JUST BECAUSE A DOCTOR PERFORMS COSMETIC SURGERY DOES NOT MEAN HE IS COMPETENT. A doctor should not just “start doing cosmetic surgery” anymore than a commercial pilot starts flying a space shuttle. He needs training. He needs supervised experience under an expert.
Unqualified cosmetic surgeons can establish a practice in two different ways:
- Entrance from another specialty without adequate “re-training” or
- Completion of an accredited residency training program that lacks specific training in cosmetic surgery
The breakdown of traditional specialty boundaries makes it more challenging to select the appropriate cosmetic surgeon for your needs. Some doctors are lax about gaining enough training, while others become highly skilled. Some examples of successful transitions are:
- Body liposuction was not devised by a cosmetic surgeon, but rather by a French gynecologist — and it was later refined by an American doctor, board certified in both internal medicine and dermatology.
- One of the most prominent hair transplant specialists in the country originally practiced psychiatry.
- The father of modern cosmetic nasal surgery was a Berlin orthopedic surgeon.
The migration of some specialists into cosmetic surgery is parallel to the deregulation of the airline industry and public utilities — you might have more choices, but it is difficult to choose wisely.
MEDIA OBSERVATIONS ON DOCTORS TRANSFERRING TO COSMETIC SURGERY
Leslie Vreeland, an experienced investigative reporter, wrote in American Health in 1992, “. . . you must make sure your surgeon is qualified. Thanks to an explosion in the number of doctors entering the field, the odds that you will choose the wrong one may be greater today than ever before.” Vreeland quotes Mark Gorney, MD, a plastic surgeon practicing at that time in San Francisco, and senior examiner for the American Board of Plastic Surgery: “Cosmetic surgery is attracting all sorts of people who lack training or scruples. There are now so many of us in this profession, we’re almost practicing on each other.” Vreeland noted that while the number of operations done for cosmetic reasons had risen significantly in the prior ten years, “the number of doctors vying for the business had increased even faster.” And that article was written a decade ago. Many more have entered the field since then.
HOW MANAGED CARE DRIVES DOCTORS INTO COSMETIC SURGERY
Revolutionary changes in medical care delivery, as orchestrated by the insurance industry, have altered physician attitudes and career directions. Many — disheartened, disillusioned and disgusted with the duplicity of their insurance company masters — have reluctantly re-evaluated their careers. They have seen one last refuge of independence: cosmetic surgery. The only specialty unburdened by unending paperwork served up by a sinister, maze-like bureaucracy adept at payment delays, payment slashes, or, worse yet, no payment.
So just in case you wanted to know one reason behind that swing to cosmetic surgery —this is the answer from an insider.
Legally, Can Any Licensed Doctor Perform Cosmetic Surgery? Technically, Yes. Practically, No
Hold on; do not panic. Having heard the media play this tune so often as part of a rating-boosting, sensational story, I must comment. The unstated implication is that a family practitioner, right out of internship, or an allergist, just finishing his specialty training, can start performing liposuction, face-lifts and nose jobs on a whim — not quite. My license to practice is granted by the State of California’s Medical Board, the state’s regulator. It is a Physician & Surgeon license. So it is for every state’s licensed doctors. The license makes no mention of specialty. Every doctor’s license is general and not specialty-specific because it is impractical for California (84,675 licensed MDs as of January 1, 2002) or any state to oversee professional competence in each of the dozens of specialties, subspecialties, and now, superspecialties. However, using a traditionally wise practice, hospitals and outpatient facilities such as radiology centers, laboratories, and surgery centers where doctors ply their trade have been charged with the background check and credentialing of its practitioners. The system works well because each facility has strict, uniform criteria for granting privileges for specialists to perform their work. The privilege-granting process, after a thorough credentialing and background check, is guided by each specialty’s recognized standards.
EXAMPLE OF HOW THE SYSTEM WORKS
If an orthopedic surgeon applies for privileges at the XYZ Surgery Center, he must present proof of licensure, liability insurance, and a credentials packet that reflects medical schooling, internship, and residency training in the doctor’s specialty in this case,orthopedics.
Further, the doctor must submit a list of surgical procedures for which he seeks performance privileges. Assuming his credentials are appropriate (board certification or board eligible in orthopedic surgery, an unrestricted state license, and personal list of procedures falling within standard orthopedic practice), he will be allowed to practice, on a temporary/guest basis, until his skills are deemed satisfactory. Only then will full staff membership be granted allowing him to practice orthopedic surgery at the XYZ Surgery Center.
Here’s a “hypothetical” example of how the watchdog system, protects you. Another board certified orthopedic surgeon comes to the same surgery center, with intentions of expanding his orthopedic practice to include liposuction on hips or thighs. He states: “Hey, I can do this. I know the anatomy of the hips and thighs. I have been operating there for years.” And indeed, while he is knowledgeable in the anatomy of that area, this alone is not an adequate qualification to begin doing a cosmetic procedure, especially when he admits he has no formal, approved training and no experience.
His application will have to be evaluated, not by the Orthopedic Surgery department but by the Plastic Surgery department. His application will be promptly denied because he does not meet the professional standard of the surgery center: specialty training in the procedure he wishes to perform. Cosmetic surgery on the hip area, such as liposuction, is a procedure that is not listed by his board — the American Board of Orthopedic Surgery — as a procedure within the scope of the specialty. The safeguard to you, the prospective patient, is that an ethical clinic allows only fully accredited, properly trained professionals to perform specific surgeries.
Besides the moral obligation to protect the public, a hospital or surgery center has a business-driven reason to scrupulously follow the privilege-granting guideline it submitted to inspectors before receiving license, certification or accreditation. Not following these guidelines would disqualify them from government and private insurance payments. This complex system of internal quality control is all “behind the scenes” — for your safety and protection. Ninety-nine percent of the time it works. Ethical surgeons and ethical surgery centers play by the rules: no qualification — no surgery.
Yes, there have been some shocking stories of general practitioners or other untrained, self- proclaimed cosmetic surgeons doing liposuction without proper training and accepted credentials. Because these doctors could not qualify for privileges in a bona fide hospital or surgery center, they have opted to “go underground” and the danger to patients is real.
The rare unscrupulous physician, with no legitimate facility to accept him, retreats to his office or some under-equipped, inadequately staffed, unlicensed, uncredentialed, underground hideout. These inadequate pseudo-clinics are the wrong place for surgery of any kind, and breed problems for the patients that can have a tragic ending.
I can assure you such a scenario is very, very rare. But, as mentioned earlier, my mission is to make sure you are savvy enough not to consider any high-risk shortcuts. These never lead to safety and excellence. By staying “mainstream,” you remain safe and you remain distant from danger.
Although the majority of specialties may not include cosmetic surgery in their practices, enough do so that the lines traditionally drawn between specialties continue to sway and weaken. Prospective patients must be aware of this evolution.
THE TRAINING PROGRAM PROBLEM
Until recently, many training programs properly fulfilled their mission. But, today’s training programs differ significantly from the programs we enjoyed a generation ago. As a trainee at the University of Illinois in the early 1970s, I had access to a generous stream of patients seeking cosmetic surgery. The university made it very affordable for patients to have surgery performed by surgeons in-training because the hospital had a plump budget, which included funds for noninsured training cases. Patients paid between $50 and $250 for a single or multiple procedures. This inflow of patients seeking our services allowed many of us to become quite accomplished during our residencies. We graduated both competent and confident in our skills. Our professors felt comfortable sending us out to do cosmetic facial surgery.
By contrast, today’s residency training programs often work against the aspiring young cosmetic surgeon. First, there is the time constraint of the training period itself. Consider this: The minimum residency requirement for plastic surgeons is only two years. For the entire body. Is this adequate time to master the 137 head-to-toe procedures that the American Board of Plastic and Reconstructive Surgery recognizes as within that specialty’s province? In fact, the training focuses on the reconstructive procedures required by accident and tumor victims, not cosmetic surgery patients. Furthermore, since most residency training is held in hospitals, rather than boutique clinics or dedicated cosmetic surgery centers, residents aspiring to be cosmetic surgeons have inadequate training and little access to the cosmetic wing of plastic surgery.
The dilemma is the same for ophthalmologists aspiring to perform cosmetic surgery on the eyelid and brow; for head and neck surgeons interested in face and neck cosmetic surgery; and for dermatologists seeking training in cosmetic procedures. Residency focus is on reconstructive—not cosmetic—surgery. What other barriers exist to proper training and experience before a doctor starts performing cosmetic procedures in practice? One is that today’s more sophisticated and well-informed patients are reluctant to have the procedures performed by novice surgeons in-training. They realize that regardless of the amount of supervision, if a doctor-in-training is performing the procedure, his inexperience may negatively influence their result.
COSMETIC SURGERY IS NOT A HOSPITAL-BASED SUBSPECIALTY
Like other subspecialties of plastic surgery, dermatology, head and neck and ophthalmic surgery, cosmetic surgery lives in an outpatient world. It is not hospital based because the patients do not require hospitalization before or after surgery. This has great significance for trainees who are generally hospital bound. How difficult must it be for a hospital bound cosmetic surgery resident to gain experience in a specialty that is not hospital based? Most highly specialized, full time cosmetic surgeons are found in larger cities, practicing apart from university hospital settings. They practice in either office or outpatient surgery centers. Not in hospitals. Contrary to reconstructive cases, the cosmetic surgeon does not see the patient preoperatively or postoperatively in the hospital. This is a major disadvantage for doctors in training.
Neophytes need to learn the entire menu of the surgical experience. The operating room is only one course. They need exposure on how to interview patients. They must learn “when to operate, and when not to operate.” Medical photography and computer imaging are rarely available in an all-purpose university hospital. Learning how to manage patients postoperatively is imperative. Dealing with patient dissatisfaction, post-operative problems and complications mean care is often given for months after surgery. Trainees often change services every two to three months and never get the full benefit of having their work evaluated on a long-term basis. Thus, we must conclude, the university training setting is not a replica of the actual practice world for the cosmetic surgeon.
Ironically, the typical cosmetic surgery patient is not anxious to go to a teaching hospital, but that’s where the trainees are based. It offers little privacy, no anonymity, and hospital charges are often prohibitive. Cosmetic surgeons are even less excited about a hospital stay for their patients. The threat of antibiotic-resistant bacteria is a concern with elective surgery, which should be done in a low risk environment. And, overworked hospital nurses are not ideal service providers for the special needs of cosmetic clients; their inherent allegiance is to the sick, not to the vain.
THE HEAVY HAND OF TODAY’S MANAGED CARE ECONOMICS
The other current major cosmetic surgery training negative is a heavy, cloud-like factor permeating all training programs and it is not healthy for any of us. Hospital budgets —particularly those of teaching hospitals — are severely constricted by managed care’s
Community hospitals concentrate on providing services to the quick, uncomplicated, routine surgical case. They are economically unable to shoulder patients who do not fit within this narrow parameter. The complex cases are shunted to the university’s teaching hospitals. Consequently, these are overflowing with the sickest patients. With full censuses and day and night operating schedules, the harried admissions department has little space for elective cosmetic surgery patients. And already stressed hospital administrators, sweating their thin budgets, do not roll out the Welcome Wagon for long, pro-bono cosmetic training cases that may consume two to three times the operating room time typically allotted to experienced surgeons.
Unfortunately, In Most Residency Programs, Cosmetic Surgery Is Still A Stepchild
Cosmetic surgery rarely finds champions in academia, either. Cosmetic cases are perceived as unimportant, extraneous and irrelevant by the university hierarchy who are dedicated to research and teaching.
Recently, in the classified section of a specialty news magazine, under “Opportunities for Plastic Surgeons” appeared these three ads: Medical school ad seeking faculty and Private practitioner ads seeking associates (there were 2 of these).
The university ad does not mention cosmetic surgery. In contrast, the ads placed by private practitioners seeking associates indicate cosmetic (aesthetic) surgery experience as a desirable qualification. This is a disconnect between the aims and interests of training programs and the requirements of the real world of cosmetic surgery.
This is not a good thing! If instructors, and even heads of training programs, are neither qualified nor interested in cosmetic surgery, how skilled will their graduates be? And, how can today’s ever increasing demand be met by these training programs?
I submit to you that university training programs are on one track, and the learning desires of trainees — and the demands of the practice community — are on another track. The tracks are well established and parallel, but, as we learned in geometry, parallel lines never meet.
With the exception of those who pursue cosmetic surgery fellowships after their training residency, the young graduate surgeon is often inadequately prepared to practice cosmetic surgery at the high level of expertise expected by today’s patient.
I am aware of several young local surgeons who, although well trained in reconstructive surgery, entered private practice with precious little facial cosmetic surgery experience, particularly in face lifting and nasal surgery. Alas, the aspiring — but neophyte — surgeons had to learn cosmetic surgery “on the job.” Uninformed, unwary patients inadvertently became the teaching cases that should have been provided during the formal training period.
It is a matter of buyer beware. As an observant colleague commented: “Some people spend less time researching their face lift than they do selecting a refrigerator or a car.