The problem with the cosmetic surgery turf war

In recent weeks, we have seen a sharp increase in media attention covering “cosmetic cowboys”. The Four Corners investigation with The Sydney Morning Herald and The Age was shocking, and I was horrified to see these poor patients exposed to, frankly, unsafe and unnecessary procedures.

Why am I so concerned? I am a general practitioner. Based in inner-Sydney, I have seen a slow but not so subtle creep of cosmetic culture in day-to-day life. On every metropolitan corner is a cosmetic clinic promising inexpensive and quick procedures. These clinics are often staffed not by trained doctors but nurses who have done a one-off private course. The doctors who work in these fields often come with a basic medical degree and that’s it.

A loved one with a patient rushed to emergency after she nearly bled out following cosmetic surgery. Credit: Kate Geraghty

Some are GPs who have ventured into the aesthetic field, who have been described as “non-specialist practitioners” – but this fails to describe the crux of the problem. GPs are specialist practitioners in primary care, but not in surgery, so they are operating way out of their scope of practice.

As doctors we must remember to first do no harm. And when I see inflated lips, buttocks out of proportion to real life, faces that look alien, I wonder: has profit been put before the patient?

It is the minority of rogue medical practitioners who give the rest of us a bad name. My biggest gripe is with those who promote themselves as highly skilled at performing these risky procedures, yet have not undergone training accredited by the Australian Medical Council, the peak body regulating medical and surgical education. Multiple self-proclaimed colleges and associations give this career move legitimacy, yet have been set up to provide training that has not been approved by the AMC.

Patients do not know this. It is unconscionable to perform body-modifying procedures without intricate knowledge of the anatomy, the surgical techniques to better infection control and wound-healing, the management of complications.

GPs are the ones who see the necrotic wounds, the disfigurement, the secondary skin infections, the nerve damage.

The Australian Society of Plastic Surgeons has responded with vigour, and I wholeheartedly agree with the need for better regulation of the cosmetic surgery industry. However, its response only covers one aspect of the story. It has forgotten to mention the monopoly wielded by the Royal Australian College of Surgeons, which covers the plastic surgeons. Very few trainees are accepted each year in per state. That is a serious concern given Australia has only 500 plastic and reconstructive surgeons for a population of 25 million.

We have a dangerous shortage of qualified surgeons but we also have a training bottleneck. Talk to any parent who has had a child suffer a facial laceration requiring sutures and they will tell you about the real-life consequences. Indeed, I can give that testimony as both parent and GP. When my son was 18 months old, he tripped and hit his head, sustaining a deep facial laceration. We waited hours and hours to see a plastic surgeon trainee, then were sent home with an open wound to care for, and the poor child was fasted for almost an entire day.

Plastic surgery cases are often bumped to the bottom of the list for what should be a straightforward and quick surgical procedure. Even if you are willing to pay private fees, you cannot find a plastic surgeon to operate on your child at short notice.

It is no wonder then that the would-be plastic surgeons – many of whom are wonderful doctors with promising surgical skills – have sought less than ideal training options.

One solution is to involve the colleges to offer training to a wider range of practitioners. This is currently non-existent in the surgical sphere, yet it already happens in general practice, where there are avenues for doctors to add to their skills in subspecialty fields such as palliative care, addiction medicine, dermatology, sexual health, and many others. (It is a myth that once medical school is over, you automatically become a GP. We have completed years of specialist primary care training resulting in a formal fellowship.)

We need to increase the avenues to plastic surgery training – or for formal cosmetic surgery training approved by the AMC.

A long time ago, I wanted to be a plastic surgeon. I had the skill and the ambition, but it was knocked out of me in my hospital years. I have since found my niche in general practice, and I am lucky to have found a path I love. I have been trained to perform minor skin cancer surgeries in my day-to-day practice, but this does not make me a surgeon. And I tell my patients so, so that they can give me true informed consent to go ahead, or to opt out and seek a plastic surgery or a dermatologist’s opinion.

GPs and emergency physicians are fully capable of stitching up or glueing a wound, but we cannot guarantee a good cosmetic result in our busy consulting rooms or emergency departments. This is not only due to time restraints but because many of us refuse to do this kind of work without having access to appropriate paediatric anaesthesia and surgical support teams. We would rather it be done once, and done well, to avoid unnecessary scar-revision surgery down the track.

Any surgery on children is not only traumatic for them, but for their parents. Our faces are ours for life. Plastic surgeons are best placed to do this kind of work, and it needs to be prioritised in the public system, where most children present once injured.

As much as I respect several of my colleagues who have entered the cosmetic surgery domain, we need better regulation to safeguard them and their patients.

When it comes to bad results, after all, it is the GPs at the coalface and picking up the pieces. We are the ones who see the necrotic wounds, the disfigurement, the secondary skin infections, the nerve damage. It is left to
us to fix the damage done, to co-ordinating the response. It takes hours, and it is a fact that GPs are not well remunerated for this, in contrast to the thousands paid to the cosmetic surgeon who then do not answer the phone after hours, nor have an avenue to co-ordinate and manage the complications.

I sighed with relief when I heard of the Australian Health Practitioner Regulation Agency’s forthcoming review of cosmetic surgery. It’s a long time coming. But we also need a review of the avenues to plastic surgery training – or formal cosmetic surgery training approved by the AMC. We need to foster and promote the skills of our colleagues who have been sidelined.

I challenge the powers that be: bring them into the fold, educate them, accredit safe practice. Increase training positions in the public and private systems. Lift us all up as a profession, without pushing others down.

Dr Samantha Saling is a general practitioner in inner-Sydney.