Australia’s problems with cosmetic surgery: why they have happened and how to fix themFeb 9, 2023
Hardly a month goes by without a new media report (and here) of alleged scandalous conduct of some doctors who call themselves ‘cosmetic surgeons’ but who lack recognised specialised surgical training. These reports have tended to focus on the harm done to patients and generally failed to explain to the public how and why the situation has arisen. While some commentators have blamed the medical profession for failing to regulate itself, this is far from the reality.
First a little history. The officially recognised specialty of plastic and reconstructive surgery had its origins in the two world wars when general surgeons sought to repair the disfiguring injuries that combatants suffered. Thus these new ‘plastic surgeons’ were treating people who were unwell. More recently, and probably originating in the USA, healthy people began to seek surgery to alter physical appearances with which they were dissatisfied. While qualified plastic and reconstructive surgeons generally were happy to undertake such surgery, it was soon an area that other doctors saw as a lucrative opportunity in which to engage.
In Australia, as cosmetic surgery was not being undertaken for illness, it was never included under Medicare, thus obviating the Medicare requirement of referral from a general practitioner. In addition, since the 1980s there has been a progressive relaxation of the rules around advertising by medical practitioners. Since any qualified and registered doctor in Australia is free to call him or herself a surgeon, we have arrived at a situation where any doctor can set themselves up as cosmetic surgeons and advertise with little restriction.
Concerns around cosmetic surgery are not new. In 1998, the NSW Health Care Complaints Commission conducted a major inquiry and made many sensible recommendations. A summary of those recommendations can be found in the 1999-2000 Annual Report of the Commission. The most important was a recommendation, accepted by the NSW Government, to establish a Cosmetic Surgery Credentialing Council. The Council membership included all the relevant craft groups including plastic surgeons (Fellows of the Royal Australian College of Surgeons-RACS) and cosmetic surgeons from the Association of Cosmetic Surgeons whose training was generally shorter, unregulated, and unstructured as compared with that of the RACS. The Council foundered because its members could never agree on anything.
This battle between the plastic surgeon fellows of the RACS and the cosmetic surgeons who in 2009 formed themselves into the Australasian College of Cosmetic Surgery continues unabated today. It will never be resolved by agreement. There is right on both sides. It seems to me correct to say that the plastic and reconstructive surgeons are thoroughly trained in a lengthy program that is accredited by the national regulator on the advice of the Australian Medical Council. It is also correct to say that while some progress has been made, the training offered by the Australasian College of Cosmetic Surgery – ACCS probably falls below that standard and that the College is not accredited by the national regulator. It is probably correct to claim that some plastic and reconstructive surgeons do not in their training gain experience in cosmetic procedures on healthy people. It is undoubtedly true that some cosmetic surgeons can rightly be called ‘cowboys’. Whether any of these are fellows of the Australasian College of Cosmetic Surgery is unknown to me.
In defence of the Australasian College of Cosmetic Surgery, there is said to be a legal obstacle to the College being accredited by the national regulator, the Australian Health Practitioner Regulation Agency (AHPRA). However, should that legal obstacle be removed, it remains questionable that the College at present could meet the high standards required for accreditation.
There are presently two inquiries afoot that are directed at resolving the impasse. Neither seems likely to achieve that aim. The first is an inquiry being conducted by Australia’s health ministers into the use of the title of ‘surgeon’. The second is an inquiry commissioned by AHPRA and the Medical Board of Australia (MBA). The inquiry is led by former Queensland Health Ombudsman, Andrew Brown, and is expected to report soon. From my reading of the consultation paper issued last March, the focus of this inquiry seems to be primarily on the guidelines on cosmetic surgery issued by the MBA in 2016.
So what should be done? Although cosmetic surgery is not medical treatment (even fellows of the AACS admit that ‘cosmetic surgery is sought by healthy patients wishing to change appearance of normal tissues’), it is widely sought by Australians and is here to stay. It needs to be regulated under an identical framework as applies to the RACS. Allowing this to happen will require compromises on both sides. The RACS will need to allow trainee cosmetic surgeons access to an adequate exposure to the principles and practice of general surgery in accredited hospitals and day surgery centres. The ACCS will need to modify its training programs to meet the high standards of accreditation set by the AMC. And there will need to be a period of accommodation by ‘grand-fathering’ existing fellows of the ACCS to allow them to be registered as specialists with AHPRA despite the likely insufficiency of their original training.
We also need to listen to health consumers. As the CEO of the Consumer Health Forum, Leanne Wells, wrote recently: ‘in the interests of patients, can it be that hard to create a recognised specialty of cosmetic surgery that would effectively outlaw unqualified doctors?’
Such accommodation may require ‘gritted teeth’ on the part of the RACS plastic surgeons but in the long term this will be the solution to the problem with the training of cosmetic surgeons that the RACS correctly perceives. In my view this is the only way by which the currently toothless AHPRA and MBA can begin to meet their aim of protecting the Australian community. Some of us are old enough to recall that we have been here before! The establishment of a College of Emergency Medicine in 1983 met with considerable resistance: now we can’t imagine not having trained specialists in our emergency departments.
But this is not all that is needed. I suggest that accreditation of the ACCS should come with a proviso that fellows of the College will only accept patients who are referred by their general practitioner. Of course there will be outcries about this but this is a small price to pay to seek safety for the community. A referral from a GP is necessary nowadays to claim Medicare reimbursement but historically when the first Australian specialist colleges (of surgeons in 1927 and of physicians in 1938) were established it was understood throughout the medical profession that such specialists would only see patients by referral.
In addition, there needs to be much tighter regulation of advertising by cosmetic surgeons – and indeed advertising by all surgical and medical specialists. But that is an argument for another day.
The endorsement model now proposed by the Australian Health Practitioner Regulation Agency and the Medical Board of Australia is doomed to fail because it does not address the issue of adequacy of surgical training. The inapt proposal might speed the urgently needed redesign of the entire “national scheme” for the regulation of the health professions, a scheme that is not national and that continues to be beset with problems.
A repost from Pearls & Irritations August 26, 2022