With the current wave of “Alice in Wonderland” mania, a recent email from a friend reminded me of a scene in that classic book. In that scene, Alice is talking to the caterpillar and he keeps asking her, “who are you?” This reminder, in my mind, led to my impressions of a current phenomenon I’ve been seeing and reading about lately regarding the business of plastic surgery. It occurred to me that it seemed apropos to ask any doctor, offering plastic surgery, that very same question. This is because the answer to that question can be very vague.
There is a disturbing trend in medicine where internists, family doctors, gynecologists and other specialists are offering to do plastic surgery procedures as a way of making a little cash, “on the side.” Dermatologists and E.N.T. (ear, nose & throat) doctors are expanding into areas where they have little or no training. Because of this, complications are escalating like never before.
I know someone who went in for a yearly checkup and found her internists now owned a roomful of lasers next-door and was promoting their use. The largest liposuction clinic in my community is run by an internists and an emergency room doctor. Family practice doctors are opening, “med spas.” Some E.N.T. doctors are beginning to perform breast augmentation surgery and gynecologists are doing face-lifts. What’s going on?
A recent article in Plastic and Reconstructive Surgery by Matthew Camp, titled Who is Providing Aesthetic Surgery? A detailed examination of the geographic distribution and training backgrounds of cosmetic practitioners in Southern California put some insight into this question.
So what is going on?
Medicine is hard-pressed for fair reimbursement by health insurance companies. Despite any statements to the contrary, it is likely going to get worse in the future. More and more doctors will be attempting to supplement their income by offering plastic surgery procedures in which they have little or no training.
Plastic surgery is literally the only cash business left in medicine, especially if you include hair transplants, laser hair removal, varicose veins, and all noninvasive treatments under that umbrella.
Individual magazines devoted to different specialties routinely promote, “boosting your income by adding cosmetic services.” Medical meetings also promote one-day workshops in different procedures and technologies.
Makers of cosmetic products and devices are actively promoting their goods to non-plastic surgeons as a way of expanding their markets. Moreover, those that are not intentionally marketing to these doctors are none-the-less bound by law to sell to these doctors if the doctor orders from them. This is because in California, a medical doctor has a license that entitles him or her to do anything they see medically fit in the office. He can do brain surgery, heart surgery, or sex changes. If something goes wrong, let the lawyers sort it out after the fact. There is no restraint of trade for physicians. Hospitals monitor doctors and only allow them to have privileges for those procedures in which they have actual training and/or certification. This is why most of these practitioners who are expanding their offerings work only in their offices where they are completely unsupervised and unregulated.
The economic situation that is leading gynecologists to start offering facelifts is also placing very young plastic surgeons, just out of school, in a difficult situation. Therefore, they are vulnerable to being scooped up by franchise corporations that have catchy names and usually offer one specialty procedure at what they suggest is a discount price that an established and experienced plastic surgeon cannot compete with. The reality is that in most cases they are at or very near regular market prices for these procedures. These “McFacelift” shops or “LipoKing” franchises perform procedures with pressure on the doctors and staff to do as many per day and as fast as they possibly can. To quote from the Camp article, “the development of aesthetic practices with individual providers are considered to be interchangeable and replaceable is becoming ever more prominent.” This is particularly the case among the “medispas.” The practices are often named after a geographic location with the cachet of affluence such as Rodeo Drive, Beverly Hills or La Jolla. In these practices, or perhaps better described as “mills,” the practitioners are employees of the corporate owner of the clinical facility and are pushed to produce revenue. The divorce of the practice from the name of a responsible physician has the potential to have a profound impact on the doctor-patient relationship and how patients select a provider.
Therefore, as the Romans said, “caveat emptor;” Let the buyer beware. This is especially true in California since there is essentially no enforcement by the medical board, which has recently been stripped of most of its funding. Many complaints and many bodies must pile up before anything will be done. Any doctor can do virtually anything in his office and will not be stopped until there are large numbers of complaints or he kills or maims a patient. It is amazing that we require such tight restrictions on many other fields such as airline pilots. What is happening is the equivalent of allowing someone who knows how to fly a single engine plane to go ahead and sit at the controls of 747, bringing it down for a landing into a major metropolitan area without any training. Do you want the professional airline pilot with a complete education or someone who had a one-day course in the 747 before he takes your life into his hands? On the flip side, I am a trained plastic surgeon who has had thousands of hours of training and experience in plastic surgery but I have also had some training in many other aspects of medicine. Legally, I can perform brain surgery and heart transplants in my own operating room, but would I be your best choice if you needed these procedures? What if I were to offer to do the surgery at a discount? …Yeah, I didn’t think so.
If you’re considering a plastic surgeon, do what the caterpillar did. Ask, “who are you?” “Are you board-certified?” “Are you board-certified in plastic surgery?” “How many of these procedures have you done?” “How long have you been providing this procedure?” “Do you have hospital privileges? Or is plastic surgery just another way to boost your income.” Or, “are you a cosmetic surgeon” which is essentially a meaningless term since there is no recognized Board of cosmetic surgery.
Caveat emptor. Do your homework and trust your gut feelings. If you feel unsure or apprehensive, regardless of whom the person is, move on. Plastic surgery is not like having your hair done. Some people spend more time researching a vacation then researching a plastic surgeon, don’t be one of them.