Some people may already be aware, following on from a spate of media coverage over the last few weeks, that from July this year there will be a range of new regulations that will apply to cosmetic surgery patients. Unfortunately, there is still some uncertainty about this and perhaps more importantly, if these regulations are enforced as currently indicated, they will offer no greater protection to our patients. In some ways, it will be quite the opposite. There are many issues with cosmetic surgery (its provision and its regulation), but I think that one of the fundamental drivers has been the collective action (or lack thereof) of Plastic Surgeons and our representative societies.
It seems to me that Plastic Surgery is caught in the midst of an existential crisis. The unfolding issues around cosmetic surgery and its safe provision are revealing a long-standing, thorny dilemma at the heart of our specialty, and I wonder whether plastic surgeons have the moral conviction to reclaim the inherent value in what we do.
The dilemma can be succinctly described by the tendency of many plastic surgeons to express a certain disdain for cosmetic surgery whilst furiously grubbing around for every bit of cosmetic work they can find. This is nowhere more evident than in our training, where a registrar expressing interest in the cosmetic arena is dismissed, reprimanded, and put firmly back in his or her box. Quite the dilemma, given that a group of unqualified doctors are now questioning our expertise in cosmetic surgery, based in no small part on the above attitudes. Having demonstrated both intellectual and moral vacancy with regards cosmetic surgery, we are now witnessing the consequences as plastic surgeons try so desperately to reclaim some authority over the field against unqualified cosmetic practitioners, AHPRA and the medical boards.
I worry greatly that the reticence in confronting head-on the corruption of the cosmetic surgery industry is a blight on the intellectual and ethical rigor of plastic surgery as a whole. Our main representative society, the Australian Society of Plastic Surgeons (ASPS) is front and centre in this failure unfortunately.
I don’t expect that the general public is aware of everything that is happening in our strange little world, but it is absolutely certain that the events I refer to will have ramifications for our patients. So, here is a little bit of background, to fill you in.
Over the last few years (and to be fair, it has been going on now for probably 15-20 years but a light has more consistently been shone on this issue through 2022 with the rather dramatic downfall of Dr Daniel Lanzer) we have seen some rather interesting media reports which have highlighted the enormous risk posed to patients considering cosmetic surgery as a consequence of the total lack of regulation of the cosmetic surgery industry, and the glaring, repeated and unaddressed failures of the health regulator (AHPRA, and the medical boards) to fulfil their basic, legislated role.
We can, to some extent, plot a timeline that really picked up momentum around 2015. You may recall a number of reports in 2015/2016 about patients experiencing local anaesthetic toxicity with admission to ICU (and in one case, a patient death) following cosmetic procedures performed by unqualified doctors under local anaesthetic. We saw the catastrophe that was “The Cosmetic Institute” with the substantial class action that followed. We witnessed the hooha with Dr Les Blackstock, another unqualified doctor doing grubby surgeries in his grubby surgery, who’s peculiar schtick was to wake patients up mid-surgery to get them to look in a mirror and make a (drug influenced) decision about their preferred implant size (followed by another class action).Then last year we watched the absolute train wreck that was Daniel Lanzer and his totally unqualified associates doing truly appalling things to patients around the country (yet another class action), followed by the equally concerning revelations about the Cosmos Clinic chain (one more class action), with even more unqualified doctors causing a trail of harm and destruction.
There has followed a war of words between plastic surgeons and the “cosmetic practitioners” who hold no recognised surgical qualifications. We’ve seen ego and narcissism laid bare on the pages of our newspapers and in tit-for-tat media releases. There are lobbyists running around all over the shop campaigning for their respective employers, trying to coerce and cajole politicians and bureaucrats into various actions that will favour one group over another. And in amongst this long-running, unedifying spectacle, we’ve seen patients continuing to suffer harm, we’ve seen surgeons and other practitioners scrambling to protect their incomes, and we’ve seen the wholly unfit-for-purpose institution that is AHPRA conduct a masterclass in shifting the regulatory burden of managing this problem onto those of us who just do our best to provide high quality care to our patients, whilst they totally ignore the elephant(s) in the room.
In July 2023, a raft of changes are being introduced by the dubious bureaucrats at AHPRA (with only an ineffectual protesting squeak from the representative societies of Plastic Surgery) which are ostensibly aimed at curtailing the poor behaviour of a small number of arseholes, both those with surgical qualifications and those without. I’ll get onto this in a sec.
Somewhat contemporaneously, there has been an agreement by the state health ministers to restrict the use of the title “surgeon” exclusively to those of us with actual surgical training (and this will include opthalmologists and gynaecologists). Specifically, this will limit the ability of the fancifully named Australian College of Cosmetic Surgery and Medicine(ACCSM) to claim that all of its members (a curious hodgepodge of failed surgical trainees who couldn’t get on to or through real surgical training, ambitious medical graduates looking for a shortcut, and axe-grinders holding a grudge against “the establishment”) are surgeons. What they’ll be reduced to calling themselves I have no idea.
The utterly baffling thing that will go hand in hand with this (entirely appropriate) titling restriction is the decision by AHPRA to provide what is termed an “endorsement” in Cosmetic Surgery to “suitable applicants” (whatever the hell that means) so that any doctor, including the above mentioned non-surgeons can apply for and receive this endorsement, which will then be visible on the public register of medical professionals (and given equal weight to specialist registration it seems). The claimed intention of this "endorsement" is to ensure that patients know who is trained to perform Cosmetic Surgery, despite there being no attempt from AHPRA or the medical boards to prevent untrained individuals from performing invasive cosmetic procedures. This is a truly spectacular state of double-think given the titling restrictions that are soon to come into place, which will prevent non-surgeons from calling themselves surgeons because they’re not. Congratulations if you can follow the logic.
Which brings us to the massive own-goal which AHPRA is about to perform from July 2023 onwards. The regulatory changes being introduced will include:
- The endorsement (which I have mentioned above) of unqualified doctors according to some as yet unknown set of rules which will continue to allow these doctors to perform cosmetic procedures and harm patients without limitation
- A mandate that ALL cosmetic patients must have a referral from their GP, ostensibly so their GP (who knows nothing about the procedure in question) can discuss with the patient their motivations, and supposedly assess the suitability of a referral, without the necessary skills or knowledge to do either. This will simply create a burden on already stretched GPs, most of whom will now be charging substantial gaps to patients, to allow a patient to then see a plastic surgeon who is the best person to assess suitability in the first place.
Oh, and of course, now that every cosmetic consultation will require a referral, that also means that technically every cosmetic consultation could receive a Medicare rebate (depending on the exact content of the discussion that takes place). It seems perverse, and perhaps unintended, that the tax payer could now be forced to partially fund some cosmetic consultations (performed by specialists) by virtue of this ridiculous intervention by the regulator.
- A mandate that ALL cosmetic patients will be subjected to a screening assessment for Body Dysmorphic Disorder regardless of the necessity. This will require that patients subject themselves to what may well feel like an insulting process of questioning in inappropriate circumstances. The VAST majority of patients seeking cosmetic procedures are NOT mentally unwell, and nor should they be treated as such. It is inherent in any cosmetic consultation by a competent plastic surgeon that the risk of issues like BDD is considered, but that does not mean that all patients should be put through this process.
- Further restrictions/requirements on the use of social media, some of which are appropriate (for example, surgeons can no longer post single images of patients in swimwear or lingerie as “proof” of their post-operative results), but many of which are absurd. I have a long record of advocating for the use of standardised high quality before and after images as a means of education, and I consider the sexualised, disingenuous nature of many plastic surgeons' posts to be an issue requiring substantial review. However I consider the additional changes (which will require every post to have some kind of disclaimer, as well as listing the surgeon’s qualifications, medical registration and “endorsements") to be utterly ridiculous.
These changes speak to AHPRA’s desperation to be seen to do something at a time when they are entirely guilty of having done nothing for many years. This regulatory over-reach is intrusive and interferes with the doctor-patient relationship in a way that no other specialty will have to tolerate.
There are additional requirements being formally regulated to stipulate that surgeons must consent patients themselves for cosmetic procedures (of course they should), and more than one consultation is required (of course it is). And finally, AHPRA have offered a little more clarity to the fact that the use of testimonials is inappropriate and surgeons must immediately modify their past advertising indiscretions (again, of course they should).
Perhaps one of the issues that is currently in play is generational change amongst plastic surgeons. For many years, plastic surgeons have operated in a cosmetic surgery environment that is totally unregulated. That has been singularly responsible for the rise of unqualified “cosmetic practitioners”, however it has disproportionately benefited a group of plastic surgeons (we can euphemistically refer to them perhaps as “senior surgeons”) who have grown fat reaping the rewards of operating within that unregulated environment. For many years, many of those same surgeons have resisted calls within the plastic surgery community to act, to be proactive in ensuring that patients are protected, and to ensure that plastic surgeons can preserve their intellectual and moral integrity. But of course, without motivation, they have failed to act whilst at the wheel of our representative bodies.
It is only now that they perceive a growing threat to their lucrative practices, not from the cosmetic practitioners they deride, but from the regulator whose over-reaction will surely impact on them. And it is only now that they will choose to respond, albeit with predictable fury devoid of a moral compass.
These “senior” plastic surgeons are now declaring that, amongst other grievances with the new regulations, they shouldn’t be expected to a)see patients more than once, b) consent patients themselves, or c) alter their social media and online behaviour. In amongst the rather puerile woe-is-us content of their complaints with the regulator (and with the professional societies no longer under their control), is the sheer audacity of a group of multi-millionaires crying poor over the impact of the (admittedly largely ridiculous) changes that AHPRA is bringing to bear.
And herein lies the bloody problem. There are abundant grounds for us to be concerned at the ineptitude of the regulator. But when the loudest voices protesting are a bunch of middle-aged, wealthy (mostly) men moaning about consenting a patient or the cost of this regulatory burden…it is very hard for Plastic Surgery to be taken seriously.
My own society, the Australian Society of Plastic Surgeons (ASPS) seems utterly plagued by a lack of philosophical and practical direction for our specialty within its leadership, and indeed its membership. The intellectual vacancy sign has been flashing for some time. Who are we and what do we stand for?
This is a situation exploited without repercussion by pretend “colleges” like ACCSM – if plastic surgeons have deserted the intellectual and ideological playing field, entities like ACCSM can occupy that space without contest – and we are seeing it in the media, and in practice.
As they say, the standard you walk past is the standard you accept. Plastic Surgeons haven't so much been walking, as sprinting past the issues in cosmetic surgery for many years. ASPS may finally be grinding into action on this issue, but I think it is all too little, too late.
Regulation for its own sake serves no purpose. This should never have been about regulation, it should always have been about standards of care and patient safety. Unfortunately, safety is not the focus of these new regulations. Patients will continue to be at risk of harm by unsafe, untrained "cosmetic doctors" who, from July 2023, may be working with the blessing of the regulator, despite all that has come before.
We shall make further updates to the website as we gain clarity on the what and how of these new regulations. Please get in touch if you have any questions.