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Six key areas that need to be tightened to improve patient safety in cosmetic surgery

Posted on Friday, 10 November 2017

Australasian Society of Aesthetic Plastic Surgeons Key priority areas to improve patient safety in cosmetic surgery

Members of the Australasian Society of Aesthetic Plastic Surgeons (ASAPS) believe there are six key areas that need to be tightened to improve patient safety in cosmetic surgery:

  1. Eliminating confusion created by the title ‘Cosmetic Surgeon

A growing number of medical practitioners without training in plastic and reconstructive surgery are performing surgery to improve the patient’s appearance.  Because it is an unregulated area, pursuing these patients can be on the basis of low cost and a reliance on volume and at the expense of patient safety and outcomes.  Recent media reports document the considerable morbidity when detailing accounts that range from breaches in safety and hygiene protocols, disfiguring results to actual patient mortality.

The problem with the term ‘Cosmetic Surgeon’ is that it doesn’t mean anything.  Cosmetic Surgery isn’t a separately recognised specialty by the AMC, the AHPRA or Medicare Australia and the title is not protected.  Consequently there is no benchmark for those who can use the term cosmetic surgeon, hence, it has become the working title for someone just out of medical school who wants to go into practicing cosmetic surgery.

a. Consistent use of nomenclature that correctly defines and reflects AMC accredited standards of training and AHPRA registrable qualifications and experience

Specialist Plastic Surgeon is a protected title only available to FRACS accredited surgeons.  There are other professions entitled to legitimately use the term surgeon that do not overlap this discussion.  Veterinary Surgeon, Podiatry Surgeon, Dental Surgeon and Oral Surgeon are examples and some are protected titles just as Specialist Plastic Surgeon is.  What binds us all together is that this title requires the completion of AMC recognised accredited training and then appropriate AHPRA registration in line with these titles (or equivalent in the case of Veterinary Surgeons).

While Dental Surgeons and Veterinary Surgeons may not require a postgraduate degree, their undergraduate degrees train them specifically for these roles.  Oral surgeons in particular require a rigorous Postgraduate Fellowship equivalent to obtaining Fellowship with the Royal Australian College of Surgeons (RACS) in other surgical disciplines.

A basic medical degree provides a framework of general knowledge that can then be honed into specific areas with additional appropriate postgraduate training co-ordinated by Colleges accredited by the AMC: GP, physician, pathologist, radiologist, anaesthetist and surgeon are all examples.

A Specialist Plastic Surgeon has a minimum of 12 years of postgraduate medical and surgical education, with at least five years of focused specialist postgraduate training approved by the AMC. The five year training is comprised of over 10,000 hours of training.

Distinctly different to this, it is possible for anyone with no additional surgical training or experience after obtaining a basic medical degree to call themselves a ‘Cosmetic Surgeon’.  As it is not a recognised specialty, there is no requirement for AMC accredited training and therefore no Specialist Registration with AHPRA. The term is misleading and therefore unsafe.

b. Restrictions on medical marketing to increase transparency regarding the practitioner’s expertise and training

The titles ‘Surgeon’, ‘Surgery’, ‘Plastic’ and ‘Cosmetic’ are currently misunderstood by the public and murky guidelines and enforcement make this even more difficult for patients.

As outlined above, surgeons who have achieved a Fellowship with the RACS, have undergone a further 10-12 years of specialist surgical training beyond their medical degree.  FRACS includes people who are Neurosurgeons, Cardiothoracic Surgeons, Orthopaedic Surgeons as well as Plastic Surgeons.

In the eyes of the consumer, a ‘Surgeon’ has an assumed level of training and experience that a lot of the time goes unquestioned however, there are discernible differences between the credentials that constitute a Specialist Plastic Surgeon and a Cosmetic Surgeon.

Because of the lack of transparency in our medical marketing system, patients cannot ascertain the differences between their potential providers.  With the current system, medical practitioners can capitalise on confusing jargon to convince patients that they are appropriately qualified to perform the procedures they advertise their expertise in.  This lack of transparency may lead a patient to make a decision they would not have otherwise made if provided a clearer picture.

Whilst AHPRA’s guidelines clearly stipulate how medical practitioners should advertise themselves the lack of enforcement and the slap on the wrists punishment is not enough to dissuade those who are practicing well outside their scope of practice.

In our interpretation of the Guidelines, it’s essentially a breach for anyone to be advertising themselves as a ‘Cosmetic Surgeon’ as this is not a recognised title.  It should then be a mandate by AHPRA and enforced by AHPRA that doctors should also only be able to advertise according to their AHPRA registrable qualifications.

Also, under section 7.3 Use of titles in advertising the guidelines stipulate the use of a protected title is an offence under the National Law.

Should the title ‘Surgeon’ be protected for use exclusively by appropriately qualified practitioners where there is appropriate AMC accredited training and AMC registrable titles?

The waters have become so muddy that it’s nearly impossible for patients to clearly and simply identify the qualifications of medical practitioners offering cosmetic services.  ASAPS members believe this would be simplified for patients if medical practitioners could only advertise according to their AHPRA registrable qualifications.  This then provides a clear benchmark for the patients to jump off from in their decision making process.

We feel that it is vital that advertising regulations limit practitioners to the use of consistent nomenclature which in both reality and in perception correctly defines and reflects AMC accredited standards of training, qualifications and experience as well as a practitioners AHPRA registration.

Specifically, the term ‘Cosmetic surgeon’ requires significant restriction or better yet, removal from use as the term ‘Surgeon’ implies accredited training and appropriate registration, which isn’t necessarily the case.

 

  1. Standardising minimum qualification requirements for cosmetic procedures and appropriate scope of practice

Currently in Australia there are no legal requirements for a medical practitioner to have adequate training or credentials to perform surgery to improve one’s appearance.  Many patients do not realise this.  A Cosmetic Surgeon could have attended a weekend course hearing about how breast augmentations are done by a presenter and then on the Monday he or she is legally able to pick up a scalpel and perform this procedure on an unassuming patient.

We would argue that many, if not most, Australians are under the belief that there would be legal protections in Australia that would prevent exposure to this type or unethical behaviour —unfortunately, this is not true.

We would hazard a guess that the vast majority of patients would be uncomfortable with medical physicians with training in dermatology, obstetrics and gynaecology, general surgery, or family practice performing surgery to improve their appearance.

Our members hear time and time again when they are seeing patients who succumb to the sales pitch of a Cosmetic Surgeon that they believed was appropriately trained and credentialed because they used the title ‘Surgeon’, because they were wearing a white coat, because they had nursing staff.  These assumptions are potentially life-threatening and these patients, more often than not, need revisions by a highly qualified Plastic Surgeon, sometimes at the cost of the public health system.  However, had the right person who was adequately trained carried out the procedure in the first place, the whole situation could easily be mitigated.

The lack of standardisation for minimum training level places patients at high risk for making uninformed decisions and potential harm.  ASAPS members believe the minimum requirement for cosmetic surgery to ensure patient safety should be the surgical training provided by the RACS.

While there are a number of specialties operating within this arena, it is equally important that the scope of practice is consistent with training. As an example an Ophthalmic Surgeon might perform blepharoplasty and an ENT Surgeon, rhinoplasty.  It is however appropriate that the training and scope of practice are aligned.

 

  1. Greater regulation of facilities, the requirements around the administration of anaesthesia and clarity regarding which procedures must be performed in licensed facilities offering Level 3 Surgical Services, or Level 3—Perioperative—Day Surgery Services.

There have been increasing reports of serious patient harm associated with procedures performed in an ‘office setting’, where either intravenous sedation and/or large and potentially toxic doses of local anaesthesia have been administered.

The joint Day Surgery Position Paper defines day-stay procedures and outlines the minimum standards upon which national, state and territory regulations for day surgery facilities should be based.  It has been prepared as a collaboration between the RACS, Australia and New Zealand College of Anaesthetists (ANZCA) and the Australian Society of Plastic Surgeons (ASPS).  The Standards have been prepared to assist in the preparation of the licensure (licencing and accreditation) regulations in each Australian jurisdiction to ensure that an organisation or individual working in those jurisdictions meets minimum standards in order to appropriately protect public health and safety.

An area of particular concern for ASAPS members in relation to patient safety is the use of twilight sedation for invasive procedures such as breast augmentations so that the procedure can be performed at a less regulated facility at a lower cost.

The lure of cut price procedures can be tempting for people whose main decision driver is cost.  But that the discounted rate comes from a shaving of key components such as being fully anaesthetised and supervised by a Specialist Anaesthetist.

A Specialist Anaesthetist is a fully qualified medical doctor who, after obtaining their medical degree, has spent at least two years working in the hospital system before completing a further five years of training in anaesthesia.  In fact, their training is as long as that of a surgeon.  Anaesthetists play a pivotal role in resuscitating acutely unwell patients, including trauma victims, and help to manage patients suffering from acute or chronic pain.

ASAPS endorses the Joint Day Surgery Position Paper believing this draws a clear line in the sand of who can administer and where the administration of anaesthetic can take place in the hope of increasing patient safety.

 

  1. Who is accredited to train surgeons?

There are those who will publicly state that Plastic Surgeons perform Reconstructive Surgery and that Cosmetic Surgeons perform and train others to perform Cosmetic Surgery.  This argument makes a good sound bite, has been around for a while but just doesn’t stack up.

Cosmetic Surgery isn’t recognised as a unique surgical specialty and despite attempts at AMC Accreditation by others, only the RACS exists as a trainer of Cosmetic Surgery which is within the curriculum of Plastic and Reconstructive Surgery.  This exists, is accredited and is registrable as a Specialist Plastic Surgeon.

So under what authority do these groups train surgeons?  Who recognises their diplomas and Fellowships?  They have misled, misinformed and deceived the public.

 

  1. Tightening of rules around Schedule 4 Drugs prescribing via Skype

Whilst well intended, the regulation pertaining to the prescribing of Schedule 4 Drugs via Skype has been exploited by beauty salons and other unscrupulous practitioners who are using the loophole to provide an inferior standard of care to patients who never see a medical practitioner face to face.

The regulatory language governing the delegation of health care services to nurses varies greatly from state to state in Australia.  In some states, the supervising medical practitioner must be continuously available in person or by electronic communications and other states require the presence of the medical practitioner in the same location (e.g. on-site and immediately available).

States are also silent on the term “medical director” and do not regulate the amount of time that a medical director must be present in a facility.  It is not uncommon for a medical director to work between several busy practices and never actually see patients face to face.

There has been a real de-medicalization of the non-surgical space with varied non-clinical settings no offering injectables and/or fillers.  These include shopping malls (excluding medical practices in or attached to retail outlets), private homes, office parties, and group social gatherings.  ASAPS members believe these non-clinical settings are inappropriate and would like to see a tightening of the rules around the prescribing rules of Schedule 4 Drugs.

 

  1. Enforcement of existing and new regulations

What may be surprising to some is that many of these guidelines already exist within the Registration Standards for AHPRA.  Unfortunately there is no enforcement.  Whatever is achieved from these COAG discussions, the present system of well-meaning but underpowered regulations of the cosmetic surgery and medical industry amount to nothing for those willing to flout the regulations to their own gain.  Unfortunately there are bad apples in every barrel and they need to be held accountable.

 

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