By Randi A. Galli, M.D., F.A.C.S.
The recent death of Dr. Donda West, 58, mother of recording artist Kanye West, in November 2007, one day after having breast reduction and abdominoplasty (tummy-tuck) procedures, has produced a greater focus on, and concern for potential risks associated with cosmetic procedures. How could this tragedy have possibly been avoided?
In a survey conducted by Harris Interactive in January 2007, 37% of cosmetic surgery patients in the United States responded that they did not verify if the American Board of Plastic Surgery certified their surgeon before undergoing a procedure. 54% of patients did not check if their surgeon had completed an accredited residency-training program in plastic surgery. 40% of patients believe that they should have been more proactive in learning about potential complications and side effects prior to plastic surgery. Every year patients who have had surgery and subsequent mishaps from undergoing ‘cosmetic surgery’ contact me for help. They often had surgery performed out of town, such as in Mexico, where a discount was offered, or by a local physician who had not gone through the rigorous training as required by the American Board of Plastic Surgery.
One case involved a patient who came to me for a consultation regarding an abdominoplasty (tummy-tuck). Unfortunately, she opted for surgery in the Los Angeles area in a non-accredited surgery center where procedures were performed that were outside of the ‘informed consent’ (see box on pg 29) and left her with a severe abdominal infection. In the ensuing several years, more than five operative procedures were performed on her to remove infected deep sutures from her abdominal wall and to attempt to improve severe scarring and disfigurement. Some patients even experience disfigurement that is beyond reconstruction. This is a tragic situation that can be avoided if the patient is better informed prior to surgery.
This takes us to a more serious problem. On a daily basis, the average patient seeking out medical advice and expertise for plastic surgery is bombarded with information from the radio, television, the newspaper, and magazines. In more recent years there has been a significant increase in non-plastic surgeons who are performing cosmetic procedures. They range from anesthesiologists to OB-GYN’s. While many of these medical specialists have taken the time to become very well trained in their respective area of expertise, others who venture outside their specific specialty area of training have not been properly trained or credentialed in plastic surgery. This all-important point is often bypassed by the ambiguous use, or lack thereof, of the word ‘board certified’ and by clever marketing. In the process, the general public has become so incredibly confused that a prospective patient is often unsure of who is qualified to carry out the desired procedure.
In the past, the State of California mandated that a board certified physician can reference in an advertisment only the board certification asociated with the American Board of Medical Specialties. Recently, the State of California voted to allow the American Board of Facial Plastic and Reconstructive Surgery, along with three other boards, to be used in advertisment even though they are not recognized by The American Board of Medical Specialies. This took place after significant lobbying and will continue to serve to confuse the consumer. It is important to understand the basis for board certification and who grants a board certification. The gold standard in our country resides with the American Board of Medical Specialties. They oversee 24 member boards, which include areas of specialty with which we are all familiar, such as the American Board of Pediatrics, American Board of Internal Medicine, the American Board of Orthopedic Surgery, the American Board of Emergency Medicine, as well as other member boards. This includes the American Board of Plastic Surgery. It does not include the “American Board of Cosmetic Surgery.” It is important to realize that medical specialty certification in our country is a voluntary process. The American Board of Medical Specialties has an excellent website (www.abms.org) that includes a very easy to understand explanation about board certification.
You will find that when a medical student graduates from medical school they become a physician or doctor of medicine. This does not imply any particular medical expertise. In order to gain medical expertise, a medical student applies for residency prior to medical school graduation. A certified residency is one that has been accredited by the Accreditation Council for Graduate Medical Education. Only after completion of the specific requirements of a residency is a physician then able to "sit" for the board examination process. For the 24 specialty member boards of the American Board of Medical Specialties, an application must be submitted to the specialty board, followed by a written board examination. After a lengthy written examination has been passed and after a specified amount of hours in the practice of the specialty have been performed, the physician may then apply to "sit" for the oral examination process. In the case of the American Board of Plastic Surgery, this is one of the most rigorous processes of all the member boards belonging to the American Board of Medical Specialties.
Presently the American Board of Plastic Surgery requires that a physician complete at least 5 years of residency, usually including at least 3 years of general surgery and at least 2 years of plastic surgery training. After completing the written board certification examination and having practiced for a period of approximately 2 years, the oral board certification process begins. One must submit a 6-month log of all procedures performed, both in hospital facilities and outpatient surgery centers. The American Board of Plastic Surgery then selects specific cases for which the applicant physician must submit a complete record of the surgical care of the patient. This would include all of the dictated and handwritten notes before and after surgery, the operative notes, before and after pictures, as well as any discussion regarding any potential complications from the operative procedure. Only after review of the submitted documents is the applicant then able to proceed on with the two full days of oral examination.
One full day of oral examination involves discussing methods of treatment in front of a number of board certified plastic surgeons, covering a multitude of various cases, varying from complex reconstructive procedures to cosmetic procedures. The second day of the oral examination involves a review of the select cases that the physician was required to submit, including notarized billing records. There was a case in which a fellow resident was dismissed on the second day of board certification examination for 'un-bundling,' or in other words, for charging the insurance company for more procedures than were performed. The physician was sent home and was given the opportunity to resubmit the entire process all over again after two years had passed. The board is extremely thorough and does not allow a physician to pass through the board certification with fancy talk and an important appearance.
Why does one have to apply to the American Board of Plastic Surgery for board certification? Why not to the “American Board of Cosmetic Surgery,” or to the “American Board of Liposuction” or to any other board that utilizes some plastic surgery-like name? Because California State Law prevents one from using the terms “board certification” and “plastic surgery” when one is not board certified by the American Board of Plastic Surgery. However, a common mistake made by the consumer is to ask a physician if they are "board certified." The physician may answer "yes" without giving further information, namely that their board certification does not reside with the American Board of Plastic Surgery.
This is where it is up to the patient to do their homework and investigate the background training of the physician with whom they are consulting. Even if your surgery is to be performed in a doctor’s own surgery suite or outpatient facility, he or she should have the same privileges at the excellent accredited hospitals in our community. For example, if one is having a face-lift procedure performed in an outpatient setting, one should ask their physician if they have the same privileges to perform that surgery at Saint Agnes Medical Center. Or, if one is undergoing a breast augmentation, does the physician have the same privilege to perform that surgery at Clovis Community Hospital or Fresno Community Hospital?
Just as the American Board of Medical Specialties thoroughly investigates the physicians who are applying for board certification, their background, their level of medical training and eventually their knowledge in their respective areas, our local hospitals are also very thorough in performing background evaluations of a physician applying for hospital privileges. When a doctor applies for hospital privileges, they fill out a very detailed checklist of the privileges they desire. They are then reviewed by their peers who are members of the credentialing committee and surgery executive committee. Additionally, one has to be monitored by a peer within the specialty of plastic surgery in our community for a specified number of operative cases before final hospital privileges are granted.
It is imperative that the consumer contact one of our accredited local hospitals to check on the privileges of a physician who is about to perform plastic surgery or a cosmetic procedure. This is important because many physicians have operating rooms in their own offices or are affiliated with outpatient surgery centers. Not all outpatient surgery centers in Fresno restrict physicians from performing surgeries outside the scope of their board certification. In these outpatient environments, safety can be compromised due to the lack of appropriate peer review. It is this peer review process by our local hospitals, as well as the very strict board certification process by the member boards of the American Board of Medical Specialties, that helps prevent a minority of unqualified doctors from taking advantage of patients or performing bizarre procedures.
It is prudent that your surgeon have hospital privileges in the region where surgery is performed so that in a rare case of complication requiring hospital treatment, they will be able to provide the care that you need. In rare situations, complications can arise that require a patient to be transferred to a hospital. The physician performing the surgery should have the same privileges at the local hospital in order to properly admit the patient to the hospital for the necessary additional care and monitoring.
Before leaving this issue of board certification, there should be a discussion regarding the confusion raised by names of other boards not recognized by the American Board of Medical Specialties, yet whose names seem to convey or imply expertise in plastic surgery. For example, the “American Board of Facial Plastic and Reconstruction Surgery” specifically states on their website that “the board is neither an educational institution nor a licensing body, and the certificates they issue are neither degrees nor legal licenses to practice medicine or the specialty of facial plastic and reconstructive surgery. Possession of a board certificate indicates neither total qualification for practice privileges nor exclusion of others not so certified.” One has to almost be a physician to be able to differentiate between these confusing board names, such as the “American Board of Facial Plastic and Reconstructive Surgery” and the “American Board of Cosmetic Surgery.” Suffice it to say that neither is recognized by the American Board of Medical Specialties and neither has residencies certified by the Accreditation Council for Graduate Medical Education. Log on to the American Board of Medical Specialties website to gain further insight to the importance of this main certifying body overseeing the 24 principal medical boards in our country.
The next area of common confusion is that of professional societies. It should be understood that physicians can belong to any number of professional societies, some of which are more meaningful than others. Once again, one can tout membership in all sorts of local, state and national societies, some with fancy names or difficult to understand medical terms. The American Society of Plastic Surgeons is the largest society or organization representing plastic surgeons in the United States. Its members are required to perform ongoing continuing medical education that is scrutinized by the society. Their members must adhere to a very high and strict ethical standard and must be board certified by the American Board of Plastic Surgery. Locally, the Fresno-Madera Medical Society is actively involved in promoting the medical needs of not only our local community, but the state as well.
There are numerous other societies that have a specific focus, which is different than the American Society of Plastic Surgeons. Societies often fulfill the need for ongoing medical education, which is required by the State of California on a yearly basis. A certain number of continuing medical education hours must be completed by each physician over a period of three years and is randomly evaluated by the California Medical Board, which requires proof of compliance. In the selection of your plastic surgeon, it is encouraged that you do your homework. It is appropriate to obtain references from close associates and friends who have undergone previous plastic surgery procedures.
After selecting 2 or 3 plastic surgeons, it is a good idea to obtain a consultation. At that point, you are usually able to make a decision. In the consultation process, do not be afraid to ask tough questions. Does your plastic surgeon seem to be concerned regarding your entire medical history? Prior to any operative procedure, have a very thorough discussion with your plastic surgeon regarding the risks and benefits of the surgery, and the specific issues, such as the length of time required for healing and the expected outcome of the surgery. Obtaining an ‘informed consent’ (see opposite page) is extremely important prior to undergoing any plastic surgery procedure. It is an opportunity for you and your plastic surgeon to thoroughly discuss the planned procedure in detail. If the surgery is to be performed in an outpatient surgery center, is the surgery center California State certified and Medicare certified?
As stated by Richard D'Amico, M.D., a member of the board of directors of the American Society of Plastic Surgeons, "It is one thing to have training, but it is another to have your competency tested. This is why board certification by the American Board of Plastic Surgery is so crucial. As a patient, you should ask yourself, why wouldn’t this surgeon be board certified in plastic surgery?" As a physician, the scrutiny by our peers in the board certification process, as well as in the local accredited hospitals, is very important in assuring that safe care is rendered to a patient.
FOR MORE INFO:
American Board of Medical Specialties
American Society of Plastic Surgeons
Medical Board of California
American Board of Plastic Surgery