The new cosmetic surgery guidelines for doctors are welcome, but only tackle half the problem, writes Professor Merrilyn Walton.
The dangers associated with cosmetic surgery, detailed in a report by the Health Care Complaints Commission in 1999, are well known and still present. The new cosmetic guidelines for doctors, published this week by the Medical Board of Australia, are welcome, but tackle only half the problem.
The guidelines for registered medical practitioners who perform cosmetic medical and surgical procedures cover all phases from patient assessment through to aftercare. They will be a valuable tool for cosmetic surgeons. But two areas of public concern – the use of the title cosmetic surgeon and the facility in which the surgery is performed – remain untouched.
Who is a cosmetic surgeon?
The public can be forgiven for thinking a person who calls themselves a cosmetic surgeon has surgical qualifications. But this is not the case. Any registered medical practitioner can use the title, even those without any specialist training.
The 1999 cosmetic surgery report recommended any medical practitioner performing invasive cosmetic surgical procedures should have adequate surgical training equivalent to that required for fellows of the Royal Australasian College of Surgeons.
It is unthinkable today that any registered doctor could start performing non-cosmetic surgical operations without qualifications from an accredited training body. But this remains permissible for surgery that is “cosmetic”, although cosmetic surgery is as complicated and risky as other forms of surgery.
The guidelines tackle this problem by recommending procedures should be provided only if the medical practitioner has the appropriate training, expertise and experience to perform the procedure and to deal with all routine aspects of care and any likely complications.
This guideline is steering doctors towards having appropriate qualifications and training. However, it stops short of mandating a minimum qualification. The decision as to the level of expertise or experience is left to the doctor.
The effect of not requiring a minimum surgical qualification or accreditation is that when doctors provide surgery without the required knowledge, expertise and experience, it will primarily leave patients responsible for bringing them to the medical board’s attention using the complaint system.
We know qualified surgeons also harm patients and generate complaints. But the fact that the public, in the case of qualified surgeons, can trust the level of training and supervision involved is some reassurance a minimum level of skill has been obtained.
The guidelines would have had more force, and offer more protection to the public, if the requirement was for any person who performs major cosmetic medical or surgical procedures to have a minimum qualification of general surgery awarded by an accredited training body.
Where is cosmetic surgery performed?
Doctors performing cosmetic surgery such as breast augmentations in their rooms, outside of a licensed hospital or day surgery centre, are prohibited from administering a general anaesthetic. They may only use conscious sedation – where medications to help patients relax and to block pain during a medical procedure are given. The patient stays awake but can’t usually speak.
This is because the real risks associated with general anaesthesia and unconscious patients require a properly equipped theatre and trained staff.
Cosmetic surgeons have been able to bypass this requirement and perform surgical procedures in unlicensed facilities because they use local anaesthetic agents and sedatives. Risks such as seizures, cardiac arrest and rapid heartbeat are associated with overdosing of local anaesthetic agents and sedatives.
Patients need to be still during any procedure. So, if a patient is moving about or agitated, additional local anaesthetic may be administered. But this could lead to an overdose, which is potentially fatal. Local anaesthetic overdose is a preventable adverse event, which can be avoided if the surgery is in a licensed facility with the equipment to manage an emergency.
Since March 2015, the Health Care Complaints Commission has identified 33 patients who had breast augmentation surgery where the level of sedation was of concern. Six had an adverse event associated with sedative drug combinations consistent with deep sedation – some even at the level of general anaesthesia.
The new guidelines require doctors to perform surgery in a facility that is appropriate for the level of risk involved in the procedure. Facilities should be appropriately staffed and equipped to manage possible complications and emergencies. The judgement as to risk and equipment is left to the doctor to decide.
Cosmetic surgeons have a significant conflict of interest – putting patient interest ahead of profits. The guidelines make clear cosmetic surgeons must place the safety of their patients first. But the Medical Board of Australia has no jurisdiction over facilities and cannot mandate the level of facility for major cosmetic medical and surgical procedures. Only the state and territory governments can do this.
The new guidelines present for the first time an opportunity to bring the cosmetic “industry” back into medicine – where ethical obligations to patients override profits. This is an important first step, but it cannot be the last.