By Jan Bowers, contributing writer, July 02, 2012
When USA Today published two articles replete with horror stories about office-based cosmetic surgical procedures gone wrong (“Lack of training can be deadly in cosmetic surgery,” Sept. 13, 2011 and “Cosmetic surgery gets cheaper, faster, scarier,” Sept. 14, 2011), it reignited controversies that have simmered for years. The articles and accompanying online videos raised questions about who is qualified to perform such procedures and highlighted some of the “disastrous results” for which some “non-plastic surgeons” were disciplined. One of the sidebar articles, advising patients about what to ask when choosing a plastic or cosmetic surgeon, stated that “the American Board of Plastic Surgery is the only cosmetic surgery board recognized by the American Board of Medical Specialties.” A third article [“Non-surgical cosmetic options also have risks,” Sept. 14, 2011], did quote a dermatologist about the importance of choosing an expert for non-invasive cosmetic procedures. However, dermatologists who read the articles were concerned that they did not mention that dermatologists undergo extensive training in office-based surgical procedures, or that dermatologists pioneered the safest form of liposuction.
The Academy, together with the American Society for Dermatologic Surgery Association, responded immediately with a letter to the editor of USA Today emphasizing dermatologists’ qualifications to perform office-based procedures; it shared this letter, information about the unique training and skills of dermatologists, and a video, “Who should be providing your cosmetic treatment?” with the public via Facebook, Twitter, the AAD website, and the Academy’s public e-newsletter. The Academy also added material specifically addressing cosmetic procedures and patient safety to its online Media Relations Toolkit. Looking to the longer term, last fall the AAD Board of Directors also created the Ad Hoc Task Force on Office-Based Surgery to confront the range of issues, encompassing both public perception and regulatory policy, created by the burgeoning demand for cosmetic surgery.[pagebreak]
“As demand increases, more and more providers are looking to meet it,” said C. William Hanke, MD, MPH, clinical professor at Indiana University School of Medicine and chair of the new task force. “As a result, cosmetic medical procedures and surgeries are being offered in non-traditional settings, such as medical spa facilities, and by providers with limited to no formal training or education in this area of medicine, and patients are being harmed.” However, overreaction by state legislators can backfire, he warned. “When state regulators and state policymakers read stories like the USA Today articles, they are led to believe that this area of medicine is highly unregulated or the wild, wild west,’” Dr. Hanke asserted. “This leads to uninformed policymaking and attempts to restrict the performance of certain procedures to certain types of facilities, or place onerous requirements on qualified and appropriate providers which are not supported by research and have little impact on patient safety.”
While specialists with expertise and training in cosmetic surgery need to advocate for patient safety, Dr. Hanke said, “the American Society of Plastic Surgeons has responded with strong statements that board-certified plastic surgeons are the only appropriate providers of cosmetic procedures and surgery, and threaten patients that seeing another type of provider will result in injury or even death Nothing could be further from the truth.”
Exemplary safety record
Fortunately, dermatologists can point to evidence that supports their claim to unparalleled expertise in the medical and surgical care of skin. Published results from investigations conducted by dermatologists during the past decade confirm that in the realm of office-based surgery, the specialty has a record of safety and experience unsurpassed by any other. The research also sheds light on other issues regarding physician qualifications, credentials, and hospital privileges.
Brett M. Coldiron, MD, clinical associate professor of dermatology at the University of Cincinnati and founder of the Skin Cancer Center in Cincinnati, who was recently elected as the Academy’s 2013 president-elect, first published an analysis of in-office adverse event data from the state of Florida in 2002. Ten years later, he was able to combine six years of data from Alabama with 10 years from Florida. With co-authors John Starling III, MD, and Maya K. Thosani, MD, he published his latest analysis in Dermatologic Surgery (2012;38(2):171-7). The study is a compilation of mandatory reporting of office surgical complications by physicians to a central agency. Reports resulting in death or a hospital transfer were further investigated over the telephone or online to determine the reporting physician’s board certification status, hospital privilege status, and office accreditation status. Among the key findings:
- Of 309 reported incidents in Florida between March 2000 and January 2010, cosmetic procedures accounted for 56.5 percent of deaths and 49.8 percent of hospital transfers. In Alabama, cosmetic procedures accounted for no deaths and 42 percent of all 52 reported incidents between December 2003 and December 2009.
- The overwhelming majority of cosmetic cases in Florida resulting in death (67 percent) or hospital transfer (79 percent) were performed under general anesthesia.
- In Florida, liposuction resulted in 28 percent of all cosmetic complications and 32 percent of cosmetic deaths. All but five cases of liposuction were performed under general anesthesia. In Alabama, liposuction performed under general anesthesia was responsible for two hospital transfers. There were no reports arising from liposuction performed under dilute local (tumescent) anesthesia.
- Dermatologists were responsible for 1.3 percent of the reported complications in Florida and 1.9 percent in Alabama. Plastic surgeons were responsible for 44.9 percent in Florida and 42.3 percent in Alabama.
- All reporting physicians in Alabama and 93 percent of those in Florida were board certified in their respective specialties.
The authors’ results indicate that “medically necessary surgery does not represent an emergent hazard to patients,” said Dr. Starling, who completed a Mohs fellowship with Dr. Coldiron and now practices in Oshkosh, Wis. “Medically necessary surgical procedures performed in the office setting by dermatologists have an exceedingly low complication rate, and cosmetic procedures performed in offices by dermatologists under local and dilute local anesthesia yielded no reported complications.” Dr. Starling further noted that according to his data, board certification, office accreditation, and hospital privileges “have had little impact on overall office safety and may restrict patient access for medically necessary procedures performed in the office.”[pagebreak]
What does seem to have an impact is experience, according to another prominent dermatologist who set out to demonstrate dermatologists’ extensive experience in performing cutaneous surgery. Steven R. Feldman, MD, PhD, professor of dermatology, pathology, and public health sciences at Wake Forest University School of Medicine, was part of a group that analyzed Medicare claims data from 1998 and 1999 to determine the numbers of cutaneous surgery procedures performed by physicians in different specialties. Their results, reported in the Journal of the American Academy of Dermatology (2005; 52(6):1045-8) established that of 2.67 million procedures reported, dermatologists performed 54 percent, plastic surgeons 15 percent, general surgeons 8 percent, and all others 23 percent. Another study, co-authored by Dr. Feldman and published in Dermatologic Surgery (2008;34(1):1-7), examined data from the National Ambulatory Medical Care Survey to estimate the number of visits for office-based cosmetic procedures from 1995 to 2003 by specialty and type of procedures. Dermatologists were found to have performed 48 percent of all cosmetic procedures, followed by plastic surgeons at 38 percent; no other specialty accounted for more than 5 percent. The study was not limited to surgical procedures; the two most common procedures reported were chemical peels and soft tissue fillers.
“On average, among the things that dermatologists do, dermatologists tend to have the most experience, and level of experience tends to result in better outcome,” Dr. Feldman said. He noted that specialists who don’t cultivate relationships with other specialists tend to develop negative impressions of those outside their specialty. “But when you have first-hand working relationships, you know that the other people are good people,” he added. “The bottom line is that all physicians are deeply committed to giving patients great medical care. Anybody who says, you ought to see my specialty and not another specialty,’ is misguided.”[pagebreak]
Armed with the facts, dermatologists can be powerful advocates for themselves and their specialty at the local level. Patricia Farris, MD, clinical associate professor of dermatology at Tulane University School of Medicine, provides media training to Academy members in sold-out sessions at the annual and summer Academy meetings. “We let them pick their subjects [for mock on-camera interviews], and most people want to talk about cosmetic procedures because that’s what they’re being interviewed about,” Dr. Farris said. “We try to prepare them for questions like, Well, shouldn’t a plastic surgeon do that?’ The kinds of hard-hitting questions they may be asked as a result of [other specialties’] PR campaigns and the USA Today articles an interviewer might see.”
In an interview situation, dermatologists should quickly establish their expertise, Dr. Farris said. “I tell them to emphasize the training they received in their residency programs; we’re trained in surgery and cosmetics. We’re not only educators and practitioners, but also innovators: dermatologists developed a number of cosmetic devices and procedures.” Zoe Diana Draelos, MD, consulting professor of dermatology at Duke University and chair of the Academy’s Council on Communications, said a key point for dermatologists to make is that tumescent liposuction was invented by dermatologists. “We pioneered the anesthesia technique, we developed all the cannulas and the pumps,” she said. “Surgeons then adopted the procedures validated by dermatologists. We are the experts at taking care of skin, hair, and nails.”
In addition to responding to interview requests, dermatologists can be proactive in building public recognition for their expertise in cosmetic surgery, Dr. Farris pointed out. “In smaller markets, it’s easy to get media exposure. Health reporters are always looking for new and exciting stories,” she said. “If you have learned a new procedure or have a new device, you can pitch that story. And the more information and prep work you do for them, the more likely they are to come back. Not only do I offer to perform the procedure on camera using one of my own patients but I will often provide them with relevant scientific information that can be used for writing the segment.” Dermatologists contacted for media interviews who would like help or background to provide to reporters can contact the Academy’s Communications Department for more information at email@example.com.
The same messages — training, experience, and expertise — can effectively reassure patients. Her patients trust her expertise with the procedures she offers, and rarely ask whether they should see a plastic surgeon for a particular cosmetic or medical procedure, Dr. Farris said. But when they do, “I have no trouble referring. I want the patient to be comfortable,” she said. “We also have patients who go to plastic surgeons for fillers, and if the plastic surgeon doesn’t feel competent, he sends them back to us. We have relationships that go both ways.” Dr. Draelos concurred, adding that “part of the job of your dermatologist is to get you the best care possible. And it’s not possible for every doctor to be good at everything.”
The real threat to patients lies with cosmetic procedures that are performed by physicians who have little or no training in cosmetic procedures, Dr. Farris said. “The turf war that we need to fight is with those physicians who are totally unqualified, totally untrained in cosmetics, who are just tired of practicing whatever medical specialty they’re trained in,” she insisted. “The plastic surgeons are under the same assault we are. We need to stand united with them and with oculoplastic surgeons, and the ENTs who do facial plastic surgery, and say, we are the cosmetic specialists.’”[pagebreak]
Task force initiatives
The Ad Hoc Task Force on Office-Based Surgery, together with other Academy groups, is tackling key issues on several fronts. In the public relations arena, the task force has created an Office-Based Surgery Communications Workgroup to develop documents that will guide Academy efforts to educate the public about dermatologists’ training and experience in surgery and the history of dermatologic surgery. The communications materials will also support the AADA’s advocacy efforts with state policymakers.
At the state level, the Academy is striving for a balance between over-regulation and protecting the public from unqualified providers of office-based surgery. “We cannot advocate for more regulation of other providers without being willing to adhere to the same policies ourselves,” Dr. Hanke said. “But facilities such as medical spas, which are offering more and more complex procedures and veering into surgery, are highly unregulated, with limited physician oversight and no training requirements for non-physician personnel. A key policy initiative of the Academy and other organizations, like the American Society for Dermatologic Surgery Association, is to work with states to statutorily recognize the performance of cosmetic medical procedures as the practice of medicine and surgery.” The Academy has developed standards of practice for medical spa facilities addressing qualifications for medical spa directors and supervising physicians, training requirements for all personnel performing cosmetic medical procedures, requirements for supervision by a qualified physician, and state oversight.
To help members achieve the highest standards of patient safety in their own offices, the Academy is in the process of building additional resources, including an office-based surgery standards guidebook and an office patient safety checklist. The Academy is also preparing a guideline on office-based anesthesia, scheduled for publication next year. Operating on the premise that one should “change before you have to,” the task force is proactively addressing patient safety, Dr. Hanke said. “We should develop voluntary programs for AAD members to document that their offices are safe places to deliver care,” he noted. “Further, we should advocate for our offices as the most cost-effective facility of choice for most procedures that maximize patient safety by using local anesthesia.”