On 1 September 2022, an Independent Review released its long-awaited Report into Cosmetic Surgery in Australia [1].
Its key recommendation reflected the sentiment of our new, peer-reviewed, paper in the American Journal of Cosmetic Surgery entitled ‘Cosmetic Surgery Regulation in Australia: Who is to be protected – Surgeons or Patients?’ [2]. The open-access publication, supported by extensive published material, urges regulators to implement changes that would require all doctors performing cosmetic surgery to be endorsed in its practice under National Law [3-20]. The research warns against the other option currently under consideration – isolated ‘title’ restriction based on existing surgical specialties with no requirement for training and competence in cosmetic surgery.
This matters because annually, 500,000 Australians undergo procedures worth $1.5bn, with per capita spend greater than the USA. Whilst such demand and social media influence has generated a huge industry, since 1999 attempts at regulation have failed due to the competing interests of surgical craft groups. Consensus could not be reached [21] and as a consequence patients have suffered avoidable harm.
From 2018 when the Council of Australian Governments Health Council (COAG HC) revisited the matter, alarming cosmetic surgical stories have been publicised. Cosmetic surgery risks have been consistently downplayed and patients placed in danger by a broken-down system.
In an industry under scrutiny, recent media coverage of six doctors has been disturbing and included cosmetic surgical disasters [22-23]. Whilst the medical practices revealed have been abhorrent, the common underlying theme has been sensationalism. Omitted from the reporting has been an understanding of cosmetic surgery, options for its regulation and a pragmatic, simple solution to enhance patient safety.
Modern cosmetic surgery is a recent development in medical practice, but current law prohibits creation of a new specialty of cosmetic surgery. Absence of a protected title therefore allows any of the more than 100,000 medical practitioners in Australia [25] to call themselves a cosmetic surgeon and practise cosmetic surgery, regardless of whether they have any formal training in it. Very few do, be they a ‘plastic surgeon’, ‘cosmetic surgeon’ or any other ‘specialist surgeon’.
Notwithstanding, Fellows of the Royal Australasian College of Surgeons (RACS) are campaigning to persuade the COAG HC to restrict the title ‘surgeon’ to themselves and ban ‘cosmetic surgeon’ [26-30]. That this will create a commercial monopoly for their members who perform cosmetic surgery may be coincidental but irrespective, such an approach relies upon the assumption that those to whom the title might be restricted are trained, qualified and safe to perform cosmetic surgery.
Most RACS surgeons, including plastic surgeons, are not trained and qualified in cosmetic surgery upon specialist registration. So says the Australian Medical Council (AMC), the independent national standards body for medical education and training, which recently reported that plastic surgeons trained by the Australian Society of Plastic Surgeons and RACS have “a deficit” in experience of cosmetic surgery and qualify with a “gap in this area of practice” [5].
Secondly, the campaign implies patient safety enhancement by channelling all cosmetic surgery patients to plastic or other RACS surgeons holding the proposed restricted title. The inconvenient truth is that an RACS specialist surgical qualification is no guarantee of safety in cosmetic surgery [2].
In 2012-13 reports of informed consent disputes found nearly two thirds of complaints relating to cosmetic surgery procedures were against plastic surgeons and that plastic surgery was the “surgical sub-speciality of practitioners who were (most frequently) the subject of cosmetic procedure complaints” [31,32]. The Australian Senate, reporting contemporary data from AHPRA concerning complaints related to cosmetic surgery, detailed that in the three years to June 2021, 52% of practitioners who were the subject of complaints concerning “botched surgeries” and specifically cosmetic procedures, were specialist surgeons and “…mostly specialist plastic surgeons” [18]; that is, 71% of the group [10]. Intriguingly, numerous illustrative cases have formed little part of the recent media coverage [7-9,33,34].
The difficult reality, observed by the Chair of the Medical Board of Australia, is that patients being harmed by surgeons inadequately trained in cosmetic surgery applies equally to specialist surgeons, including plastic surgeons, as it does to other practitioners [35].
Such a widespread problem requires an encompassing, non-partisan solution. Internationally, in relation to identical considerations of patient safety in cosmetic surgery as those in Australia, plastic surgeons have recently stated –“We need validated evidence of hands-on competency in aesthetic surgery to keep patients safe” [36] and “In summary: qualifications per se are pretty meaningless. A qualification which comes with a guarantee of competence is something else” [37].
Accordingly, our new research argues that if patients are to be truly protected, a mandatory independent National Accreditation Standard for all doctors performing cosmetic surgery – including plastic surgeons, cosmetic surgeons and any other specialist surgeons – is urgently needed. The Standard must ensure core surgical training and competence, along with specific training, qualifications, objective competency and recertification in cosmetic surgery.
The mechanism already exists under s98 of Australian Health Practitioner National Law, which governs registration of doctors in Australia. It allows Government to mandate Endorsement of an Area of Practice. Designed for new areas of practice not fitting criteria for a new medical specialty, yet requiring regulatory restriction, this solution provides an immediate mechanism regulators can introduce to ensure that doctors practising cosmetic surgery are competent and safe. Precedent exists of endorsement of acupuncturists and also endorsement to administer scheduled medication by enrolled nurses.
Doctors who meet the competency Standard set by the AMC would be endorsed to perform cosmetic surgery and would be readily identifiable on the AHPRA Register. Those not meeting it would not be endorsed and would be prohibited from engaging in cosmetic surgery.
This would protect patients, remove confusion and prevent commercial monopoly formation. Competition between safe practitioners based on competence, price and service would further protect patients by improving standards. Title restriction may then have a place but only if doctors using the protected title, for example ‘cosmetic surgeon’, are competent and have met the Standard.
Politicians and regulators ought not be distracted from the central objective of the current review processes, which is to ensure patient safety [10,18,38-40]. Isolated ‘title’ protection, advocated by some specialist craft groups (who would in practice benefit commercially from the change), will not improve patient safety. It will not ensure doctors practising in cosmetic surgery are properly trained and competent and patients will continue to suffer. The Review confirmed this by its observation that “…title protection, or title protection alone, does not provide enough clarity or sufficient protection to the public and more needs to be done” [1].
When the findings of the Review, including the endorsement model, were communicated by confidential briefing to specialist practitioner representatives prior to formal publication, the outcome was reportedly as predictable as it was disappointing [41,42].
If patients, not surgeons, are to be protected, evidence must be distinguished from the muddle of vested interests and sensationalism. The natural consequence in Australia is endorsement of competent medical practitioners trained in cosmetic surgery [43,44]. Global policymakers may soon consider following suit. It is the right and only thing to do.
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