care of the patient from start to
finish not just to between nine to five
absolutely and that’s something where if
you’re not getting the care you need
whether it’s from your PCP or from your
specialist that’s something to consider
and I know we can’t roll back the clock
to you know back when you’re in
residency or because we talk about that
often how medicine used to be as opposed
to the like assembly line that is today
sure but it is something where like they
should know you and they should know
what your issues are and be able to take
care of it absolutely and I mean there’s
been a growth in an industry called
concierge medicine country medicine
medicine which is really a prepaid you
for for like family practice or Internal
Medicine where you prepay your doctor
for the year a fee and that fee would
cover you for the whole year for your
basic office visits maybe even some
blood blood work things like that and
that model uh is still growing it hasn’t
you know just become dominant but it is
still growing because it makes a lot of
sense
um you know to to Really when we look at
what happens is if the patients know
that they can get to their doc doctor
and it doesn’t cost them anything more
so even for a patient of mine’s post-op
if they know they can reach me versus
going to the ER when you factor all
those things in their outcomes are
better their costs are significantly
lower so you really want to encourage
that are unfortunately in a lot of areas
that’s kind of disappeared right yeah
and I think too so if everyone’s
thinking well yeah but doesn’t all this
cost money a lot of the times the costs
of insurance-based healthcare and I know
that at a cent we take insurance but so
like crashing the insurance whenever I can
honestly that the costs aren’t always
visible like sometimes it’s waiting six
hours in an ER or weighing two hours to
get back from your doctor or the pain
and suffering of waiting for someone to
get back to you or of course the wrong
interventions
there was a time where
there was a woman who had an absent
seizure in a church so I broke the
seizure with the jaw thrust and then
asked her about her medical history I
was like “oh no you probably shouldn’t go
to the ER” it was extremely complicated
history where it wasn’t going to get any
better or change any outcome
sure that
wasn’t they weren’t going to do anything
except probably ordered but that’s
something scans and then not be able to
do anything and at the end of a day in
the hospital or ER they would have said
okay now go see a neurologist or a
neuropsychiatrist right and plus add a
couple CT scans in there very good
measure
yeah so sure
so if a patient is interested in in
anything you have because obviously it’s
not only surgery like you said sometimes
I’ll start out with fillers or Botox or
something what’s their first step
first step is call the office have a
consultation Jessica who is my coordinator does an amazing job
even pre-visit going over things with
patients trying to get to to understand
what your goals are so you can make the
right appointment because you don’t want
somebody coming in for for Botox it
really wants a breast augmentation so we
want to make sure the appointment’s
right and then you come in we go through
a consultation process I spend the time
with you examine you go through what I
think are your best options if I don’t
think there are options I’ll tell you if
I think there’s better options that I
don’t offer I’ll even say Hey you know
there’s something better that I don’t do
I can probably give you a recommendation
and then we’ll sit down Jessica will go
through uh pricing scheduling and if you
need financing help she does all that
and you know our goal is to have
patients have an amazing experience that
they couldn’t have anywhere else
absolutely and it’s interesting too
because of everything you’ve said I
originally thought oh we’ll probably
talk about plastic surgery for a minute
and then get some really good stuff
about American Health Care but
everything you said is an analogy for
how Healthcare Works
How it should work
and what people should expect that you
need to be with people who know you and
and we’ll take care of you and
understand what’s going on with you not
just an assembly line of oh you paid
your co-pay okay here’s a medicine try
to come back it makes it it makes a huge
difference and it goes back to my
training days and I trained as a general
surgeon first and that’s how I was
trained you the page didn’t matter the
patient was your patient you are my
patient I’m there for you 24 7. if you
need referrals I take care of it if
there’s an issue with getting a test
done I’d take care of it that’s what it
should be right instead of oh I think
someone on the insurance side should
maybe do something so
and again if you
need any mental health needs at Ascend
Health Center we’re just in Fairlawn so
it’s 330-754-4844 we have therapists
Psychiatry for treatment resistant
depression we have Spravato, ketamine,
transcranial magnetic stimulation, but
it’s the same idea of that sometimes you
need something and you need it now and
it’s important and other times you can
start out with something that isn’t
quite “okay let’s get four experts
together and try something
invasive” but it’s all about knowing
yourself and having that education of
“what do I really need and why do I want
it”
absolutely
yeah well thanks for being
on the show
thanks for having me
you’re welcome
[Music]
thank you
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