Special Topic Clinicians Performing Cosmetic Surgery in the Community: A Nationwide Analysis of Physician Certification Jason S. Barr, M.D. Sammy Sinno, M.D. Marcus Cimino, B.S. Pierre B. Saadeh, M.D. New York, N.Y.
Background: Practitioners who are not board-certified by the American Board of Plastic Surgery are practicing cosmetic surgery. The extent of this issue across the United States has yet to be examined in detail. Methods: A systematic search using Google was performed to evaluate the qualifications of clinicians marketing themselves as plastic surgeons. For every U.S. state, the following searches were performed: [state] plastic surgery, [state] cosmetic surgery, and [state] aesthetic surgery. The first 50 Web sites returned for each search were visited and scrutinized using the American Society of Plastic Surgeons and American Board of Plastic Surgery Web sites. Results: In total, 7500 Web sites were visited, yielding 2396 board-certified plastic surgeons (77.9 percent of all practitioners). There were 284 boardcertified ear, nose, and throat surgeons, 61 (21.5 percent) of whom practice outside their scope; 106 board-certified general surgeons, 100 (94.3 percent) of whom practice outside their scope; 104 board-certified oral and maxillofacial surgery surgeons, 68 (65.4 percent) of whom practice outside their scope; 70 board-certified ophthalmologists/oculoplastic surgeons, 49 (70 percent) of whom practice outside their scope; and 74 board-certified dermatologists, 36 (48.6 percent) of whom practice outside their scope. There were also 16 internal medicine doctors, 13 obstetrics and gynecology physicians, six emergency medicine physicians, three pediatricians, two urologists, two anesthesiologists, and finally one phlebotomist; all of these practitioners practice outside their scope as defined by Accreditation Council for Graduate Medical Education core competencies. Conclusions: Many clinicians performing cosmetic surgery are not boardcertified. This finding has important implications for patient safety. (Plast. Reconstr. Surg. 135: 92e, 2015.)
I
t is well known in the field of plastic surgery that practitioners who are not board-certified by the American Board of Plastic Surgery are practicing cosmetic surgery on patients throughout the United States. In recent years, the number of non–plastic surgeons performing aesthetic surgery has been increasing.1 Unfortunately, patients may not be appropriately informed of their From the Institute of Reconstructive Plastic Surgery, Department of Plastic and Reconstructive Surgery, New York University Medical Center. Received for publication May 6, 2014; accepted June 12, 2014. Presented at the 93rd Annual Meeting of the American Association of Plastic Surgeons, in Miami, Florida, April 5 through 8, 2014. Copyright © 2014 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000000774
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surgeon’s qualifications.2 The extent to which this phenomenon is occurring across all 50 United States has yet to be examined in detail. In this study, through a systematic search using the most commonly used Internet search engine, Google (Google, Inc., Mountain View, Calif.), we aimed to evaluate the qualifications of clinicians who are marketing themselves as plastic surgeons. In addition, we strove to assess which of these practitioners is practicing outside of his or her scope of practice. This is the first study to examine and scrutinize the qualifications of surgeons marketing themselves on the Internet as plastic surgeons in the United States. Disclosure: The authors have no financial interest to declare in relation to the content of this article.
www.PRSJournal.com
Volume 135, Number 1 • Cosmetic Surgery Practitioners METHODS Between May and July of 2013, a systematic search using the Internet search engine Google was performed to evaluate the qualifications of providers who are marketing themselves on the Internet as plastic surgeons. For every U.S. state, three searches were performed: (1) [state] plastic surgery, (2) [state] cosmetic surgery, and (3) [state] aesthetic surgery. For each of these searches, the first 50 Web sites meeting inclusion/ exclusion criteria were visited, and the medical practitioners on those Web sites had their qualifications scrutinized and confirmed using the American Society of Plastic Surgeons and American Board of Plastic Surgery Web sites (www. plasticsurgery.org and www.abplsurg.org, respectively). Therefore, 150 Web sites were visited for each state in the country, totaling 7500 Web sites visited and examined in detail. Because of the nature of Internet searches, strict inclusion and exclusion criteria were set. Inclusion criteria included the following: (1) private solo and group practices that were offering
aesthetic surgery procedures on their Web sites (see below for definition of aesthetic surgery procedures), (2) university-associated academic medical centers, and (3) Web sites that contained the educational qualifications of the practicing providers. Exclusion criteria included all suggested Web sites and advertisements (those highlighted at the top of the search page results or along the side bars of the page), and large medical conglomerates (e.g., Kaiser Permanente). There were a total of three reviewers for every state and search query. Two reviewers visited the 7500 Web sites independently. These reviewers also independently produced raw data for total number of surgeons, board certification status, and practices that are out of scope. A third reviewer subsequently analyzed the data from each of these independent reviewers. This third reviewer scrutinized each list for inclusion and exclusion criteria, board certification status, and other factors. Any disagreements were settled in a group setting, with all three reviewers coming to a consensus. This built-in redundancy ensured agreement among all authors (Fig. 1).
Fig. 1. Flow chart demonstrating the methodology used in the study. There were a total of three reviewers for every state and search query. Two independent reviewers searched the first 50 results for each state for each of the search criteria and produced raw data for total surgeons, board certification status, and out-of-scope practice. A third reviewer subsequently analyzed the data from each of these independent reviewers. This third reviewer scrutinized each list for inclusion and exclusion criteria, board certification status, and other factors. Any disagreements were settled in a group setting, with all three reviewers coming to a consensus.
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Plastic and Reconstructive Surgery • January 2015 Physicians who appeared more than once were used only one time in the analysis. Only those Web sites offering aesthetic plastic surgery were included in the analysis. In addition, non– American Board of Plastic Surgery surgeons had their qualifications examined to determine how many surgeons practice outside their scope of practice based on educational merits. For the purposes of this study, we define elective, aesthetic surgery as including but not necessarily limited to the following procedures: abdominoplasty, blepharoplasty, augmentation mammaplasty, reduction mammaplasty, mastopexy, gluteal augmentation/lift, cosmetic labioplasty, augmentation phalloplasty, nontraumatic rhinoplasty, rhytidectomy, brow-lift procedures, brachioplasty, body lifts, liposuction, chin/cheek augmentation, chemical peels, fillers/injectables, and laser therapy. Scope of practice was determined as offering/ performing procedures outlined by the Accreditation Council for Graduate Medical Education for a respective residency or additional fellowship training in a specific area. Offering procedures outside of these areas would be defined as out of scope. For instance, ear, nose, and throat and oral and maxillofacial surgeons, irrespective of whether they completed a facial plastic surgery fellowship or cosmetic surgery fellowship (as these are not recognized by the American Board of Medical Specialties), were considered to be practicing out of scope if they were performing elective, aesthetic surgery below the clavicles. Dermatologists were considered to be practicing out of scope if they were performing elective, aesthetic surgery outside of injectables, chemical peels, laser therapy, and other similar minimally invasive procedures. General surgeons were considered to be practicing out of scope if they were performing elective, aesthetic surgery as defined above without additional training (again not including cosmetic surgery fellowships). Oculoplastic surgeons were considered to be practicing out of scope if they were performing elective, aesthetic surgery outside of the “eye-mask” distribution. Obstetrician and gynecologist physicians and urologists were considered to be practicing out of scope if they were performing elective, aesthetic surgery (aside from vaginoplasty/labioplasty, phalloplasty). Internal medicine doctors, pediatricians, internal medicine doctors, emergency medicine doctors, anesthesiologists, and phlebotomists were considered to be practicing out of scope if they were performing any elective, aesthetic surgery without additional training.
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RESULTS A total of 7500 Web sites were visited. These 7500 Web sites produced a total of 3077 unique clinicians that had their educational qualifications reviewed. As previously stated, repetitive Web sites/individuals were only counted one time in the results analysis. The number of clinicians offering plastic/cosmetic/aesthetic surgery on their respective Web sites was evaluated. These Web sites yielded 2396 plastic surgeons board-certified by the American Board of Plastic Surgery. This corresponded to 77.9 percent of total practitioners identified. Every one of these physicians had his or her professional merits verified by the American Board of Plastic Surgery and the American Society of Plastic Surgeons databases to confirm membership. In addition to board-certified plastic surgeons, there were many other types of physicians and nonphysicians offering aesthetic surgery procedures as defined above. There were 284 boardcertified ear, nose, and throat surgeons, 61 (21.5 percent) of whom practice outside their scope; 106 board-certified general surgeons, 100 (94.3 percent) of whom practice outside their scope; 104 board-certified oral and maxillofacial surgeons, 68 (65.4 percent) of whom practice outside their scope; 70 board-certified ophthalmologists/ oculoplastic surgeons, 49 (70 percent) of whom practice outside their scope; and 74 board-certified dermatologists, 36 (48.6 percent) of whom practice outside their scope. In addition, there were 16 board-certified internal medicine doctors, 13 board-certified obstetrics and gynecology physicians, six board-certified emergency medicine physicians, three board-certified pediatricians, two board-certified urologists, two board-certified anesthesiologists, and finally one phlebotomist; 100 percent of these practitioners practice outside their scope (Table 1 and Fig. 2). Interestingly, there is a geographic distribution in which some areas had a smaller proportion of practitioners performing aesthetic surgery out of scope (Northeast) and some areas with a greater proportion of practitioners performing aesthetic surgery out of scope (Southeast) (Fig. 3). Of the 3077 practitioners identified, 2236 are in solo private practices, 290 are in group practices (two or more practitioners), and 551 are at university-associated academic medical centers. Not surprisingly, plastic surgeons at group practices were all board-certified by the American Board of Plastic Surgery. There was not a single example of a board-certified plastic surgeon in
Volume 135, Number 1 • Cosmetic Surgery Practitioners Table 1. Total Number of Non–American Board of Plastic Surgery Surgeons Identified by Specialty, the Number of Those Who Are Practicing Out of Scope, and the Percentage to Which This Corresponds
Specialty Ear, nose, and throat General surgery Oral and maxillofacial surgery Dermatology Ophthalmology Internal medicine Obstetrics and gynecology Emergency medicine Pediatrics Urology Anesthesia Phlebotomy
No. % Total Practicing Practicing No. of Outside Outside Practitioners Scope Scope 284 106
61 100
21.5 94.3
104 74 70 16
68 36 49 16
65.4 48.6 70 100
13 6 3 2 2 1
13 6 3 2 2 1
100 100 100 100 100 100
group practice with non–board-certified counterparts. In addition, group practices of clinicians practicing outside their scope were all practicing out of scope. Interestingly, there were academic medical centers that had non–American Board of
Plastic Surgery surgeons performing cosmetic surgery outside of scope as defined above. That being said, the majority of those clinicians practicing out of scope were in solo group practice as above. Of those clinicians above practicing outside their scope, all offered the majority (if not all) of the aesthetic surgery procedures listed above. There were three oculoplastic surgeons and two dermatologists offering only rhytidectomy. It was surprising to find internal medicine doctors, pediatricians, emergency physicians, anesthesiologists, and even a phlebotomist performing surgery. Many of these practitioners offered all of the aesthetic surgery procedures defined above.
DISCUSSION The American Board of Plastic Surgery and the American Society of Plastic Surgeons are committed to providing patients with as much information and education as possible. On each of the societies’ Web sites, there are numerous links that strive to guide patients and professionals toward correct information. The work of these governing bodies is crucial, as various Web sites we visited in this study were glossy, elaborate, and potentially
Fig. 2. Chart showing the total number of non–American Board of Plastic Surgery surgeons identified by specialty, the number of those who are practicing out of scope, and the percentage to which this corresponds. ENT, ear, nose, and throat; OMFS, oral and maxillofacial surgery; OB-GYN, obstetrics and gynecology; ER, emergency room.
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Fig. 3. U.S. map showing a geographic distribution in which some areas had a smaller proportion of practitioners performing aesthetic surgery out of scope (Northeast) and some areas had a greater proportion of practitioners performing aesthetic surgery out of scope (Southeast).
distracting. The importance of marketing American Board of Plastic Surgery board certification in an age of Internet and mass marketing has already been established by Rohrich.3 Fifteen years later, the magnitude of the problem continues to grow. A study just published by Rufai and Davis4 used a protocol similar to ours and discovered that aesthetic surgery in the United Kingdom is “ubiquitous, unregulated and enticing,” with “low compliance to national guidelines.” Furthermore, in a response to this article, Berry5 points out the difficulties the United Kingdom faces in regulating cosmetic surgery and brings up a not uncommon case of “a so-called ‘cosmetic surgeon’, actually a general practitioner by training, who required the interventions of the [government].” In the United States we face similar challenges. It has been shown previously in the literature that the most important factor for patients in selecting an aesthetic surgeon is board certification in plastic surgery.6,7 However, as we have found in the present study, there are many practitioners providing cosmetic procedures who are not board-certified by the American Board of Plastic Surgery.8 Furthermore, in a recent study by Galanis et al., the most commonly cited factor preventing patients from pursuing plastic surgery is “fear of a poor result.”9 To curtail this concern, standardization in aesthetic surgery training is crucial.
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A 2010 study examined the backgrounds of practitioners performing aesthetic surgery in Southern California, focusing primarily on liposuction and minimally invasive injection treatments. Camp et al. found that there are 1867 practitioners providing these services in the Southern California area and that only 495 were trained in plastic surgery.1 Furthermore, they identified primary care physicians as the third largest group providing hyaluronic acid injections and the fourth largest group providing liposuction. We similarly identified a wide range of individuals with varying training backgrounds performing aesthetic surgery. In the present study, we aimed to identify clinicians practicing aesthetic surgery by means of a Google search. We sampled those clinicians who both provide aesthetic surgery and list their qualifications somewhere on their Web site. We also identified clinicians who were performing procedures outside their scope of practice. Obviously, defining a specialty’s “scope” is a controversial subject, but given our conservative definition guided by Accreditation Council for Graduate Medical Education guidelines and American Board of Medical Specialties–recognized fellowship training, we feel comfortable stating that the groups we identified as out of scope were fairly characterized. We identified ear, nose, and throat surgeons; oral and maxillofacial surgeons; dermatologists;
Volume 135, Number 1 • Cosmetic Surgery Practitioners general surgeons; internal medicine doctors; ophthalmologists; obstetrics and gynecology physicians; pediatricians; emergency medicine doctors; urologists; anesthesiologists; and a phlebotomist performing aesthetic surgery. Although some of these specialists train in various aesthetic procedures during residency (i.e., ear, nose, and throat surgeon with rhinoplasty; oculoplastic surgeon with blepharoplasty), the majority of the above do not. The question, then, is twofold: Who is qualified to perform cosmetic surgery procedures and how do we standardize cosmetic surgery training? Given the findings in this study, we feel it is imperative to standardize training in aesthetic surgery. Surgeons of differing educational backgrounds ought to be eligible to attend cosmetic/ aesthetic surgery fellowships and develop their practices as desired, within reason. However, these fellowships are currently not regulated or standardized in the same manner as Accreditation Council for Graduate Medical Education/ American Board of Medical Specialties–recognized residencies and fellowships. Aesthetic/cosmetic fellowships must become standardized with regard to training and procedural requirements. Furthermore, they must more tightly regulate who is accepted to the program, and the quality of the surgeon that is produced. Most readers would agree that internists, pediatricians, emergency physicians, anesthesiologists, and phlebotomists should not be performing cosmetic surgery. In contrast, surgeons trained in
other nonplastic specialties (i.e., ear, nose, and throat; general surgery, oral and maxillofacial surgery) certainly obtain the necessary technical skills and thought processes to safely and reliably perform cosmetic surgery. The purpose of labeling these surgeons as practicing out of scope is not to ostracize or question technical skills or training. Instead, the point is to demonstrate the unregulated manner in which cosmetic surgery is being performed across the country. We need greater oversight and transparency to improve patient safety and result reliability. Currently, the American Society of Plastic Surgeons is working to increase public education and awareness with regard to plastic surgery training and board certification. The “Do Your Homework” campaign (Fig. 4)10 is vital in this regard. Furthermore, as of June of 2014, the American Society of Plastic Surgeons is beginning a new campaign to promote member surgeons and discourage encroachment by other specialties. This will be accomplished by both television advertisements and a toll-free call center that prospective patients can contact and be directly connected to a member surgeon based on zip code and desired procedure(s). This study is the first attempt to broadly characterize the issues that the American Board of Plastic Surgery, the American Society of Plastic Surgeons, and their members face. Certainly, there are weaknesses to this analysis. First and foremost, the search results of Internet queries
Fig. 4. Screen shot from the American Society of Plastic Surgeons Web site advertising the “Do Your Homework” campaign. (From American Society of Plastic Surgeons. Find a plastic surgeon. Available at: http://www1.plasticsurgery.org/find_a_surgeon/. Accessed May 4, 2014.)
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Plastic and Reconstructive Surgery • January 2015 may not accurately represent the true proportions or practices of surgeons treating patients in the community. However, in the current global market, the Internet is the primary means by which people ascertain information. Therefore, these data assess those practitioners whom a lay community member is likely to come across when searching for an aesthetic surgeon. It must be borne in mind that each surgeon is responsible for his or her results. We recognize that board certification in plastic surgery does not necessarily equate with being a good surgeon. What it does indicate is that the surgeon has been trained, and ultimately it is the outcomes that are important. Future studies will be necessary to ascertain whether or not board certification in plastic surgery actually equates with safer surgery and/or improved patient outcomes in aesthetic surgery. A possibility would be to investigate whether non– American Board of Plastic Surgery surgeons face greater proportions of litigation compared with American Board of Plastic Surgery–certified surgeons. Our study did not address this issue, and this would be a logical next step in the progression of this research. In addition, future research may examine the impact of the mobile application industry on patient surgeon selection when looking for aesthetic surgery procedures. A simple search on the Apple App Store (Apple, Inc., Cupertino, Calif.), for example, returns over 200 applications with an interesting variety of practitioners. This may be another, albeit less common, avenue by which people are finding aesthetic surgeons. The driving undercurrent of this article is patient safety. The American Board of Plastic Surgery and the American Society of Plastic Surgeons are committed to providing patients with the most current information and the safest and most efficacious, evidence-based surgery available. To achieve this goal, we must continue to educate patients and ensure consistent and reliable results in aesthetic surgery regardless of the training background of the individual. Standardization of training in cosmetic surgery is essential.
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CONCLUSIONS There are a significant number of clinicians who are performing cosmetic surgery in the United States who are not board-certified by the American Board of Plastic Surgery. Although the majority of practitioners identified were either board-certified plastic surgeons or other surgeons, there are unfortunately many who are not. We must standardize aesthetic surgery training to ensure patient safety and deliver consistent results. Jason S. Barr, M.D. Institute of Reconstructive Plastic Surgery New York University 305 East 33rd Street New York, N.Y. 10016 [email protected]
references 1. Camp MC, Wong WW, Wong RY, Camp JS, Son AK, Gupta SC. Who is providing aesthetic surgery? A detailed examination of the geographic distribution and training backgrounds of cosmetic practitioners in Southern California. Plast Reconstr Surg. 2010;125:1257–1262. 2. Manstein CH. Preferences regarding board certification and organization relating to aesthetic surgery. Plast Reconstr Surg. 1998;101:863–864. 3. Rohrich RJ. So you are board-certified in plastic surgery: What it means in the new millennium. Plast Reconstr Surg. 2000;105:1473–1474. 4. Rufai SR, Davis CR. Aesthetic surgery and Google: Ubiquitous, unregulated and enticing websites for patients considering cosmetic surgery. J Plast Reconstr Aesthet Surg. 2014;67:640–643. 5. Berry MG. Commentary to ‘Aesthetic surgery and Google: Ubiquitous, unregulated and enticing websites for patients considering cosmetic surgery’. J Plast Reconstr Aesthet Surg. 2014;67:644–645. 6. Nowak LI, Washburn JH. Patient sources of information and decision factors in selecting cosmetic surgeons. Health Mark Q. 1998;15:45–54. 7. Waltzman JT, Scholz T, Evans GR. What patients look for when choosing a plastic surgeon: An assessment of patient preference by conjoint analysis. Ann Plast Surg. 2011;66:643–647. 8. Housman TS, Hancox JG, Mir MR, et al. What specialties perform the most common outpatient cosmetic procedures in the United States? Dermatol Surg. 2008;34:1–7; discussion 8. 9. Galanis C, Sanchez IS, Roostaeian J, Crisera C. Factors influencing patient interest in plastic surgery and the process of selecting a surgeon. Aesthet Surg J. 2013;33:585–590. 10. American Society of Plastic Surgeons. Find a plastic surgeon. Available at: http://www1.plasticsurgery.org/find_a_ surgeon/. Accessed May 4, 2014.
Background: Practitioners who are not board-certified by the American Board of Plastic Surgery are practicing cosmetic surgery. The extent of this issue across the United States has yet to be examined in detail. Methods: A systematic search using Google was performed to evaluate the qualifications of clinicians marketing themselves as plastic surgeons. For every U.S. state, the following searches were performed: [state] plastic surgery, [state] cosmetic surgery, and [state] aesthetic surgery. The first 50 Web sites returned for each search were visited and scrutinized using the American Society of Plastic Surgeons and American Board of Plastic Surgery Web sites. Results: In total, 7500 Web sites were visited, yielding 2396 board-certified plastic surgeons (77.9 percent of all practitioners). There were 284 boardcertified ear, nose, and throat surgeons, 61 (21.5 percent) of whom practice outside their scope; 106 board-certified general surgeons, 100 (94.3 percent) of whom practice outside their scope; 104 board-certified oral and maxillofacial surgery surgeons, 68 (65.4 percent) of whom practice outside their scope; 70 board-certified ophthalmologists/oculoplastic surgeons, 49 (70 percent) of whom practice outside their scope; and 74 board-certified dermatologists, 36 (48.6 percent) of whom practice outside their scope. There were also 16 internal medicine doctors, 13 obstetrics and gynecology physicians, six emergency medicine physicians, three pediatricians, two urologists, two anesthesiologists, and finally one phlebotomist; all of these practitioners practice outside their scope as defined by Accreditation Council for Graduate Medical Education core competencies. Conclusions: Many clinicians performing cosmetic surgery are not boardcertified. This finding has important implications for patient safety. (Plast. Reconstr. Surg. 135: 92e, 2015.)
I
t is well known in the field of plastic surgery that practitioners who are not board-certified by the American Board of Plastic Surgery are practicing cosmetic surgery on patients throughout the United States. In recent years, the number of non–plastic surgeons performing aesthetic surgery has been increasing.1 Unfortunately, patients may not be appropriately informed of their From the Institute of Reconstructive Plastic Surgery, Department of Plastic and Reconstructive Surgery, New York University Medical Center. Received for publication May 6, 2014; accepted June 12, 2014. Presented at the 93rd Annual Meeting of the American Association of Plastic Surgeons, in Miami, Florida, April 5 through 8, 2014. Copyright © 2014 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000000774
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surgeon’s qualifications.2 The extent to which this phenomenon is occurring across all 50 United States has yet to be examined in detail. In this study, through a systematic search using the most commonly used Internet search engine, Google (Google, Inc., Mountain View, Calif.), we aimed to evaluate the qualifications of clinicians who are marketing themselves as plastic surgeons. In addition, we strove to assess which of these practitioners is practicing outside of his or her scope of practice. This is the first study to examine and scrutinize the qualifications of surgeons marketing themselves on the Internet as plastic surgeons in the United States. Disclosure: The authors have no financial interest to declare in relation to the content of this article.
www.PRSJournal.com
Volume 135, Number 1 • Cosmetic Surgery Practitioners METHODS Between May and July of 2013, a systematic search using the Internet search engine Google was performed to evaluate the qualifications of providers who are marketing themselves on the Internet as plastic surgeons. For every U.S. state, three searches were performed: (1) [state] plastic surgery, (2) [state] cosmetic surgery, and (3) [state] aesthetic surgery. For each of these searches, the first 50 Web sites meeting inclusion/ exclusion criteria were visited, and the medical practitioners on those Web sites had their qualifications scrutinized and confirmed using the American Society of Plastic Surgeons and American Board of Plastic Surgery Web sites (www. plasticsurgery.org and www.abplsurg.org, respectively). Therefore, 150 Web sites were visited for each state in the country, totaling 7500 Web sites visited and examined in detail. Because of the nature of Internet searches, strict inclusion and exclusion criteria were set. Inclusion criteria included the following: (1) private solo and group practices that were offering
aesthetic surgery procedures on their Web sites (see below for definition of aesthetic surgery procedures), (2) university-associated academic medical centers, and (3) Web sites that contained the educational qualifications of the practicing providers. Exclusion criteria included all suggested Web sites and advertisements (those highlighted at the top of the search page results or along the side bars of the page), and large medical conglomerates (e.g., Kaiser Permanente). There were a total of three reviewers for every state and search query. Two reviewers visited the 7500 Web sites independently. These reviewers also independently produced raw data for total number of surgeons, board certification status, and practices that are out of scope. A third reviewer subsequently analyzed the data from each of these independent reviewers. This third reviewer scrutinized each list for inclusion and exclusion criteria, board certification status, and other factors. Any disagreements were settled in a group setting, with all three reviewers coming to a consensus. This built-in redundancy ensured agreement among all authors (Fig. 1).
Fig. 1. Flow chart demonstrating the methodology used in the study. There were a total of three reviewers for every state and search query. Two independent reviewers searched the first 50 results for each state for each of the search criteria and produced raw data for total surgeons, board certification status, and out-of-scope practice. A third reviewer subsequently analyzed the data from each of these independent reviewers. This third reviewer scrutinized each list for inclusion and exclusion criteria, board certification status, and other factors. Any disagreements were settled in a group setting, with all three reviewers coming to a consensus.
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Plastic and Reconstructive Surgery • January 2015 Physicians who appeared more than once were used only one time in the analysis. Only those Web sites offering aesthetic plastic surgery were included in the analysis. In addition, non– American Board of Plastic Surgery surgeons had their qualifications examined to determine how many surgeons practice outside their scope of practice based on educational merits. For the purposes of this study, we define elective, aesthetic surgery as including but not necessarily limited to the following procedures: abdominoplasty, blepharoplasty, augmentation mammaplasty, reduction mammaplasty, mastopexy, gluteal augmentation/lift, cosmetic labioplasty, augmentation phalloplasty, nontraumatic rhinoplasty, rhytidectomy, brow-lift procedures, brachioplasty, body lifts, liposuction, chin/cheek augmentation, chemical peels, fillers/injectables, and laser therapy. Scope of practice was determined as offering/ performing procedures outlined by the Accreditation Council for Graduate Medical Education for a respective residency or additional fellowship training in a specific area. Offering procedures outside of these areas would be defined as out of scope. For instance, ear, nose, and throat and oral and maxillofacial surgeons, irrespective of whether they completed a facial plastic surgery fellowship or cosmetic surgery fellowship (as these are not recognized by the American Board of Medical Specialties), were considered to be practicing out of scope if they were performing elective, aesthetic surgery below the clavicles. Dermatologists were considered to be practicing out of scope if they were performing elective, aesthetic surgery outside of injectables, chemical peels, laser therapy, and other similar minimally invasive procedures. General surgeons were considered to be practicing out of scope if they were performing elective, aesthetic surgery as defined above without additional training (again not including cosmetic surgery fellowships). Oculoplastic surgeons were considered to be practicing out of scope if they were performing elective, aesthetic surgery outside of the “eye-mask” distribution. Obstetrician and gynecologist physicians and urologists were considered to be practicing out of scope if they were performing elective, aesthetic surgery (aside from vaginoplasty/labioplasty, phalloplasty). Internal medicine doctors, pediatricians, internal medicine doctors, emergency medicine doctors, anesthesiologists, and phlebotomists were considered to be practicing out of scope if they were performing any elective, aesthetic surgery without additional training.
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RESULTS A total of 7500 Web sites were visited. These 7500 Web sites produced a total of 3077 unique clinicians that had their educational qualifications reviewed. As previously stated, repetitive Web sites/individuals were only counted one time in the results analysis. The number of clinicians offering plastic/cosmetic/aesthetic surgery on their respective Web sites was evaluated. These Web sites yielded 2396 plastic surgeons board-certified by the American Board of Plastic Surgery. This corresponded to 77.9 percent of total practitioners identified. Every one of these physicians had his or her professional merits verified by the American Board of Plastic Surgery and the American Society of Plastic Surgeons databases to confirm membership. In addition to board-certified plastic surgeons, there were many other types of physicians and nonphysicians offering aesthetic surgery procedures as defined above. There were 284 boardcertified ear, nose, and throat surgeons, 61 (21.5 percent) of whom practice outside their scope; 106 board-certified general surgeons, 100 (94.3 percent) of whom practice outside their scope; 104 board-certified oral and maxillofacial surgeons, 68 (65.4 percent) of whom practice outside their scope; 70 board-certified ophthalmologists/ oculoplastic surgeons, 49 (70 percent) of whom practice outside their scope; and 74 board-certified dermatologists, 36 (48.6 percent) of whom practice outside their scope. In addition, there were 16 board-certified internal medicine doctors, 13 board-certified obstetrics and gynecology physicians, six board-certified emergency medicine physicians, three board-certified pediatricians, two board-certified urologists, two board-certified anesthesiologists, and finally one phlebotomist; 100 percent of these practitioners practice outside their scope (Table 1 and Fig. 2). Interestingly, there is a geographic distribution in which some areas had a smaller proportion of practitioners performing aesthetic surgery out of scope (Northeast) and some areas with a greater proportion of practitioners performing aesthetic surgery out of scope (Southeast) (Fig. 3). Of the 3077 practitioners identified, 2236 are in solo private practices, 290 are in group practices (two or more practitioners), and 551 are at university-associated academic medical centers. Not surprisingly, plastic surgeons at group practices were all board-certified by the American Board of Plastic Surgery. There was not a single example of a board-certified plastic surgeon in
Volume 135, Number 1 • Cosmetic Surgery Practitioners Table 1. Total Number of Non–American Board of Plastic Surgery Surgeons Identified by Specialty, the Number of Those Who Are Practicing Out of Scope, and the Percentage to Which This Corresponds
Specialty Ear, nose, and throat General surgery Oral and maxillofacial surgery Dermatology Ophthalmology Internal medicine Obstetrics and gynecology Emergency medicine Pediatrics Urology Anesthesia Phlebotomy
No. % Total Practicing Practicing No. of Outside Outside Practitioners Scope Scope 284 106
61 100
21.5 94.3
104 74 70 16
68 36 49 16
65.4 48.6 70 100
13 6 3 2 2 1
13 6 3 2 2 1
100 100 100 100 100 100
group practice with non–board-certified counterparts. In addition, group practices of clinicians practicing outside their scope were all practicing out of scope. Interestingly, there were academic medical centers that had non–American Board of
Plastic Surgery surgeons performing cosmetic surgery outside of scope as defined above. That being said, the majority of those clinicians practicing out of scope were in solo group practice as above. Of those clinicians above practicing outside their scope, all offered the majority (if not all) of the aesthetic surgery procedures listed above. There were three oculoplastic surgeons and two dermatologists offering only rhytidectomy. It was surprising to find internal medicine doctors, pediatricians, emergency physicians, anesthesiologists, and even a phlebotomist performing surgery. Many of these practitioners offered all of the aesthetic surgery procedures defined above.
DISCUSSION The American Board of Plastic Surgery and the American Society of Plastic Surgeons are committed to providing patients with as much information and education as possible. On each of the societies’ Web sites, there are numerous links that strive to guide patients and professionals toward correct information. The work of these governing bodies is crucial, as various Web sites we visited in this study were glossy, elaborate, and potentially
Fig. 2. Chart showing the total number of non–American Board of Plastic Surgery surgeons identified by specialty, the number of those who are practicing out of scope, and the percentage to which this corresponds. ENT, ear, nose, and throat; OMFS, oral and maxillofacial surgery; OB-GYN, obstetrics and gynecology; ER, emergency room.
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Plastic and Reconstructive Surgery • January 2015
Fig. 3. U.S. map showing a geographic distribution in which some areas had a smaller proportion of practitioners performing aesthetic surgery out of scope (Northeast) and some areas had a greater proportion of practitioners performing aesthetic surgery out of scope (Southeast).
distracting. The importance of marketing American Board of Plastic Surgery board certification in an age of Internet and mass marketing has already been established by Rohrich.3 Fifteen years later, the magnitude of the problem continues to grow. A study just published by Rufai and Davis4 used a protocol similar to ours and discovered that aesthetic surgery in the United Kingdom is “ubiquitous, unregulated and enticing,” with “low compliance to national guidelines.” Furthermore, in a response to this article, Berry5 points out the difficulties the United Kingdom faces in regulating cosmetic surgery and brings up a not uncommon case of “a so-called ‘cosmetic surgeon’, actually a general practitioner by training, who required the interventions of the [government].” In the United States we face similar challenges. It has been shown previously in the literature that the most important factor for patients in selecting an aesthetic surgeon is board certification in plastic surgery.6,7 However, as we have found in the present study, there are many practitioners providing cosmetic procedures who are not board-certified by the American Board of Plastic Surgery.8 Furthermore, in a recent study by Galanis et al., the most commonly cited factor preventing patients from pursuing plastic surgery is “fear of a poor result.”9 To curtail this concern, standardization in aesthetic surgery training is crucial.
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A 2010 study examined the backgrounds of practitioners performing aesthetic surgery in Southern California, focusing primarily on liposuction and minimally invasive injection treatments. Camp et al. found that there are 1867 practitioners providing these services in the Southern California area and that only 495 were trained in plastic surgery.1 Furthermore, they identified primary care physicians as the third largest group providing hyaluronic acid injections and the fourth largest group providing liposuction. We similarly identified a wide range of individuals with varying training backgrounds performing aesthetic surgery. In the present study, we aimed to identify clinicians practicing aesthetic surgery by means of a Google search. We sampled those clinicians who both provide aesthetic surgery and list their qualifications somewhere on their Web site. We also identified clinicians who were performing procedures outside their scope of practice. Obviously, defining a specialty’s “scope” is a controversial subject, but given our conservative definition guided by Accreditation Council for Graduate Medical Education guidelines and American Board of Medical Specialties–recognized fellowship training, we feel comfortable stating that the groups we identified as out of scope were fairly characterized. We identified ear, nose, and throat surgeons; oral and maxillofacial surgeons; dermatologists;
Volume 135, Number 1 • Cosmetic Surgery Practitioners general surgeons; internal medicine doctors; ophthalmologists; obstetrics and gynecology physicians; pediatricians; emergency medicine doctors; urologists; anesthesiologists; and a phlebotomist performing aesthetic surgery. Although some of these specialists train in various aesthetic procedures during residency (i.e., ear, nose, and throat surgeon with rhinoplasty; oculoplastic surgeon with blepharoplasty), the majority of the above do not. The question, then, is twofold: Who is qualified to perform cosmetic surgery procedures and how do we standardize cosmetic surgery training? Given the findings in this study, we feel it is imperative to standardize training in aesthetic surgery. Surgeons of differing educational backgrounds ought to be eligible to attend cosmetic/ aesthetic surgery fellowships and develop their practices as desired, within reason. However, these fellowships are currently not regulated or standardized in the same manner as Accreditation Council for Graduate Medical Education/ American Board of Medical Specialties–recognized residencies and fellowships. Aesthetic/cosmetic fellowships must become standardized with regard to training and procedural requirements. Furthermore, they must more tightly regulate who is accepted to the program, and the quality of the surgeon that is produced. Most readers would agree that internists, pediatricians, emergency physicians, anesthesiologists, and phlebotomists should not be performing cosmetic surgery. In contrast, surgeons trained in
other nonplastic specialties (i.e., ear, nose, and throat; general surgery, oral and maxillofacial surgery) certainly obtain the necessary technical skills and thought processes to safely and reliably perform cosmetic surgery. The purpose of labeling these surgeons as practicing out of scope is not to ostracize or question technical skills or training. Instead, the point is to demonstrate the unregulated manner in which cosmetic surgery is being performed across the country. We need greater oversight and transparency to improve patient safety and result reliability. Currently, the American Society of Plastic Surgeons is working to increase public education and awareness with regard to plastic surgery training and board certification. The “Do Your Homework” campaign (Fig. 4)10 is vital in this regard. Furthermore, as of June of 2014, the American Society of Plastic Surgeons is beginning a new campaign to promote member surgeons and discourage encroachment by other specialties. This will be accomplished by both television advertisements and a toll-free call center that prospective patients can contact and be directly connected to a member surgeon based on zip code and desired procedure(s). This study is the first attempt to broadly characterize the issues that the American Board of Plastic Surgery, the American Society of Plastic Surgeons, and their members face. Certainly, there are weaknesses to this analysis. First and foremost, the search results of Internet queries
Fig. 4. Screen shot from the American Society of Plastic Surgeons Web site advertising the “Do Your Homework” campaign. (From American Society of Plastic Surgeons. Find a plastic surgeon. Available at: http://www1.plasticsurgery.org/find_a_surgeon/. Accessed May 4, 2014.)
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Plastic and Reconstructive Surgery • January 2015 may not accurately represent the true proportions or practices of surgeons treating patients in the community. However, in the current global market, the Internet is the primary means by which people ascertain information. Therefore, these data assess those practitioners whom a lay community member is likely to come across when searching for an aesthetic surgeon. It must be borne in mind that each surgeon is responsible for his or her results. We recognize that board certification in plastic surgery does not necessarily equate with being a good surgeon. What it does indicate is that the surgeon has been trained, and ultimately it is the outcomes that are important. Future studies will be necessary to ascertain whether or not board certification in plastic surgery actually equates with safer surgery and/or improved patient outcomes in aesthetic surgery. A possibility would be to investigate whether non– American Board of Plastic Surgery surgeons face greater proportions of litigation compared with American Board of Plastic Surgery–certified surgeons. Our study did not address this issue, and this would be a logical next step in the progression of this research. In addition, future research may examine the impact of the mobile application industry on patient surgeon selection when looking for aesthetic surgery procedures. A simple search on the Apple App Store (Apple, Inc., Cupertino, Calif.), for example, returns over 200 applications with an interesting variety of practitioners. This may be another, albeit less common, avenue by which people are finding aesthetic surgeons. The driving undercurrent of this article is patient safety. The American Board of Plastic Surgery and the American Society of Plastic Surgeons are committed to providing patients with the most current information and the safest and most efficacious, evidence-based surgery available. To achieve this goal, we must continue to educate patients and ensure consistent and reliable results in aesthetic surgery regardless of the training background of the individual. Standardization of training in cosmetic surgery is essential.
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CONCLUSIONS There are a significant number of clinicians who are performing cosmetic surgery in the United States who are not board-certified by the American Board of Plastic Surgery. Although the majority of practitioners identified were either board-certified plastic surgeons or other surgeons, there are unfortunately many who are not. We must standardize aesthetic surgery training to ensure patient safety and deliver consistent results. Jason S. Barr, M.D. Institute of Reconstructive Plastic Surgery New York University 305 East 33rd Street New York, N.Y. 10016 [email protected]
references 1. Camp MC, Wong WW, Wong RY, Camp JS, Son AK, Gupta SC. Who is providing aesthetic surgery? A detailed examination of the geographic distribution and training backgrounds of cosmetic practitioners in Southern California. Plast Reconstr Surg. 2010;125:1257–1262. 2. Manstein CH. Preferences regarding board certification and organization relating to aesthetic surgery. Plast Reconstr Surg. 1998;101:863–864. 3. Rohrich RJ. So you are board-certified in plastic surgery: What it means in the new millennium. Plast Reconstr Surg. 2000;105:1473–1474. 4. Rufai SR, Davis CR. Aesthetic surgery and Google: Ubiquitous, unregulated and enticing websites for patients considering cosmetic surgery. J Plast Reconstr Aesthet Surg. 2014;67:640–643. 5. Berry MG. Commentary to ‘Aesthetic surgery and Google: Ubiquitous, unregulated and enticing websites for patients considering cosmetic surgery’. J Plast Reconstr Aesthet Surg. 2014;67:644–645. 6. Nowak LI, Washburn JH. Patient sources of information and decision factors in selecting cosmetic surgeons. Health Mark Q. 1998;15:45–54. 7. Waltzman JT, Scholz T, Evans GR. What patients look for when choosing a plastic surgeon: An assessment of patient preference by conjoint analysis. Ann Plast Surg. 2011;66:643–647. 8. Housman TS, Hancox JG, Mir MR, et al. What specialties perform the most common outpatient cosmetic procedures in the United States? Dermatol Surg. 2008;34:1–7; discussion 8. 9. Galanis C, Sanchez IS, Roostaeian J, Crisera C. Factors influencing patient interest in plastic surgery and the process of selecting a surgeon. Aesthet Surg J. 2013;33:585–590. 10. American Society of Plastic Surgeons. Find a plastic surgeon. Available at: http://www1.plasticsurgery.org/find_a_ surgeon/. Accessed May 4, 2014.
