COVER: The 'doctor' will see you now...

Non-plastic surgeons and non-medical practitioners alike are ramping up efforts to perform cosmetic procedures. Leaning on vague language to tout credentials and a public drawn to low prices, patient safety remains in the crosshairs.

By Paul Snyder

ASPS member Liza Wu, MD, Philadelphia, knows how easy it can be for patients to decide upon a non-plastic surgeon for a cosmetic procedure – because she knows doctors who do the same thing. She doesn’t have to look any further than her own family.

“About 10 years ago, my mother wanted a laser treatment for hyperpigmentation on her face,” she recalls. “I was home visiting and she’s telling me about how she went to a doctor to get laser work for the dark spots on her face, but it didn’t help at all.”

Puzzled, Dr. Wu asked her mother who she saw for the treatment. She casually replied that it was an OB/GYN.

“My mom’s a physician, a family practitioner,” Dr. Wu says. “I’m looking at her, saying, ‘Why would you do that?’ She just said her friend had recommended him and she trusted him. That’s it. It was just shocking to me that a doctor would do that – never mind a doctor whose daughter is a plastic surgeon – but a recommendation from a friend can be enough. They just assume the doctor knows what they’re doing.”

An ineffective treatment is one thing, but similar assumptions on the parts of patients have led to a number of complications, which often end up in the hands of plastic surgeons for revision. Yet despite the discomfort and dissatisfaction with results from the original practitioner, lessons aren’t always learned.

“We deal with it all the time,” says ASPS/ PSF Vice President of Health Policy and Advocacy Gregory Greco, DO. “The patients were treated at such-and-such place and now we have to solve the problem. What’s odd is that the patients still go back to the place – because it’s cheaper.”

The fact that non-plastic surgeons continue to perform plastic surgery procedures is neither a new nor surprising story, as several ASPS members point to the financial enticements of taking on cosmetic procedures.

Still, with the increase in weekend courses that focus on particular procedures (from fillers to fat reduction techniques to offerings such as the education program held earlier this year by general surgeons – and originally endorsed by the ACS – on oncoplastic surgery that advertised lessons on reductions and mastopexies for symmetry on the contralateral breast), the once-anecdotal mentions of dentists doing rhinoplasties, OB/GYNs doing breast surgery and dermatologists doing facelifts are growing in number. Legislative moves at state and federal levels designed to remove supervisory protections for nurse practitioners and physician assistants are steering more patients to non-plastic surgeons for cosmetic work – and despite advocacy efforts by ASPS, even the terminology surrounding “board-certified plastic surgeon” is becoming a play on words within physical and digital advertising.

This, of course, all runs parallel to the steady flow of stories about complications and deaths arising from patients who sought procedures in settings ranging from basements to apartments and fly-by-night clinics, and from individuals who have no medical credentials at all.

“We’re no longer in competition with just physicians,” Dr. Greco says. “It’s almost become an issue of physician vs. non-physician practitioner now. The pendulum has swung so far that when a complication comes in, we are almost oddly relieved with the knowledge that at least the patient was treated by a physician provider.”

Unfortunately, these providers are not always entirely truthful with their credentials, which leads to harming unsuspecting patients.

“I recently dealt with a patient who came to me for a secondary facelift revision,” says ASPS past President Jeffrey Janis, MD. “We sat down and discussed what had happened, which revealed that the doctor who performed her original procedure was an ophthalmologist. She was distraught and kicking herself – she felt duped, because more and more of these doctors are advertising themselves in such a way that would make a patient think they’re a plastic surgeon. Time and again, it’s the plastic surgeons who are called-in to get these patients out of their jams, but because of these experiences, the term ‘plastic surgeon’ gets even more and more confusing from a public perception standpoint.”

Legislative gateways

On the advocacy side, there’s rarely a shortage of legislative or regulatory movement at the state or federal level to open the doors for more plastic surgery work by non-plastic surgeons. One look at the Society’s advocacy efforts during this year alone shows efforts designed to curb scope-expansion attempts for dentists in Georgia and Maine; for nurse practitioners in Florida, Louisiana, Mississippi, Tennessee, Virginia; for optometrists in Alabama, Mississippi and Oregon; for PAs in Utah; and for naturopaths in Maryland and Oregon.

As part of the new Medicare omnibus bill proposed at the federal level, Medicare could make direct payment to PAs for professional services furnished at the start of January 2022. Medicare currently can only make payment to the PA’s employer or independent contractor, so as it stands, PAs cannot bill and be paid by the Medicare program directly for their professional services; they also do not have the option to reassign payment for their services, or to incorporate with other PAs to bill the program for PA services. The argument lodged by PAs against the current situation is that it hinders them from fully participating in emerging models of healthcare delivery, but Dr. Greco sees a consequence of allowing this expansion.

“If this goes through, it just opens things up at the state level to roll back supervisory requirements and enable scope creep,” he says.

Although ASPS has not taken a position on that provision of the omnibus bill, the Society has been keeping tabs on recent moves by PAs to increase their own scope of practice. In May, the American Association of Physician Assistants (AAPA) House of Delegates passed a resolution affirming “physician associate” as the official title for the PA profession (as opposed to the longstanding “physician assistant” title), a move ASPS opposes.

Due to the gap in training and expertise between medical doctors and ancillary providers, most states have historically required that PAs be closely supervised by physicians – including chart review, co-location of physicians wherever physician assistants practice and a limited scope for PAs. In most cases, a written collaborative agreement with a physician that can outline the procedures a PA is allowed to perform is required. Supervision is determined at the practice level in 31 states, and by the state medical board or within state law in 19 states. However, in recent years, more statehouses have taken up legislation that eases these supervisory rules and provides more independence for PAs to provide healthcare services.

The Society is reaching out to PA-related organizations, including the Physician Assistant Education Association, which represents PA educational programs; and the National Commission for Certification of Physician’s Assistants, which certifies PAs. Both groups expressed reservations about the title change and are responsible for knowing and validating exactly the appropriate role for PAs.

Word play

Again, however, PAs are just one group eager to take on the work that doesn’t have the same amount of training as a plastic surgeon. As chief of hand and upper extremity surgery at Vanderbilt University in Nashville, ASPS member Brian Drolet, MD, does not perform cosmetic procedures, but sees the greater public safety concern in expanding scope without proper training.

“I think plastic surgery has the only true claim to cosmetic surgery because we’re the only specialty that has required cosmetic surgery experience during our accredited residency training,” he says. “Our research has found that many providers doing cosmetic surgery are practicing far outside the scope of their accredited training backgrounds – like an oral surgeon performing abdominoplasty. Meanwhile, the only specialty that has any cosmetic surgery training requirement is plastic surgery. So, this comes back to the issue of public safety. People should be able to trust the brand of plastic surgery because they know we have thorough training experiences that include cosmetic surgery.

“No one should be allowed to just call themselves a plastic surgeon because they are doing ‘plastic surgery,’ ” Dr. Drolet adds. “Those people are taking our good name and credit for all the work we’ve put in to become plastic surgeons. It’s a competitive field and we need to be proactive in protecting our brand, which is earned through years and years of training.”

Although there has been and continues to be active work by the Plastic Surgery Education Campaign and ABPS to highlight the importance of finding a board-certified plastic surgeon when pursuing a procedure – not to mention notable legislative victories in states such as California where the state medical board deemed that certification from the American Board of Cosmetic Surgery (ABCS) was not equivalent to the standards of ABPS – Dr. Janis notes the years spent focused on the words “board-certified plastic surgeon” also gave the competition the ammunition needed to exploit loopholes.

“A lot of practitioners are conflating certification in cosmetic surgery with ‘board-certified plastic surgeon,’ ” he tells PSN. “Although it’s been legislated at the state level, it’s not being policed enough and there are some who would leverage that in their terminology. If they say they’re board-certified and perform plastic surgery procedures, is that lying? No. But is it entirely truthful? It’s certainly a bit disingenuous.

“People will take that and parlay it into a twist on words,” Dr. Janis adds. “You can market yourself as ‘double board-certified,’ but when you look, it might be in OB/ GYN and the American Board of Cosmetic Surgery (ABCS). For the average consumer who’s seeing all these doctors tout that they’re ‘board-certified,’ well, ‘double board-certified’ sounds even more impressive. It doesn’t matter that the certification comes from a specialty with no standardized training in cosmetic or reconstructive plastic surgery or a non-ABMS recognized program.”

Although it’s more of a mouthful, Dr. Janis suggests that education should perhaps turn to terminology that underscores the fact that ASPS members are ABPS-certified, as a way to address the vagaries around “board-certified” terminology.

ABPS Executive Director Keith Brandt, MD, says the board is aware of these concerns and continues to discuss the problem. From an enforcement perspective, however, he notes that with the exception of legislation, there isn’t a solid route to influence non-plastic surgeons on the use of the term “board-certified.”

“We are reviewing websites we know about and asking the uncertified to remove the term ‘board-certified,’ but it’s tougher with ABCS- and even ABMS-certified physicians who are certified in another specialty,” he says. “There needs to be more education so that the general public understands the difference in ABPS certification. ABPS plastic surgeons continuously verify their certification through continuous education. We stay up-to-date and learn the new issues. We continue to learn how to avoid complications. ABCS offers one exam and they’re done. Their training doesn’t even come close.”

After years of debate about whether to let members use the ABPS emblem on their websites, the board developed a specialized “board-certified” emblem that ABPS-certified plastic surgeons can use. The problem, Dr. Brandt notes, is that much like the ASPS logo that members use, these symbols that should immediately signify a standard in training and excellence are often buried at the bottom of a practice webpage or on an “about” page.

“It is interesting that, say, if you hire somebody to work on your house, you know to look for someone who is experienced and insured in that trade and to check for the credentials,” Dr. Wu says. “I think it needs to be impressed upon people that if you’re going to go search for cosmetic surgery or any kind of procedure, that the person you’re going to is board-certified in that particular area – and not just someone who is a doctor or a self-proclaimed expert.”

While such measures aren’t enforced, the deceit continues. Dr. Janis notes that while driving to a Michigan Academy of Plastic Surgeons meeting earlier this summer, he saw several billboards touting procedures such as fat treatment and various fillers performed by a particular “board-certified” doctor.

“Turns out it was a board-certified OB/ GYN,” Dr. Janis says. “It incensed me, especially as this is quite confusing to the public.”

From an advocacy standpoint, Dr. Greco says he would like to see the push continue for full-training disclosure – even though he concedes it’s something that likely will never materialize.

“The more information we can get legally disclosed about truth in medical expertise and training will help the consumer,” Dr. Greco says. “Because even when you look at plastic surgery, it at times seems like a very steep uphill battle. Social media is potentially delegitimizing the art and science of the profession and purely morphing it into medical entertainment. People are looking at someone’s number of followers and falsely equating that to competency – even though there’s absolutely no correlation.”

Despite the ever-present existence of scope battles, Dr. Drolet says pushing for better truth in advertising is preferable to trying to limit scope of practice.

“Most doctors, deep down inside, don’t want scope of practice too narrow,” he says. “Because if I’m qualified to do nerve surgery by whatever standards you’re looking at, but somebody says, ‘Oh, you didn’t do a neurosurgery residency – you shouldn’t be allowed to do nerve surgery,’ well, that’s a big part of my practice as plastic surgeon and now I’m being restricted from doing something that I should otherwise be able to do. But I do think that people who aren’t plastic surgeons advertising that they are plastic surgeons is where a line gets crossed.”

Despite the frustration inherent in treating patients who suffered complications as a result of non-practitioners or as a result of traveling for lower-cost surgery, Dr. Wu also says it’s incumbent upon plastic surgeons to continue to fix the work that others could not perform.

“I know there are many of us who defer seeing these patients to other surgical services when they show up in the emergency department,” she says. “It’s one thing if the patient is in extremis, but if its a patient who has a complication from a tummy tuck like a seroma or a mild infection, it’s easy to say, ‘I don’t own this complication,’ and point out that the people who aren’t board-certified plastic surgeons aren’t trained to deal with these issues.

“But you can’t let the patient suffer for it,” Dr. Wu adds. “It’s our duty to take care of them. Should there be repercussions for the person that did the original procedure? Yes. But we have a responsibility to help when and where we can.”