Discussion Discussion: Clinicians Performing Cosmetic Surgery in the Community: A Nationwide Analysis of Physician Certification Robert X. Murphy, Jr., M.D., M.S. Tampa, Fla.; and Allentown, Pa.
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ne of the most vexing issues facing board-certified plastic surgeons today is the increasing competition for patients seeking plastic surgical procedures from practitioners not recognized by the American Board of Plastic Surgery. Assured of our competence by untold years of rigorous education and surgical training, we are incredulous that physicians of other specialties and, indeed, nonphysicians can be having the impact they are in the marketplace. In this article, the authors attempt to document the extent of this issue as played out on the Internet. To their great credit, the authors approach this in a very temperate, nonparochial fashion by not assuming the ideological position that any physician who is providing aesthetic services and not certified by the American Board of Plastic Surgery is practicing outside his or her “scope.” Rather, they define those who are practicing beyond the parameters outlined for their specialty as outlined by the Accreditation Council for Graduate Medical Education or those who have not participated in additional fellowship training as, in fact, practicing beyond their scope, taking the position that this is a matter of quality and patient safety. Their findings come as no surprise—namely, that of those practitioners not certified by the American Board of Plastic Surgery who are advertising themselves as plastic surgeons, the great majority are practicing beyond their scope. We ask ourselves, How can this be? How can a nation immersed in a health care transformation based on providing the highest possible quality medical care and one in which so much information is so readily available be so oblivious when it comes to picking individual health care providers? The answer is, quite simply, that aesthetic procedures and health care in general, are seen increasingly as commodities by consumers and not medical procedures by patients. Rohrich and From the Lehigh Valley Health Network and Morsani College of Medicine, University of South Florida. Received for publication August 26, 2014; accepted August 27, 2014. Copyright © 2014 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000000820
Weinstein1 have noted that “the Internet is effectively a free-for-all,” and when so much is available to so many, one can reasonably be assured that the profession of marketing, and not medicine, is the one that will have the greatest impact on consumer choice. At no time was the commoditization of health care made more apparent to me than in a recent survey conducted in my institution’s catchment areas when the overwhelming response to what defined “quality” to today’s consumer was not the observed versus expected mortality in open heart surgery, not the 30-day readmission rate, not even an appearance in U.S. News and World Report listing of top hospitals, but rather “cleanliness” of the institution. We have taken comfort in the assumption that board certification in plastic surgery would be the sine qua non of choosing a medical practitioner to provide an aesthetic procedure. The authors cite the works of Nowak and Washburn2 and Waltzman et al.,3 which seem to support this concept. However, statistics are tricky tools and can often provide different answers with the same results depending on how the question is asked. In this article, Barr et al. note that “the American Society of Plastic Surgeons is working to increase public education and awareness with regards to plastic surgery training and board certification.” In fact, our (American Board of Plastic Surgery) foray into this arena has proven very telling. The marketing research generated on our behalf4 cites two noteworthy statistics: • Twenty-five percent of those surveyed believe that board certification in plastic surgery is the most important factor when choosing a physician. • Fifty-seven percent of those surveyed noted that it was a factor influencing physician choice. Disclosure: The author has no financial interest to declare in relation to the content of this Discussion or of the associated article.
www.PRSJournal.com
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Plastic and Reconstructive Surgery • January 2015 Although advertising and marketing professionals see these numbers as being very encouraging, as a board-certified plastic surgeon, I am aghast that 75 percent, if not 100 percent, of consumers who will be placing their very well-being in the hands of a stranger do not consider board certification as the most important factor in making that decision. This information documents how important it is that we, the board-certified plastic surgeon members of the American Society of Plastic Surgeons, maintain an active presence in the world of marketing. It is interesting to note that even as I am writing this missive, an e-mail arrives that solicits me to join a “board” that claims to be “the official medical society that is dedicated to the practice and advancement of aesthetic medicine.” As individual practitioners, the challenge of fighting this battle is overwhelming. As a professional society, the American Society of Plastic Surgeons can marshal our collective resources to bring our very important message to our patients. The recent cable television marketing campaign, which was the first undertaken by the American Society of Plastic Surgeons on behalf of the membership, was able to reach 54 million households nationally over its 2-month course. Certainly, it was a very impressive start. Our marketing colleagues live by what is called the “rule of seven,” which maintains that prospects must see or hear your message seven times before they purchase a service. This speaks to the necessity of boardcertified plastic surgeons maintaining an ongoing presence and distinguishing ourselves on the basis of their certification, in the marketplace. That said, what is the content of the message that we wish to convey? Simply put, we, the boardcertified community of plastic surgeons, want to communicate that we provide the highest quality, safest outcomes. Although we intrinsically feel this to be true, unfortunately, we have yet to make this case. However, given the times in which we practice in which outcomes are beginning to be publicly reported, we do have the opportunity to begin to make our case. Our Tracking Outcomes in Plastic Surgery database is a robust platform that provides each American Society of Plastic Surgeons member with the opportunity to contribute their operating experience and report their outcomes. To date, the Tracking Outcomes in Plastic Surgery database has accrued approximately 1.3 million cases over the course of its existence. If each member
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of the American Society of Plastic Surgeons were to contribute to the Tracking Outcomes in Plastic Surgery database on a regular basis, we would be able to make a very powerful case to the public. Finally, Dr. Barr and his coauthors make the point that standardizing the education of those practicing cosmetic surgery would be a significant step in ensuring patient safety. This admonition calls for quite a paradigm shift. As advocates of patient safety, we recognize how this is surely the right thing to do. As surgeons who take great pride in satisfying all the requirements to become board-certified plastic surgeons, we are quite comfortable with the fact that the training offered by our Accreditation Council for Graduate Medical Education–approved programs is standardized and that our American Board of Plastic Surgery examination process ensures that each graduate can provide safe, high-quality care. In this spirit of establishing educational parity, the Accreditation Council for Graduate Medical Education has facilitated discussions between plastic surgery and facial plastic surgery to begin this journey toward standardized, interprofessional education at the fellowship level—a significant shift to say the least. The authors are to be congratulated for their very timely and thought-provoking work. Confucius said, “May you live in interesting times.” We most certainly seem to be doing so in medicine today. It is only by means of evolving our own paradigm as individual practitioners and as a professional society that we can ensure this euphemism bespeaks an ongoing evolution in which our specialty becomes driven by outcomes and quality and not one that sees us succumb to the trivialization of Madison Avenue. Robert X. Murphy, Jr., M.D., M.S. Lehigh Valley Health Network 2597 Schoenersville Road, Suite 206 Bethlehem, Pa. 18017
REFERENCES 1. Rohrich RJ, Weinstein AG. Connect with plastic surgery: Social media for good. Plast Reconstr Surg. 2012;129:789–792. 2. Nowak LI, Washburn JH. Patient sources of information and decision factors in selecting cosmetic surgeons. Health Mark Q. 1998;15:45–54. 3. 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. 4. ASPS Consumer Research, Confidential Report of Findings, March 2014. Research Conducted and prepared by Chadwick Martin Bailey and CareCredit.
O
ne of the most vexing issues facing board-certified plastic surgeons today is the increasing competition for patients seeking plastic surgical procedures from practitioners not recognized by the American Board of Plastic Surgery. Assured of our competence by untold years of rigorous education and surgical training, we are incredulous that physicians of other specialties and, indeed, nonphysicians can be having the impact they are in the marketplace. In this article, the authors attempt to document the extent of this issue as played out on the Internet. To their great credit, the authors approach this in a very temperate, nonparochial fashion by not assuming the ideological position that any physician who is providing aesthetic services and not certified by the American Board of Plastic Surgery is practicing outside his or her “scope.” Rather, they define those who are practicing beyond the parameters outlined for their specialty as outlined by the Accreditation Council for Graduate Medical Education or those who have not participated in additional fellowship training as, in fact, practicing beyond their scope, taking the position that this is a matter of quality and patient safety. Their findings come as no surprise—namely, that of those practitioners not certified by the American Board of Plastic Surgery who are advertising themselves as plastic surgeons, the great majority are practicing beyond their scope. We ask ourselves, How can this be? How can a nation immersed in a health care transformation based on providing the highest possible quality medical care and one in which so much information is so readily available be so oblivious when it comes to picking individual health care providers? The answer is, quite simply, that aesthetic procedures and health care in general, are seen increasingly as commodities by consumers and not medical procedures by patients. Rohrich and From the Lehigh Valley Health Network and Morsani College of Medicine, University of South Florida. Received for publication August 26, 2014; accepted August 27, 2014. Copyright © 2014 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000000820
Weinstein1 have noted that “the Internet is effectively a free-for-all,” and when so much is available to so many, one can reasonably be assured that the profession of marketing, and not medicine, is the one that will have the greatest impact on consumer choice. At no time was the commoditization of health care made more apparent to me than in a recent survey conducted in my institution’s catchment areas when the overwhelming response to what defined “quality” to today’s consumer was not the observed versus expected mortality in open heart surgery, not the 30-day readmission rate, not even an appearance in U.S. News and World Report listing of top hospitals, but rather “cleanliness” of the institution. We have taken comfort in the assumption that board certification in plastic surgery would be the sine qua non of choosing a medical practitioner to provide an aesthetic procedure. The authors cite the works of Nowak and Washburn2 and Waltzman et al.,3 which seem to support this concept. However, statistics are tricky tools and can often provide different answers with the same results depending on how the question is asked. In this article, Barr et al. note that “the American Society of Plastic Surgeons is working to increase public education and awareness with regards to plastic surgery training and board certification.” In fact, our (American Board of Plastic Surgery) foray into this arena has proven very telling. The marketing research generated on our behalf4 cites two noteworthy statistics: • Twenty-five percent of those surveyed believe that board certification in plastic surgery is the most important factor when choosing a physician. • Fifty-seven percent of those surveyed noted that it was a factor influencing physician choice. Disclosure: The author has no financial interest to declare in relation to the content of this Discussion or of the associated article.
www.PRSJournal.com
99e
Plastic and Reconstructive Surgery • January 2015 Although advertising and marketing professionals see these numbers as being very encouraging, as a board-certified plastic surgeon, I am aghast that 75 percent, if not 100 percent, of consumers who will be placing their very well-being in the hands of a stranger do not consider board certification as the most important factor in making that decision. This information documents how important it is that we, the board-certified plastic surgeon members of the American Society of Plastic Surgeons, maintain an active presence in the world of marketing. It is interesting to note that even as I am writing this missive, an e-mail arrives that solicits me to join a “board” that claims to be “the official medical society that is dedicated to the practice and advancement of aesthetic medicine.” As individual practitioners, the challenge of fighting this battle is overwhelming. As a professional society, the American Society of Plastic Surgeons can marshal our collective resources to bring our very important message to our patients. The recent cable television marketing campaign, which was the first undertaken by the American Society of Plastic Surgeons on behalf of the membership, was able to reach 54 million households nationally over its 2-month course. Certainly, it was a very impressive start. Our marketing colleagues live by what is called the “rule of seven,” which maintains that prospects must see or hear your message seven times before they purchase a service. This speaks to the necessity of boardcertified plastic surgeons maintaining an ongoing presence and distinguishing ourselves on the basis of their certification, in the marketplace. That said, what is the content of the message that we wish to convey? Simply put, we, the boardcertified community of plastic surgeons, want to communicate that we provide the highest quality, safest outcomes. Although we intrinsically feel this to be true, unfortunately, we have yet to make this case. However, given the times in which we practice in which outcomes are beginning to be publicly reported, we do have the opportunity to begin to make our case. Our Tracking Outcomes in Plastic Surgery database is a robust platform that provides each American Society of Plastic Surgeons member with the opportunity to contribute their operating experience and report their outcomes. To date, the Tracking Outcomes in Plastic Surgery database has accrued approximately 1.3 million cases over the course of its existence. If each member
100e
of the American Society of Plastic Surgeons were to contribute to the Tracking Outcomes in Plastic Surgery database on a regular basis, we would be able to make a very powerful case to the public. Finally, Dr. Barr and his coauthors make the point that standardizing the education of those practicing cosmetic surgery would be a significant step in ensuring patient safety. This admonition calls for quite a paradigm shift. As advocates of patient safety, we recognize how this is surely the right thing to do. As surgeons who take great pride in satisfying all the requirements to become board-certified plastic surgeons, we are quite comfortable with the fact that the training offered by our Accreditation Council for Graduate Medical Education–approved programs is standardized and that our American Board of Plastic Surgery examination process ensures that each graduate can provide safe, high-quality care. In this spirit of establishing educational parity, the Accreditation Council for Graduate Medical Education has facilitated discussions between plastic surgery and facial plastic surgery to begin this journey toward standardized, interprofessional education at the fellowship level—a significant shift to say the least. The authors are to be congratulated for their very timely and thought-provoking work. Confucius said, “May you live in interesting times.” We most certainly seem to be doing so in medicine today. It is only by means of evolving our own paradigm as individual practitioners and as a professional society that we can ensure this euphemism bespeaks an ongoing evolution in which our specialty becomes driven by outcomes and quality and not one that sees us succumb to the trivialization of Madison Avenue. Robert X. Murphy, Jr., M.D., M.S. Lehigh Valley Health Network 2597 Schoenersville Road, Suite 206 Bethlehem, Pa. 18017
REFERENCES 1. Rohrich RJ, Weinstein AG. Connect with plastic surgery: Social media for good. Plast Reconstr Surg. 2012;129:789–792. 2. Nowak LI, Washburn JH. Patient sources of information and decision factors in selecting cosmetic surgeons. Health Mark Q. 1998;15:45–54. 3. 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. 4. ASPS Consumer Research, Confidential Report of Findings, March 2014. Research Conducted and prepared by Chadwick Martin Bailey and CareCredit.
