Did Doctors in the 1800's really not wash their hands?

Spoiler: They washed their hands.

Earlier this year Google made a doodle for their main search page about Dr. Ignaz Semmelweis who practiced medicine in Vienna, and later in his native Hungary in Pest. Dr. Semmelweis is famous for advocating for hand washing before we even knew about the existence of germs. At his hospital in Vienna he was able to greatly reduce maternal mortality rates by simply having the doctors and medical students wash their hands. Supposedly there were doctors across Europe who resisted this idea and fought against the suggestion that they were killing their patients. Only later when doctors discovered the existence of germs and understood how they caused disease was Semmelweis vindicated. Countless lives could have been saved if people had just listened to Semmelweis, but doctors were obstinate and stubborn and refused to listen.

This version of the story is the one that gets repeated in numerous news stories from NPR to the Washington Post, along with other places. It makes for a dramatic story, which is why it gets repeated, but there is a problem with it. It isn't true.

To understand what happened we have to consider the context, and also look at what Semmelweis himself wrote about his own ideas and also what we wrote about his supporters and critics.

In 1847 Semmelweis started an experiment in national hospital in Vienna. In the maternity ward the mortality rate was terrible, to the point that it was reported that women would rather give birth in the street than go to the hospital. During some months one out of every seven women who entered the maternity ward died there. But for women who used midwives and not doctors, even in the hospital, the mortality rate was closer to one out of every hundred women. To Semmelweis this indicated that the problem was the doctors and the medical students.

Because the hospital was also a research institution, an autopsy was performed on every woman who died there. Usually the same doctors and students who performed the autopsies were the same doctors who later attended the births. You can probably see where this is going.

A woman dies after childbirth because of an infection. The doctor performs an autopsy on her, and later attends another birth and the woman also dies from an infection. Semmelweis noticed this and implemented strict handwashing procedures.

But here is where actual history diverges from the story that usually gets told. When people tell the story of Semmelweis they portray it like washing their hands was a new, unusual, and radical practice. But in reality the radical change Semmelweis started was to change what the doctors washed their hands with. The doctors routinely used soap and water to wash their hands. They weren't barbarians. If they did an autopsy they would always wash their hands with soap and water before doing anything else. They were doctors, and knew how to keep things clean, just not sanitized by our standards.

Semmelweis had the doctors wash their hands with a solution of chlorine (bleach) after an autopsy. In the months that followed the mortality rate dropped dramatically. After two years of collecting data the difference was so clear that Semmelweis's students began travelling across Europe to explain the new theory of how to prevent what they called "childbed fever". As reported in letters from his students the reception of his ideas was positive and enthusiastic. Much of this we know because Semmelweis later published a book entitled The Etiology, Concept, and Prophylaxis of Childbed Fever where he laid out his theories and data. At the end of his book he included a chapter on reactions to his theories with excerpts from personal letters and also formal published responses to his ideas. He took extra care to respond to all those he thought had unfairly criticized his work.

It is from his own book that we get the story that he was persecuted and rejected by doctors across Europe. He made sure to bitterly complain of his critics inability to understand what to him was very plain. But it turns out that while his data was compelling, it didn't actually support his conclusions.

Semmelweis thought that dead or decaying matter would get on the doctor's hands, which would then release its miasma (smell) causing the women to get sick and die. Other doctors responded that after washing their hands, because every doctor actually did wash their hands, there wouldn't be enough dead material left on their hands to cause the sickness.

Essentially Semmelweis was saying that the raw matter of a dead body was one of the most potent poisons known to man. But this poison could only kill women, and kill them when they were giving birth. Furthermore he insisted, without evidence, that this was the only cause of "childbed fever", and there could be no other cause. This last point was the source of most criticism.

Dr. Carl Levy from Denmark pointed out doctors at his hospital did not perform autopsies. They outsourced autopsies to other doctors who did not work directly with patients. Also in Dr. Levy's reply to Semmelweis's own response to Dr. Levy, he casually mentioned that the doctors in Denmark would regularly wash with soap and water, and in some cases would wash with a chloride solution, just as Semmelweis demanded that doctors do. This exchange is recorded in Semmelweis's book, and shows that doctors in Europe actually did wash their hands.

Also recorded in Semmelweis's book was a letter from Sir James Simpson (the "father of anesthesiology"). Semmelweis attributed most of the criticisms from Simpson to issues of translation (he assumed that when his letter was translated from German into English something must have been lost since Simpson was not ecstatic about his ideas). But based on what Simpson wrote it is clear that he actually had no issue with Semmelweis one way or the other.

Simpson was surprised to learn that in Vienna they treated up to 32 women in the same room, and noted that in the UK they only had one patient per room. Also Simpson was not particularly impressed with reports that in Vienna they failed to change the sheets between patients. Additionally Simpson was not moved by Semmelweis's insistence that the English adopt his theories since, as Simpson noted, in England they had already been using chlorine solution washes before attending patients for many years. 

In fact one medical textbook published in 1854, quoted by Semmelweis in his book, noted that in English hospitals they had already adopted the practice of chlorine washes. When Simpson responded to Semmelweis he was a bit dismissive because he didn't think much of the hygienic practices of the doctors in Vienna who had apparently just barely discovered hand washing.

So what about the hospital in Vienna? Some versions of the story mention that the hospital administrator opposed hand washing. But this is contradicted by what Semmelweis wrote in his own book. It is true that his superior in the hospital didn't agree with Semmelweis, but his disagreement was over Semmelweis's theory, not the actual hand washing. After Semmelweis left Vienna the doctor who replaced him continued the practice of handwashing and kept the mortality rate low.

Semmelweis's reason for departure from Vienna is frequently cited as proof that he was persecuted for his ideas. Semmelweis was not promoted to the equivalent of full professor, and was also given a lower position along the lines of adjunct faculty. Frustrated Semmelweis left Vienna and returned to Hungary where he ultimately ended up working in the hospital in Pest.

To understand this we need to look at the larger events at the time. Vienna was the capitol of Austria, which was at the time part of the Austro-Hungarian Empire. Austria-Hungary was an unstable collection of nations that would very quickly collapse in the aftermath of WW I. As a Hungarian Semmelweis was viewed with suspicion in Austria, especially since his siblings and other family members supported the Hungarian revolution in 1848 and 1849. It was precisely at the end of the revolution, with at least one of Semmelweis's brothers being executed for treason, that Semmelweis was passed over for promotion. Even though many of his colleagues recommended him, the hospital administration decided to hire an Austrian because of political considerations. He also had a contentious relationship with some of the doctors in the hospital, including his direct superior. So being passed over for promotion was more about politics and personal relationships than disrespect for his research.

But in his book Semmelweis maintains that it was because his superiors disapproved of his theories and wanted someone who would not promote them. But, as already noted, his replacement continued using a chloride solution for washing hands, and also wrote a textbook that included a section on Semmelweis's theory. 

So just based on the information included in Semmelweis's book, we learn that doctors commonly washed their hands with soap and water. The medical practices were not uniform across Europe, even down to how many patients were kept in a room and how often they changed the sheets. But in some countries, such as England, it was apparently routine for doctors performing surgery, or delivering a baby, to wash their hands with a chlorine solution. It was not the case that doctors all over the continent were repositories of unmitigated filthiness.

They did inadvertently spread disease because they did not know about germs, but there was nothing in Semmelweis's theory to imply the spread of germs. From the way he understood it he found a cure for a single, though deadly, disease. He never extended his ideas to other diseases such as dysentery, because he focused on a single problem. In his writing there is no indication that hand washing with a chloride solution could be a way of avoiding any other diseases. It was only later with the development of germ theory that doctors could recognize using a chloride solution (bleach) as a general way of controlling germs.

In retrospect Semmelweis is remembered for being correct about washing hands, but he was not correct about the core of his theory which assumed that miasma (vapor or gasses) emanating from decaying matter from a corpse was the primary source of the disease he was studying. A few of the articles written about him mention only in passing those things that made up the bulk of his theories. It was those things, that disease was caused by particles of decaying organic matter, that his contemporaries rejected. They were not opposed to hand washing, they did it anyway, they just didn't think that it was necessary to wash their hands to remove the minute traces of decaying organic matter.

Later because hand washing became such an important thing, that part of his writings were remembered and emphasized, and nothing else. He was only known for telling people to wash their hands, and not for ideas like self-infection through dead organic matter. Thus it was assumed that opposition to him was because of hand washing. And the only conceivable way someone could be opposed to hand washing was if they did not wash their hands. This is the unfortunate source of the idea that doctors in the 1800's did not wash their hands. But just using the writings of the man who is always cited for proof that doctors did not wash their hands, we can see that doctors did in fact wash their hands.

A Fundamental Disconnect in What is Important

I spend a lot of time reading a variety of views on the Church and Mormonism in general. Every so often some online community of saints or former saints who are critical of the Church whip themselves into a moral panic. They talk about all the problems with the Church and bring out a laundry list of things that must be talked about or things that every Church member should know. Whenever I spend too much time listening to the tinkling cymbals and sounding brass I listen to what the Church leaders are actually concerned about and what they are talking about I notice a fundamental disconnect between what the Church critics think is important and what Church leaders think is important.

I was reminded of this when a visiting General Authority spoke in my ward a few months ago, and again last General Conference, and again today.

What happened to the Church of Scotland?

What has happened to the Church of Scotland? I don't mean what is happening to it now, because it is obvious that whatever happened, happened years ago and just now we are seeing the effects.

A recent article from the BBC has the slightly misleading headline, "Religious affiliation in Scotland 'declines sharply'". The title explicitly points to a decrease in the number of Scots who self identify as members of a church. The apparent conclusion is that religion in general in the country is becoming less important. But if we dig into the data we get a slightly different picture.

Right off the bat the article notes that since 1999 the percentage of people reporting "no religion" has increased from 40% to 58%. This definitely makes it look like religion in general is struggling in Scotland. But not until the end of the article do we find out that as a percentage of the overall population all other religions or Christian denominations have remained constant. Within statistical uncertainty there has been no change for everyone other than the Church of Scotland (the Kirk). The entire increase in people reporting "no religion" is driven by former members of the Kirk.

It is interesting to note that while the other denominations are not picking up those leaving the Kirk, their membership is keeping pace with population growth. They may have a hard time bringing in new converts but they are not in the state of crisis seen in the Kirk. From the data the number of people who self identify as members of the Kirk has decreased by a half since 1999. If half the members of the church of Scotland chose to leave in 18 years while all other religions and denominations have continued to grow, albeit at the rate of population growth, then that indicates that there is, or was, something about the Church of Scotland that resulted in this sudden drop that was not present in other denominations and religions.

This kind of thing does not just happen overnight, or even in just a few years. In order for there to be this dramatic of a decrease over the last 20 years means that the seeds of this crisis were sown long ago. That is why at the beginning I said that it is not happening now but happened years ago.

So there was something about the culture or the teachings of the Church of Scotland that brought it to this crisis. I do not have enough insight or data to determine how it got to this point. But it is also interesting to note that there is data that shows that similar trends hold for the church of England. Since 1983 the number of people in England who self report as Anglican has dropped from 40% to 17%, while the number of non-religious has climbed from 31% to 48%. The proportion of people from other Christian denominations have remained roughly constant, with some fluctuation, but the number of non-Christians has climbed from 2% to 8%.

But this is not isolated data. I recently read an article from The West Australian entitled, "We’re losing our religion". This article followed the format set by the BBC article by noting that the number of people reporting "No Religion" has increased, but when we look at the data the same trend holds. The percentage of Anglicans has declined, while all other denominations have stayed the same (with the exception of Catholics, whose representation declined by 5% of the population).

So while there are definitely more people who self identify as having "No Religion" the vast majority have come from either the Church of Scotland or the Church of England. This massive shift in social attitudes definitely has put pressure on other denominations, but the data indicate that at least in Scotland, England and Australia, religion in general is not going away, just a particular form of it.

Is Salt Lake City America's Vainest City? Correcting Forbes

Background

In 2007 Forbes magazine published an article entitled "America's Vainest Cities" which dealt with how Americans have become obsessed with their looks and as a result were having more plastic surgery. Associated with the article was a list of the 10 vainest cities in America, according to their criteria which was largely based on the number of plastic surgeons per 100,000 adults. This was a fairly unremarkable list except for the fact that #1 on the list was Salt Lake City. That result caused a minor stir among some news outlets in Utah. Many expressed surprise, while others said in triumphant self-righteousness "I knew it!". But the furor quickly died down.

The article, and the fact that they ranked Salt Lake City as #1, would have been forgotten and only mentioned in the occasional blog post and local news article had it not been resurrected by a recent article published in Time. The article had the provocative lead "Believe it or not, the rise in Mormon breast implants and $100,000 Jewish dowries can explain why you're alone on Friday night."

While the article in Time dealt mostly with male to female ratios in Utah, it did cite the 2007 Forbes article to support its assertion that Mormon women in Utah were going to great lengths to attract a potential mate. As stated in the article, "A culture of plastic surgery has taken root among Mormon women." So according to the Time article, this "culture of plastic surgery" has resulted in Salt Lake City having the highest number of plastic surgeons per 100,000 adults, based on the Forbes data. This argument was not central to the Time article but it did support a major point.

The Time article has been getting a lot of traction lately with a few news articles and blog posts in response and numerous shares on social media. The first time I ran across the article I glanced over the assertion that Salt Lake City has more plastic surgeons per capita than any other city and did not think anything of it. The second time someone I know shared something that used the original Forbes article I stopped just long enough to do a simple calculation and determined that something was wrong with the original numbers from Forbes.

The Original Results

Below is the original top 10 "Vainest Cities" with the number of plastic surgeons and surgeons per 100,000 adults. The data comes from 2007.

Rank	State	City	Surgeons	per 100,000 adults
1	Utah	Salt Lake City	45	6.0
2	California	San Francisco	175	5.4
3	California	San Diego	115	5.2
4	California	San Jose	70	5.2
5	Florida	Miami	218	5.2
6	Kentucky	Louisville	41	4.4
7	Tennessee	Nashville	48	4.4
8	Virginia	Virginia Beach	51	4.1
9	New York	New York	591	4.1
10	California	Los Angeles	384	4.1

Even though the Forbes article also gave data about the amount of money spent on cosmetics, personal care, hair dye, and other similar items, the ranking was based entirely on the number of plastic surgeons per 100,000 adults. They acknowledged that Salt Lake City coming in first was surprising, but that did not deter them or raise questions about their data or methodology.

They explain their data gathering and methodology in the following way.

"To rank the cities, we collected the number of plastic surgeons in the country’s 50 most populated cities. We excluded residents under the age of 18, leaving out a small number of children and adolescents who undergo reconstructive or cosmetic plastic surgery.... We obtained the number of plastic surgeons in each city from the American Society of Plastic Surgeons, a membership organization that represents about 90% of all plastic surgeons certified by the American Board of Plastic Surgery."

If we look at the data from Salt Lake City, 45 surgeons and 6 surgeons per 100,000 adults means for their calculation they assumed that in 2007 Salt Lake City had a total adult population of 750,000 adults. According to the 2010 census 23.6% of the population of Salt Lake City is under 18, which means Forbes was assuming a total population of ~980,000 people in 2007. The current (2014) estimate of Salt Lake City's population is 190,884. Already we see there is a problem since Forbes was assuming a population almost 530% larger than the actual population of Salt Lake City. Using 2010 census data I checked how the other cities on the list fared.

Rank	State	City	per 100,000 adults	Under 18	"Apparent Population"	2010 Population
1	Utah	Salt Lake City	6.0	23.6%	981,675	186,440
2	California	San Francisco	5.4	13.4%	3,742,195	805,235
3	California	San Diego	5.2	24.0%	2,909,919	1,307,402
4	California	San Jose	5.2	24.8%	1,790,098	945,942
5	Florida	Miami	5.2	21.7%	5,354,161	399,457
6	Kentucky	Louisville	4.4	24.3%	1,230,936	597,337
7	Tennessee	Nashville	4.4	22.0%	1,398,601	626,681
8	Virginia	Virginia Beach	4.1	27.5%	1,715,728	437,994
9	New York	New York	4.1	24.0%	18,966,624	8,175,133
10	California	Los Angeles	4.1	23.1%	12,179,264	3,792,621

As can be seen in the table above the population used for the calculation in the original Forbes article is much higher than the actual population of the cities. Based on the numbers it would seem that Forbes used the 2007 metropolitan population which includes more than just the listed city. That would not be a problem, but based on their description of their methodology they were not considering metropolitan areas, but individual cities.

The next logical question is to check if the number of plastic surgeons in each city was accurate. I went to the web site of the American Society of Plastic Surgeons to check Forbes's numbers. For Salt Lake City I found only 15 surgeons with an address in Salt Lake City and a total of 47 for the entire state of Utah. There are a total of 26 plastic surgeons with an address somewhere in Salt Lake County but nowhere near the 45 reported by Forbes. I did notice that if I searched for a specific city then the American Society of Plastic Surgeons site returned results from nearby that city, though "nearby" is a relative term. A search for surgeons in "Salt Lake City" returned results from Ogden and Provo, which are both outside the Salt Lake City metropolitan area, but still "nearby". But further down the list are results from Idaho, Wyoming and Colorado. So assuming that the search mechanism on the American Society of Plastic Surgeons website has not been modified since 2007 it would be quite easy to find more plastic surgeons in a particular city than are actually in that city.

I have no insight into how the reporters did their search, but if they were using 2007 metro area populations then they may have rationalized using all or most of the results returned by entering a specific city into the search field. The problem with this is that they may have included plastic surgeons from as far away as Logan and St. George, and then only used the population of the Salt Lake City metro area. This would skew the numbers for all the cities in unexpected ways.

Corrected Results

With this in mind I decided to check all the cities on the Forbes list and also to expand the search to all cities, towns, villages, hamlets or Census Designated Places that had a plastic surgeon listed on the American Society of Plastic Surgeons website. For my analysis I used the total population from the most recent available estimates.

For cities over 100,000 people I used 2014 population estimates, for locations smaller than that I used the most recent estimates, which generally were 2013, but with a few exception for 2010 data and an even smaller number (~5) for which the most recent data was from the 2000 census. This covered a little more than 1400 locations in the US with populations ranging from 132 (Crestone, Colorado) to 8,491,079 (New York, New York). This included five military bases for which there is no population data.

Below I give the results for the original top 10 "Vainest Cities" as reported by Forbes, along with my count of surgeons in that city and a recalculation of the number of surgeons per 100,000 people.

Forbes Rank	State	City	Surgeons	per 100,000 adults	Actual Surgeons	Actual/100,000
1	Utah	Salt Lake City	45	6.0	15	7.9
2	California	San Francisco	175	5.4	50	5.9
3	California	San Diego	115	5.2	38	2.8
4	California	San Jose	70	5.2	11	1.1
5	Florida	Miami	218	5.2	47	10.9
6	Kentucky	Louisville	41	4.4	23	3.8
7	Tennessee	Nashville	48	4.4	31	4.8
8	Virginia	Virginia Beach	51	4.1	15	3.3
9	New York	New York	591	4.1	192	2.7
10	California	Los Angeles	384	4.1	45	1.1

As you can see when we only consider the cities and not the metro areas the rankings change significantly. Just in these cities Salt Lake City drops to #2 with 7.9 surgeons/100,000, while Miami moves to #1 with 10.9 surgeons/100,000. Also both New York and San Jose drop to last place with 1.1 surgeons/100,000. Just this small sample indicates that my new methodology will significantly change the results. If we just consider the 50 largest cities, not metropolitan areas, the top 10 become:

City	Surgeons	Population	Surgeons/100,000
Atlanta	51	456,002	11.2
Miami	47	430,332	10.9
San Francisco	50	852,469	5.9
Boston	36	655,884	5.5
Dallas	67	1,281,047	5.2
Baltimore	31	622,793	5.0
Nashville	31	644,014	4.8
Seattle	31	668,342	4.6
Austin	38	912,791	4.2
Houston	91	2,239,558	4.1

In this case Salt Lake City does not make it into the list of the 50 largest cities since it is currently the 124th largest city in the US. All of the other cities in the original Forbes top 10 are in the list of 50 largest cities in the US. If we include Salt Lake City despite its lower rank it would come in at #3. But if we expand our criteria to include all cities (and Census Designated Places) larger than 100,000 people then the top 10 changes with Scottsdale, Arizona leading the pack.

State	City	Surgeons	Population	Surgeons/100,000
Arizona	Scottsdale	40	230,512	17.4
Michigan	Ann Arbor	16	117,770	13.6
South Carolina	Charleston	17	130,113	13.1
Michigan	Grand Rapids	25	193,792	12.9
California	Pasadena	17	140,881	12.1
Georgia	Atlanta	51	456,002	11.2
Georgia	Savannah	16	144,352	11.1
Florida	Miami	47	430,332	10.9
Pennsylvania	Pittsburgh	33	305,412	10.8
Florida	Fort Lauderdale	19	176,013	10.8

In this case Salt Lake City comes in at #22 right behind Cincinnati, Ohio and Tampa, Florida. It even has a lower rate of surgeons/100,000 people than Metairie, Louisiana which is not even a city but is a Census Designated Place near New Orleans. As can be seen, only Atlanta and Miami are on this new to 10 from the previous top 10 where the selection criteria was limited to the 50 largest cities. This shows that as we go to progressively smaller populations the rate of surgeons/100,000 goes up. This means that a population limited sample, such as the one used by Forbes, even if they used correct numbers, would skew the results since the highest rates of surgeons/100,000 occur in the smallest population centers.

We can see this effect if we now include any population center with a plastic surgeon. Below are the top 10 population centers with the highest rates of surgeons/100,000 people.

State	City	Surgeons	Population	Surgeons/100,000
Colorado	Crestone	1	137	729.9
Maryland	Chevy Chase	20	2,824	708.2
Michigan	St. Joseph	1	276	362.3
California	Beverly Hills	89	34,658	256.8
Pennsylvania	New Castle	1	407	245.7
New York	Great Neck	21	10,088	208.2
New York	Lake Success	6	3,030	198.0
Kentucky	Crestview Hills	6	3,159	189.9
New York	Cooperstown	3	1,834	163.6
Pennsylvania	Lebanon	1	670	149.3

Here the highest population is Beverly Hills California with 34,658, but has 89 plastic surgeons for a rate of 256.8 surgeons/100,000 people. As an interesting #1 is Crestone, Colorado, a tiny community of 132 people. While the 89 plastic surgeons in Beverly Hills might tell you something about that city, the one plastic surgeon in Crestone only tells you that a plastic surgeon happened to open her practice there. As can be seen this list is dominated by tiny communities with very few plastic surgeons that presumably service a larger area. Then there are others like Beverly Hills, Great Neck, Lake Success, Chevy Chase and Crestview Hills that are suburbs of larger cities.

These extremely high rates of plastic surgeons/100,000 for extremely small populations indicates that a better selection criteria would be a limit on the number of plastic surgeons rather than a limit on population. To show this in graphical form I plot the number of plastic surgeons/100,000 people vs. population for the 50 largest cities, cities with more than 100,000 people and for all population centers.

If we consider the above graph there is no real trend, but when we extend it to all cities a distinct trend emerges.

This demonstrates the problem of using a population limited sample.

The Beverly Hills

Upon further inspection there are a few places that stand out from the rest. These are the ones I like to call The Beverly Hills. Beverly Hills, California is in a class of its own with 89 plastic surgeons, but there are several cities just like it with a small population, close proximity to a large metropolitan area and a large number of plastic surgeons. Below are 24 cities that fit the Beverly Hills classification.

State	City	Surgeons	Population	Surgeons/100,000
Maryland	Chevy Chase	20	2,824	708.2
California	Beverly Hills	89	34,658	256.8
New York	Great Neck	21	10,088	208.2
Florida	Naples	15	20,537	73.0
California	Newport Beach	47	87,273	53.9
New Jersey	Paramus	14	26,342	53.1
New York	Garden City	10	22,552	44.3
Kansas	Leawood	13	32,991	39.4
California	La Jolla	18	46,781	38.5
Virginia	McLean	18	48,115	37.4
Minnesota	Edina	17	49,596	34.3
Delaware	Newark	11	32,549	33.8
Maryland	Annapolis	10	38,880	25.7
Florida	Boca Raton	22	89,407	24.6
Florida	Sarasota	13	53,326	24.4
California	Palo Alto	15	66,642	22.5
Michigan	Troy	15	80,980	18.5
Maryland	Rockville	11	62,334	17.6
Arizona	Scottsdale	40	230,512	17.4
Georgia	Marietta	10	59,089	16.9
California	Walnut Creek	11	66,900	16.4
California	Santa Monica	13	92,472	14.1
Michigan	Ann Arbor	16	117,770	13.6
Texas	Sugar Land	11	83,860	13.1

Making this list are small cities that no one making up a list such as "Vainest Cities in America" would think about including but only show up when you look at all of the data. Cities like Edina, Minnesota; Leawood, Kansas; Troy, Michigan; and Chevy Chase, Maryland. Most are not surprising for anyone who lives near one of these places (I was personally not surprised by Scottsdale). I have included La Jolla even though it technically is part of San Diego, since it is, at least by this measure, the Beverly Hills of San Diego. Almost all of these cities have less than 100,000 people but a large number of plastic surgeons. If Forbes had wanted to do a real list of the vainest cities in America this would be a good place to start.

The Centers

Then there are a group of cities that I call The Centers. These cities are usually the center of metropolitan areas, have more than 100,000 people and are surrounded by smaller cities with few or no plastic surgeons. These cities obviously service more people than those who live in that city. These include cities such as Charleston, South Carolina; Albany, New York, Salt Lake City, Utah; Birmingham, Alabama; Chattanooga, Tennessee; and Houston, Texas. Some of these centers have a Beverly Hills next door (for example, Sugar Land, Texas for Houston), but others such as Salt Lake City have no other cities close by that contain a significant number of plastic surgeons.

There are a few notable outliers among the Centers that deviate from the rest to the point that they are almost Beverly Hills. Below is a list of cities that deviate significantly from other cities of comparable population that they can be considered Beverly Hills-Centers. Some of these cities have a Beverly Hills right next door, such as Houston with Sugar Land.

State	City	Surgeons	Population	Surgeons/100,000
South Carolina	Charleston	17	130,113	13.1
Michigan	Grand Rapids	25	193,792	12.9
California	Pasadena	17	140,881	12.1
Georgia	Atlanta	51	456,002	11.2
Georgia	Savannah	16	144,352	11.1
Florida	Miami	47	430,332	10.9
Pennsylvania	Pittsburgh	33	305,412	10.8
Florida	Fort Lauderdale	19	176,013	10.8
Alabama	Birmingham	22	212,247	10.4
Virginia	Richmond	21	217,853	9.6
Missouri	St. Louis	29	317,419	9.1
Florida	Tampa	31	358,699	8.6
Ohio	Cincinnati	24	298,165	8.0
Ohio	Cleveland	28	389,521	7.2
California	San Francisco	50	852,469	5.9
Massachusetts	Boston	36	655,884	5.5
Texas	Dallas	67	1,281,047	5.2
Texas	Houston	91	2,239,558	4.1

Properly Placing Salt Lake City In Context

When you properly place Salt Lake City in context it drops from 1st place according to Forbes to #499 out of 1407 cities, towns, villages, military bases and CDPs that have plastic surgeons. With its rate 7.9 surgeons/100,000 it may seem high compared to other cities of similar size. But it is a Center so it has more plastic surgeons than most cities of similar size. But even as a Center it does not rise to the level of being a Beverly Hills-Center since for Centers of a similar size the average is 7.7 surgeons/100,000.

If we consider Salt Lake County the rate drops to 2.4 surgeons/100,000 and for the entire Wasatch Front there are 1.7 surgeons/100,000. This compares with an average of 1.6 for the entire nation and about 1.9 surgeons/100,000 if we just consider urban areas. For the entire state of Utah there are 1.6 surgeons/100,000 perfectly inline with the national average.

Below I plot the results for all cities, The Beverly Hills, The Centers, the original top 10 from Forbes with corrected results, and Salt Lake City.

So rather than being a surprising result according to Forbes, Salt Lake City is rather unsurprising. Forbes's strange result that found that Salt Lake City had more plastic surgeons/100,000 than any other city is due to using a population limited sample, combined with some unclear counting that cannot be cleared up without input from Rebecca Ruiz who wrote the original article for Forbes.

If you would like to take a look at the raw data I used, here is a link to a Google Spreadsheet of the data.

The Geeky Extra Stuff

Congratulations on making it this far into my post. You are one in ten, as in probably only one person out of my total ten readers will make it this far. Because I am a scientist and not a journalist I feel compelled to explain the complications associated with my methodology.

The data from the American Society of Plastic Surgeons is not the cleanest data, nor is the search function entirely reliable. As noted above, if you search for a particular city it will return results from places other than that city, sometimes from a significant distance away. For example a search for Salt Lake City will return results from Sandy and West Jordan, but also as far away as Twin Falls, Idaho. Also I found that a search for a particular city did not always return all of the plastic surgeons associated with that city. But if you search by state and then sort them by city it showed all listed surgeons. This did not significantly affect the numbers and was rare but noticeable.

Some surgeons were listed more than once because they had more than one office. For one surgeon I noticed that she had five offices spread over a state. I counted each office as a surgeon. These cases were rare but noticeable.

Some surgeons had nonsensical addresses. For example, I found a "New York, South Carolina" with a New York City zip code. There were a handful of cases like this where the city and zip code did not correspond to state listed. By my count this affected nine out of 5129 surgeons. Some surgeons were listed twice with slight variations of the same address, so I only counted one surgeon.

There were others that had variations in their address that made it hard to determine what town, village or hamlet they were associated with. This was prevalent in Maryland, Pennsylvania, New York, Massachusetts and Connecticut.

Some listed the city they lived in incorrectly. This is different from listing the wrong state as noted above. For example, there were several surgeons who listed their city as "Crestview, Kentucky", but their zip codes and address indicated they were in Crestview Hills, Kentucky. Both Crestview and Crestview Hills are directly across the Ohio river from Cincinnati and are very small communities just a few miles from each other, but are distinct incorporated places. There were some other variations on names that were particular to the location. Other than Crestview this did not affect rankings.

Some listed their address to indicate a particular borough or neighborhood. For example, there were several listings for Queens, Brooklyn, the Bronx, Manhattan and Staten Island, in addition to addresses for just New York City. There was no overlap as far as I could tell (i.e. surgeons double listed), so when counting the total number of surgeons for New York I included all those that listed their city as one of the boroughs. I did not try to determine how many that listed their city as New York were in each borough, so the number of surgeons and surgeons/100,000 for the boroughs are lower bounds only. The same was done for other neighborhoods of major cities, such as La Jolla in San Diego, but only as far as was aware of it (sorry, I am not intimately knowledgeable about all neighborhoods in all major cities to the point that I know them by name, who do you think I am? Ken Jennings?).

Not all plastic surgeons had up-to-date addresses with American Society of Plastic Surgeons. A spot check indicated that this may affect ~2% of the surgeons listed, but that would not change the rankings nor classification of cities as Centers or Beverly Hills. I also only used data from the American Society of Plastic Surgeons (ASPS) but I did gather statewide data from the American Society for Aesthetic Plastic Surgery (ASAPS) which is another major society of plastic surgeons. Some surgeons are members of both but with a significant number being members of only one. In all states there were fewer members of ASAPS than ASPS, with the notable exception of Texas. Also interesting to note is Florida which had, by a large margin, a higher rate of ASAPS members/100,000.

While I tried to use either 2014 or 2013 data, for a few places that data was not readily available. For all cities with a population over 100,000 and for all cities that fall into the category of the Beverly Hills 2014 data was used. I have assumed that the number of plastic surgeons did not significantly change from 2014 to 2015.

State Stuff

I calculated the total number of surgeons in each state and calculated the number of surgeons/100,000. For both states and cities with more than about 300,000 there is a power law relationship where,

Surgeons = α Population^β

where β = 1.08 and α = 4.4e-06. [Edit: When I put this equation in I accidentally grabbed the wrong numbers from my Matlab output. The values for α and β are now correct.]

Surgeons/100,000 for all cities and states.

Total surgeons for all cities and states.

Answers to Random Questions

Q: Why do you care whether an article in Forbes from 2007 is accurate?

A: I don't. But lately some people (i.e. the Time article mentioned at the beginning) have been using the data to support dubious claims about Utah and by extension Mormons in general. I couldn't pass up the opportunity to undercut the support for that claim when the original data could be shown to be questionable.

Q: Don't you have better things to do?

A: As someone I know once said, "Some people eat, sleep and chew gum, I do genealogy and write...". I don't own a TV, nor do I have a Hulu Plus/Amazon Prime/Netflix account, nor do I have a gaming station. So for entertainment I look up random things on the internet and research stuff like this. It's what I do.

Q: What about all the other data in the Time article?

A: It may or may not be correct (the demographics definitely are correct), but some of the conclusions are not correct, especially those relating to plastic surgery and the statement "A culture of plastic surgery has taken root among Mormon women." My data seriously call into question that statement.

Q: Should Forbes retract their article?

A: I don't care. The original author has long since moved elsewhere, but if Forbes wants to issue a correction, by all means go ahead. If anyone in the Salt Lake City government cares enough about it they can ask Forbes to retract it. But I don't live or work in Salt Lake City.

Q: Are you really an astrophysicist?

A: Yes.

Q: Can I get your original data?

A: Yes. You can find it here in this Google spreadsheet. If you use it for anything make sure you cite your source (me, this blog). I always take points off from my student's lab reports if they don't cite their sources and I will do the same to you.

Q: Did you just threaten to take points off if I don't cite you?

A: Yes.

Q: Did I really just read all of this?

A: Yes. Yes you did.