Will the Real Cosmetic Surgeon/Physician Please Stand Up?

“My own religion has been to do all the good I could to my fellow men, and as little harm as possible.” —William Mayo, M.D. WHO IS THE COSMETIC SURGEON? The Internet has dramatically altered the landscape of daily life, including how the consumers of health care (our patients) interact with those who provide it (medical professionals). As patients seek improvement in their self-esteem and psychological well-being, the demand for cosmetic surgery continues to grow.1,2 In spite of this growth, there has not been a parallel increase in regulations, with regard to who can perform aesthetic surgery and the associated price of the procedures being offered.3,4 Cosmetic surgery is an excellent example of the “principal-agent problem” as the principal (the patient) selects an agent (the medical provider) to make a decision on behalf of his or her behalf. Specifically, the patient trusts that the physician will use his or her professional knowledge along with the patient’s preferences to formulate a safe operative plan. However, cosmetic surgery is characterized by “asymmetries” of information, where patients must identify a qualified provider and understand the nuances of the complex procedures that they are being offered.5 In addition, because of the potential financial incentive, the provider may act in his or her own economical interest, which further exacerbates the problem.6 A provider may capitalize on misinformation and, without the oversight of a regulatory agency, perform a procedure that could jeopardize patient safety. Accumulating evidence indicates that procedures performed by those without appropriate training and qualifications can and do compromise patient care and safety and thus result in an increased chance for medical error. Mainstream publications have exposed the cautionary tales of patients whose lives ended at the hands of unqualified surgeons.7–9 These anecdotes, and supporting statistics from academic studies,10 illustrate the very real risk of choosing to undergo plastic surgery performed by an unqualified provider. The purpose of this editorial is not to limit the scope of a physician’s practice, but rather to help plastic surgeons educate consumers of cosmetic surgery on how to appropriately identify qualified providers. Two major factors compromise the transparency of selecting a cosmetic surgeon. The first is the lack of regulation or oversight with regard to “medical marketing,” and the second is the lack of awareness by the consumer on the differences among the different types of cosmetic surgeons. To understand the first issue, consumers must be educated that any physician can legally market himself or herself as he or she chooses. The core of this medical marketing problem is that physicians today have pliant, arguably questionable, marketing regulations, as there are no legal impediments for how physicians market themselves. For example, I can legally name myself a “wellness doctor” or an “emergency room physician,” although I may not have training or qualifications to do so. Although such medical marketing examples are essentially nonexistent, there are many physicians who do name themselves “plastic surgeons,” irrespective of their credentials, to garner credibility as a cosmetic surgeon. The impetus for this marketing strategy stems from the general perception held by the public, who inherently believe that plastic surgery and cosmetic surgery are one and the same. Despite the fact that real board-certified plastic surgeons with specialty training are qualified and capable of performing craniofacial and hand surgery, the public tends to link plastic surgery primarily with cosmetic surgery. It is far more likely that the image of a plastic surgeon conjures up thoughts of breast augmentation and gluteal lifts rather than revascularization efforts and soft-tissue coverage. Therefore, by marketing oneself as a plastic surgeon, a physician can potentially attract cosmetic surgery patients. However, this ambiguity ultimately affects the patient’s ability to select a “real” cosmetic surgeon while “knowing all the facts.” WHO IS A BOARD-CERTIFIED PLASTIC SURGEON? To understand the second part of this debate, we need to provide more discernible definitions between the credentials that constitute a board-certified plastic surgeon and a cosmetic surgeon. Plastic surgeons are board certified in plastic surgery by the American Board of Plastic Surgery, which is recognized by the American Board of Medical Specialties.11 Two approved residency models, the independent and integrated pathways, exist for plastic surgery training. Common to both is the prerequisite training demonstrating acquisition of “basic surgical science knowledge and experience with basic principles of surgery” and requisite training demonstrating “plastic surgery principles and practice, which includes advanced knowledge in specific plastic surgery techniques.”11 In the independent pathway, residents finish the prerequisite training outside of the plastic surgery training program. This enables residents who meet the American Board of Plastic Surgery’s prerequisite requirements and complete formal training in one of the American Board of Medical Specialties–recognized surgical specialties (i.e., general surgery, neurologic surgery, oral and maxillofacial surgery, orthopedic surgery, otolaryngology, thoracic surgery, or urology) to become plastic surgeons by means of the independent pathway. To be eligible for the American Board of Plastic Surgery certification, the training in plastic surgery must occur at a U.S. program approved by the Residency Review Committee for Plastic Surgery and accredited by the Accreditation Council for Graduate Medical Education; for Canadian plastic surgery trainees, these residency programs must be approved by the Royal College of Physicians and Surgeons of Canada. In addition, the trainee must complete a significant set number of operations in various disciplines, including cosmetic, craniofacial, and hand surgery and microsurgery to graduate these approved programs. Only then can a graduated plastic surgery candidate sit for the written examination administered by the American Board of Plastic Surgery. If the individual can pass the written examination, the candidate can be eligible for the oral examination administered by the American Board of Plastic Surgery. Both the Residency Review Committee for Plastic Surgery and the American Board of Plastic Surgery take rigorous steps to ensure that trainees who take and pass these oral and written examinations can safely perform aesthetic, plastic, and reconstructive surgery. If the trainee can pass the oral examination and fulfill the aforementioned criteria, the candidate will be recognized by the American Board of Plastic Surgery and the American Board of Medical Specialties as a board-certified plastic surgeon. WHO IS A COSMETIC SURGEON? The American Board of Cosmetic Surgery grants a certification to those physicians who complete at minimum a 1-year program in cosmetic surgery and pass a written and oral examination provided by the American Board of Cosmetic Surgery. The American Board of Cosmetic Surgery allows applications from physicians who have completed their residency in dermatology, general surgery, obstetrics and gynecology, ophthalmology, plastic surgery, or oral surgery to enter a program accredited by the American Board of Cosmetic Surgery. If the individual fulfills the program and passes these examinations, the trainee is recognized by the American Board of Cosmetic Surgery as a board-certified cosmetic surgeon. It should be noted that the American Board of Medical Specialties does not recognize the designation of a board-certified cosmetic surgeon. The standards of “board-certification” granted by bodies that are not recognized by the American Board of Medical Specialties remain unclear. HOW DOES THE PUBLIC PERCEIVE WHO CAN PERFORM COSMETIC SURGERY? A recent study has illustrated the confusion among the lay population with regard to who they believe can (and cannot) perform aesthetic surgery.12 Over 5000 people were surveyed for their opinions on providers who perform aesthetic surgery and the training received to claim expertise. Only 13 percent of persons surveyed realized that there are no legal requirements for a provider to have adequate training or credentials to perform aesthetic surgery. The remaining 4900 people either did not know, or believed that the system would prevent providers from performing surgery that they are not trained to perform. Furthermore, 61 percent of people surveyed either believed that board certification in plastic surgery is a legal requisite to perform aesthetic surgery, or did not know. Many of the respondents believed that there are legal protections that would prevent exposure to medical complications associated with uninformed choices—unfortunately, this is not true. Only 10 percent of those surveyed stated that board certification was unimportant, provided that the surgeon had a good reputation; 90 percent of respondents believed board certification to be important and necessary. These data then demonstrate how a board may use patients’ desire to ensure their provider is “board certified”—the patients hear this phrase, and its inherent legitimacy provides them with a sense of comfort in their choice of surgeon. Another area of confusion is determining who has the qualifications and training to perform cosmetic medicine, which encompasses minimally and noninvasive techniques such as soft-tissue fillers, lasers, botulinum toxin type A, and others. How do we spread the word about who is truly qualified to perform cosmetic medicine? The American Society for Aesthetic Plastic Surgery, the American Academy of Facial Plastic and Reconstructive Surgery, the American Society for Dermatologic Surgery, and the American Society of Ophthalmic Plastic and Reconstructive Surgery have forged the Physicians Aesthetic Coalition13 to “advance and promote patient safety and both public and physician education in the fields of cosmetic medicine and aesthetic surgery” through heightened collaborative efforts among its members. Through joint meetings among these societies, Physicians Aesthetic Coalition members can educate each other on cosmetic techniques and technology in an effort to deliver safe and successful cosmetic medicine to patients. Returning to the principal-agent problem, practitioners must remain the “perfect” agent by acting in the best interest of their patients. Plastic surgeons, often regarded as experts in cosmetic surgery, must assist patients in identifying an appropriately trained cosmetic surgeon. To be sure, there are surgeons trained outside of plastic surgery who perform aesthetic surgery routinely and safely. The key is to help the public develop ways to identify which aesthetic surgeons can deliver safe and successful results. Because everyone appears “famous” on their Web site, and the Internet advertising has the potential to be misleading, we provide the following suggestions to patients looking to improve their appearance in an effort to make the buyer beware: Ensure the surgeon or physician is board certified in a specialty recognized by the American Board of Medical Specialties: a. http://www.abms.org/member-boards/specialty-subspecialty-certificates/. Ensure that the physician is part of the Physicians Aesthetic Coalition, particularly when pursuing cosmetic medicine options such as fillers and neuromodulators. The consumer should ask about the “3 E’s”: experience, expertise, and exceptional results: a. Experience: How long has the provider been performing the procedure? How many times per week does the provider perform this procedure? b. Expertise: Does the provider teach other medical professionals this procedure through publications in peer-reviewed journals or lecturing at meetings recognized by the American Board of Medical Specialties? c. Exceptional results: Can the provider show the patient a series of the procedure with preprocedural and postprocedural results including photographs? What are the risks and down time for this procedure? What does the provider do if the procedure does not go correctly? Ensure that the physician/surgeon has hospital privileges: a. If the operation is being performed at an outpatient facility, ensure that the facility is an accredited ambulatory facility. Ask who administers the anesthesia: a. This provider must be a medical doctor or certified registered nurse anesthetist. For the first 24 postoperative hours, find out whether a nursing facility is available. Seek a second opinion that includes a board-certified plastic surgeon. Do not rely solely on the Internet or media for information: a. Ask family, friends, physicians, and former patients for opinions. Patients who pursue cosmetic surgery must do their homework by researching their procedure well in advance of undertaking it and by asking questions to assess whether the medical professional can deliver a safe and successful outcome. A true specialist in cosmetic medicine or surgery will demonstrate expertise through his or her American Board of Medical Specialties–recognized training or certification, peer-reviewed journal articles, and preprocedural and postprocedural results. By educating our patients and adhering to safe medical practice, we as medical practitioners can adhere to lessons learned in the first days of medical school—primum non nocere (first, do no harm).

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