13th Nov 2015
This month, there has been a focus on a cosmetic surgery practice, with reports that ambulances are being called to a popular Sydney breast implant clinic to rush young patients to hospital emergency departments.
What is a cosmetic surgeon? What is a plastic surgeon? Do they differ? If you were considering a breast augmentation or were unhappy about the shape of your nose, who would you want to advise you and potentially operate on you?
Unknown to most, there is a significant difference between cosmetic and plastic surgeons. The Australian College of Plastic Surgeons warns against ‘unregulated office-based cosmetic surgery and anaesthetic use’.
Health practitioners in Australia are regulated by the Australian Health Practitioner Regulation Agency (AHRPA). Each health profession that is part of the National Registration and Accreditation Scheme is represented by a National Board. There are 14 National Boards, one of which is the Australian Medical Council, which represents medical practitioners, and also oversees doctor training in hospitals and universities.
The titles of medical specialties are highly regulated by the Australian Medical Council, and it is not permissible for doctors to title themselves as medical specialists in a particular field, if they do not hold appropriate qualifications.
The Medical Board of Australia does not recognise ‘cosmetic surgery’ as a specialty practice of surgery. Fields of speciality practice within surgery that are recognised include plastic surgery, oral and maxillofacial surgery, general surgery, orthopaedic surgery, among others. ‘Cosmetic surgery’ is not included.
The title ‘cosmetic surgeon’ therefore is not indicative of certain qualifications, such as would be expected of a ‘plastic surgeon’. It is important to note that a Bachelor of Medicine/Bachelor of Surgery is the general qualification of a General Practitioner, and does not qualify someone to practice in plastic surgery. The Australian Society of Plastic Surgeons notes that: ‘currently in Australia, it is legal for any doctor with a basic medical degree to perform surgery. Specialist Plastic Surgeons, on the other hand, have extensive surgical education and training including a minimum of 12 years medical and surgical education, with at least 5 years of specialist postgraduate training.’
However, it appears that someone with the same qualifications as a General Practitioner can call themselves a ‘cosmetic surgeon’, potentially after doing a short course. The Australasian College of Cosmetic Surgery offers training with diplomas available in cosmetic medicine, cosmetic nursing and cosmetic injectables, as well as registrar programs. However, despite submissions by the Australasian College of Cosmetic Surgery to the Australian Medical Council to be recognised as a specialty, this has been refused and the Australian Medical Council does not recognise ‘cosmetic surgeons’ as a medical speciality or accreditation.
By contrast, plastic surgery includes both cosmetic surgery and reconstructive surgery. Plastic surgery has its origins in the treatment of burns injuries. The author has witnessed the horror of these dreadful injuries and subsequent disfigurement. Plastic surgeons have had an important role in the management of burns injuries. However, while some plastic surgeons still treat burns patients, a significant number only work in the domain of aesthetics. To understand various variations and definitions, it is helpful to talk about aesthetic surgery.
Aesthetics is about appearance; many plastic surgeons predominantly perform aesthetic surgery. This may include rhinoplasty (nose jobs), breast augmentation or reduction, face-lifts, liposuction and more. These plastic surgeons often have glossy websites showing beautiful young women with ‘ideal’ bodies.
This further adds to the confusion around surgery that is being performed for an aesthetic purpose. To the layperson, surgery performed for an aesthetic purpose may be understood as ‘cosmetic surgery’, and therefore a ‘cosmetic surgeon’ is the best qualified to undertake it. However, this is not the case.
The President of the Australian Society of Plastic Surgeons, Associate Professor Bartholomeusz, has said that:
‘[W]e can only reiterate that cosmetic surgery is not trivial surgery. Anaesthesia and surgery carries risks and it is vitally important that all surgeries, including all cosmetic procedures, are carried out, not just by appropriately qualified surgeons, but also in properly accredited facilities with an anaesthetist present.’
An internet search might reveal a woman can have a breast augmentation costing between $3,900 and $5,500 performed by a cosmetic surgeon. A plastic surgeon might charge $10,000 for the same surgery. For the most part, patients cannot claim Medicare rebates on this type of surgery. The decision for an individual may be financially straightforward. Unfortunately, the patient has no idea what is behind the difference in cost.
One submission to the Medical Board of Australia’s recent consultation on cosmetic surgery asserted (at 7) that:
‘[I]n our opinion, patients rely on the belief that the industry is properly regulated when they make decisions about which service they choose on the basis of price. Furthermore, advertising regulations for the medical workforce, make it difficult to advertise on the basis of suggesting to the client that one medical practice has better professional standards than another.’
Aesthetic surgery is based on a fantasy. The woman usually has a vision of what she will look like following the surgery. However, she may be disappointed with the outcome. This disappointment is possibly behind the statistical fact that plastic surgeons are amongst the most litigated doctors.* There are no statistics on cosmetic surgeons, but it might be hypothesised that their litigation rates are higher.
The author is aware of a cosmetic surgeon who has come to the attention of the Medical Board on many occasions. She had restrictions put on her medical practice for some time, but after the period of the restrictions expired, there was no evidence of her having been previously disciplined.
Despite the lack of ongoing information about the safety of a doctor’s practice, it is worthwhile for prospective patients to refer to the Australian Health Practitioner Regulation Agency which is the register of all health practitioners in Australia.
For usually three years, AHPRA will show if there is an outstanding notification that a health practitioner (including doctors, nurses, physiotherapists and other clinicians) has been the subject of complaint or concern by patients. After three years, these notifications are removed. No record is publicly available of these previous notifications, which raises concerns regarding how an individual may make an informed choice in selecting a medical practitioner.
In September 2015, the Medical Board of Australia published 489 submissions provided to a consultation on cosmetic medical and surgical procedures provided by medical practitioners. A wide range of views were represented in the consultation.
One anonymous submission argued that:
‘The culture in this industry and amongst its practitioners is often one of lax standards. The drug companies seem to care very little about the regulations regarding supply of the drug to registered practitioners. They also train practitioners (such as nurses) to perform injections but provide them with little to no training in respect to the extent of the risks and the constraints of their legal and professional scopes of practice. Little mention is made in the training about the need to be properly supervised by a qualified doctor.
Many practitioners order nurses to administer Schedule 4 poisons and surgical implants without proper assessments, whilst being fully aware that these procedures are going to be carried out in unsupported and ill-equipped locations, most often in parlors owned and run by beauty therapists or hair salons. Increasing numbers of non-medical commercial entities and chains are now also entering this field of practice as it is seen as lucrative and unregulated. These beauty therapists, entities and chains employ like-minded nurses and doctors.
Keeping up with the legal and professional regulations in this field with proper staffing, training, facilities, equipment and medical care, comes with significant commercial costs. In our observation, many practitioners exhibit an intentional disregard of the legal rules and regulations that apply in this field, choosing instead to favour commercial interests, whilst openly labelling AHPRA as a 'toothless tiger' which is unlikely to 'do anything to enforce breaches in the industry'.
A Decision Regulation Impact Statement (RIS) is now being prepared which will be considered by the Office of Best Practice Regulation (OBPR). When the OBPR confirms the RIS is compliant, the Board will decide what if any regulatory action is needed to protect patients who seek cosmetic medical and surgical procedures performed by medical practitioners.
The outcome to be decided could be significant in terms of its impacts on individuals seeking elective and cosmetic surgical procedures, and how informed they are as consumers of their choice.
It is recommended that any individual considering surgery of an aesthetic nature:
Consider the difference between plastic and cosmetic surgeryCheck that the health practitioner from whom they are seeking treatment is registered, as required by law, with AHRPA, and seek if any restrictions are placed upon their practice.
* Bismark NM, et al., Identification of doctors at risk of recurrent complaints: a national study of healthcare complaints in Australia, Quality and Safety in Health Care 2013; 10:1-9.
Ngaire Watson practices as a barrister in Sydney and specialises in medical negligence. Prior to being admitted to the Bar, Ngaire had over 20 years experience in nursing, providing a unique insight into the cases that she takes on. She tweets at @RN_Barrister.
The views and opinions expressed in these articles are the authors' and do not necessarily represent the views and opinions of the Australian Lawyers Alliance (ALA).