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Wednesday
Jul182007

A Plastic Surgeon on Dermatologists & boob jobs.

RLS posts his thoughts on Dermatologists who perform surgeries while unprepared for the complications from the thread on a Dermatologist who's pissed at medspa FP's and OB's.

fingerprint_definition.jpg"In my opinion (as a plastic surgeon), we as physicians would all like to assume that we are uniquely gifted and qualified to perform the procedures and/or treatments that we do. Are there FPs, derms, ect that can do fillers, lasers, ect. better than me? Most likely.

But the real issue in regard to training and ability is not the difficulty of the procedure- I think someone above alluded to the fact that these treatments are for the most part pretty basic- but are you able, willing, and have the training (and hospital privileges) necessary to handle the complications that can arise from these treatments. If you really feel like you do, great. If not, I think you need to rethink about the disservice you may be providing to your patients.

There is a dermatologist here where I live who does breast augmentations in his office. He advertises heavily and has a pretty busy practice, but when he runs into trouble with his cases (which is not infrequent), he calls the ambulance, tells the driver to take them to the ER of the nearest hospital (of which I am on staff), and tells the patient "good luck!!". The ER doc calls the plastic surgeon on call And now it is our problem to deal with. Now my afternoon is shot because he does not have the ability to deal with the complications. Not fair to me, and certainly not fair to the patients.

just my two cents"

Not having much experience with sending patients to the ER, I'm somewhat surprised by this and would like to hear some thoughts regarding complications that require an anbulance exit.

Reader Comments (11)

I for one am happy that RLS has posted his thoughts and I'm looking forward to hearing more of them. Not only do I agree with him but it's about time that the plastic surgeons on the site started commenting more.

07.18 | Unregistered CommenterDr. Grumpy

I am also happy that RLS has responded. I am always lookinb for ways to improve my practice and sometimes the improvement is listening to others and their concerns.

I want to know what others true concerns are. I do not want the concerns that are political or fear of competition. I think RLS's concerns over the situation he mentioned are valid. If I were the derm mentioned I would want to know the concern and fix it. If that means learning to take care of the complications than he needs to take care of the complications. If he does not want to learn how to take care of the complication then he should quit doing the procedure.

I think the majority of physicians on this site are always trying to improve the care they give to patients. I want to take care of the patient from the beginning to the end of a procedure even if there is a complication.

I hope that RLS and others like him will continue to post their concerns as well as ways they feel things can be improved.

07.18 | Unregistered CommenterLH

Patient goes to his FP Doc for his monthly appointment for high blood pressure. During the office appointment the patient has a heart attack. The FP Doc calls the squad who takes the patient to the hospital. Should the FP Doc be required to know how to perform the necessary heart surgery before she can treat high blood pressure?

07.18 | Unregistered CommenterPro Docs

Er... That's a red herring. What your analogy should be is this:
Patient goes into FP. FP decides to perform surgery. Patient has a heart attack during surgery. Doc calls 911. And yes, an ethical physician should be careful since complications will happen. Knowing that complications will happen, a doc should act in the patients best interest when they do. If you're next door to an ER... maybe.

07.18 | Unregistered CommenterDr. Grumpy

Dr. Grumpy,

There is no red herring in my post. I asked a simple question. You changed the question but I think I agree with your different analogy. Let me ask the question in a different way.

Patient goes to Wrinkles-R-Us for a face treatment. Wrinkles is owned and operated by a knowledgeable and experienced FP Doc. Unfortunately, on that day, the Wrinkle Master Laser malfunctioned because the machines auto calibration unit quit working, which resulted in a bad burn and cut on the patients face. The FP Doc owner of Wrinkles called the squad and they took the patient to the hospital for needed surgery. Question (similar to above): Should the FP Doc be required, authorized and permitted to perform the necessary surgery at the hospital before she can use the Wrinkle Master Laser?

As to the ethical argument, which I see often on this site, after federal law, state law, medical board rules and regs and other legal requirements, ethics, like art, is in the eye of the beholder.

07.18 | Unregistered CommenterPro Docs

People;

It may be more of a legal question than ethical argument. In the state that I practice medicine (and I believe in most if not all states) it's a medical board regulation that a physician have: 1)admitting priviledes, 2)in an accredited hospital, 3)within the area of his practice, 4)for any procedure performed outside the hospital. That's why a Urologist can't admit a fractured hip for surgery, etc.

On a personnal note, I tried to get privileges at a local suri- center for Liposuction procedures but was refused because I did not and could not get hospital admitting privileges at a local hospital.

Compliance with this regulation prevents the "drop-off syndrome". Non-compliance is out side of regulations and ILLEGAL!

07.19 | Unregistered CommenterJRAMD

I'm the one who originally posted about doing procedures that "you may not be able to handle the complications of" and the reponse was that....when was the last time you saw a plastic surgeon repair a bowel perf from a lipo... ( or a Gastro from a colonoscopy for that matter). So, I think there's a level of comfort that docs have to develope w/ a procedure and a system to deal with complications..its as simple as that.

07.19 | Unregistered CommenterDermaRogue

I agree that if I got a bowel perf from a lipo (perish the thought!) I would call in one of my general surgery buddies to help, but I am board certified in general surgery as well as plastic surgery, and have hospital privileges for both.

Look, you and I both know that most plastic surgeons are not going to go waltzing into the OR and do an exploratory lap for a bowel perf without a little help from someone who does it daily. Whether I have the experience and privileges may be seen as posturing to some, I personally feel very confident that I can handle just about every catastrophic potential complication from the procedures I do, and have the blessing of the state medical boards and the hospitals to back me up.

07.20 | Unregistered CommenterRLS

i would guess that most plastic surgeons could not handle a severe retrobulbar hemorrhage after a lower blepharoplasty requiring more than a canthotomy and cantholysis, could not handle severe lid retraction after the same procedure requiring hard palate grafting to correct blinding corneal exposure, or handle injury to the inferior oblique muscle requiring strabismus surgery to correct debilitating diplopia. just a few examples from another specialty that would need consultation from something considered a 'routine plastics procedure'.

I agree that it is not OK to dump your patients at the ER. I am an FP and I do have admitting privileges at our local hospitals. For the things I do infection is the most likely reason to have an admission.

If you are smart, you will have a working relationship with a specialist or surgeon to assist with any complications should they arise. As you can see above, it is unlikely that you can as a physician (no matter what your training is) be able to handle ALL possible complications. I have seen plastic surgeons consult dermatology etc. So there is always some gray area.

JRAMD, you should look at your state laws. The states I have been licensed in do not require you to have privileges at a hospital to do an in office procedure. Most of those things you are talking about are in the by-laws of the surgi-center or clinic. Also, you will find some malpractice insurers will not cover you unless you have privileges for a specific procedure at a hospital.

07.21 | Unregistered CommenterLH

LH, I agree that many of these regs are multi-level. However, NJ (and most other states) specifical addresses this issue. The following is an excerpt of the regulations copied right from the NJ medical board site.

On June 29, 2005, the State Supreme Court affirmed the Appellate Division's decision upholding the Medical Board regulation governing Surgery, Special Procedures and Anesthesia Services Performed in an Office Setting, Processing of Alternative Privileges applications has resumed. Physicians and podiatrists who do not currently possess privileges at a hospital to perform the surgery (other than minor surgery) or special procedures which they intend to provide in their offices need to obtain these privileges from the Board. In addition, the rule now prohibits a physician from concurrently performing surgery or special procedures in the office and supervising the administration of general or regional anesthesia by a certified registered nurse anesthetist (C.R.N.A.). For implementation guidance, please click here. For the application for an exension, needed only by physicians who are concurrently performing surgery or special procedures in the office and supervising the administration of general or regional anesthesia by a certified registered nurse anesthetist (C.R.N.A.).Please click here for the application for an extension .

As you can see more states are moving to reduce the amount of these surgeries and potential complications preformed by untrained physicians. And again, compliance prevents the 'drop off' syndrome since you'll be able to follow your patient thru the hospitalization process and failure to obtain privleges remains illegal in NJ.

08.1 | Unregistered CommenterJRA

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