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« Medical Spa MD: Why email doesn't work. | Main | Core Physicians, Non-Core Physicians and Non-Core Physician Extenders »
Monday
Feb092009

Dermatologists vs Plastic Surgeons vs Non-Core Physicians vs Non-Core Physician Extenders.

The MAPA blog has a new post up with a number of comments about dermatologists, non-core Physicians and non-core physician extenders competing for cosmetic medical dollars. Here's a blurb:

For years, dermatologists and plastic surgeons have been arguing about whether noncore physicians have a place in cosmetic medicine. Now, it seems more competition is likely, as nurse practitioners (NPs) and physician assistants (PAs) are pursuing careers in this lucrative field.

One way to thwart this trend is to deny them access to MD-directed training.

(Name Deleted) MD, also gave his viewpoint. Just because more NPs and PAs are assisting physicians doesn't mean doctors should give them even more control, said the clinical professor of dermatology.

"The more you promote them, the more problems we'll see," said (Name Deleted), alluding to NPs and PAs who act independently without physician supervision. Others set up their own practices with a name-only ­doctor on the payroll. The result, said Dr. (Name Deleted), is the potential for increased patient complications and a watering down of the expert skills dermatologists provide.

Reader Comments (7)

Here's my opinion:

1. non-core physicians should not be performing cosmetic SURGERY, or any surgical procedure that they are not properly trained and credentialed in, regardless of the type of anesthesia used. "If you didn't complete an ACGME-approved residency in it, then don't do it".

2. Non-surgical, or medical procedures (injectables.) can often be safely performed by properly trained physicians of many specialties. But they need to know when they are over their head - and to refer to core-trained physicians in these circumstances.

3. Physician extenders, valuable though they are, require medical supervision by a physician supervisor with more cosmetic experience, training and/or credentialling than the extender they are supervising. This should ideally be on-site supervision.

4. Non-physicians, other than as listed above, have no business in cosmetic surgery or cosmetic medicine.

Tom

----

Tom: What is your definition of "cosmetic surgery"? I would assume that your comments would apply to derms as well? What is your opinion of derms vs.non-derms practicing "aesthetic medicine"? I have always been curious what would beleft if you subtracted the course work specifically related to skin diseases from all the standard dermatology curricula. Perhaps a new short track specialty could be created which would provide everythingthe standarddermatology specialtygenerallyminus the hours devoted to skin diseases.

---

I have only done Aesthetic medicine (a speciality in Canada) since 2003. Those in my area that have tried to do a little cosmetic medicine on the side have actually been good for my business. One primary care physician(now left the area) and the other plastic surgeon did not do effective treatments and people came to me on the rebound. The patients willing to travel to the larger city to the North of me for the cheap prices go to a "doc in the box" situation where the physician is hired to come in once/twice per week. These patients rebound to me as well. No one has been permanently injured by their treatments that I am aware. However, they are all mad about the money they wasted. When they come to my office, they are not yet turned away from trying another person out and I strive to do my best in giving them the treatment/outcome they want no different than any other patient, though.

I believe that no matter what, I do no harm, but I want to do the best treatment possible for my patients. The rapport with our patients is parliament.

Yes, I don't like competition because most of our patients,women, are shoppers. However, I price my services above average, because I give them the best treatment that I can. The difference is that my services are the best value for their money, period. I don't sell my self short. As a business, I am not Walmart, but I believe my services and all of us on this email list are above Macys or Nordstroms or any other high end business you can think of. All of us care enough to ask others how to do the best treatments for our patients. We are professionals and people need to know that our quality is thee best and they need to be aware of the quality involved with our services. How do we do this?

Can we stop non-physicians or NP's from starting up cosmetic businesses? It may have to come about through each state's regulation. In my state there is no law that states a non-physician can run any class of machines, there are only suggestions of care. I would love to be Aesthetic Medicine Board Certified if it meant anything, see 4M's new money maker.... Any others, suggestions?

Sandra

---

I don't worry excessively about the competition in the area, whether it be from other PS, derms, or non-core providers.

I just try to do the best I can for each patient....and word about who's good gets around by itself.

My prices are about market average, and we don't try to be the cheapest.

BTW: the word you are looking for is "paramount", not "parliament" :)

Tom

---

I think a differentiation needs to be made when talking about Providers. You have PA's and NP's which are lumped together because they are the only non physicians who can legally practice medicine, though their education is significantly different. Then you have a list of others which are allowed to perform specific duties depending on state.

Most people including physicians are not familiar (unless you work with or teach them)with PA education and training. This is an FYI not a confrontation, I know my limits and place as a PA.

PA's are educated in the medical model, the curriculum is the same as MD's but some non essential aspects are truncated in order to expedite the process to clinical practice. Three current program "specialties" exist; primary care, surgery and emergency medicine.The coreis essentially the same with much overlapbecause of national accreditation to sit for the board exam, all schools in all states follow the same criteria. A residency (16 specialties currently) is optional at this point but encouraged. Yes, even Dermatology and Surgery are available.

PA Residency Specialties

http://www.appap.org/prog_specialty.html

Curriculum From Albany Medical College (example is the one I attended). If you think they must be watered down, check the course description link at the bottom.

http://www.amc.edu/Academic/PhysicianAssistant/Curriculum.html

Sandra, I think its too late to stop this at a state level. This has been in motion with PA/NP for almost forth years at a state and federal level.

Tom, I have to respectfully disagree with you. Saying "If you didn't complete an ACGME-approved residency in it, then don't do it" is saying a physician or provider can not learn outside of this environment. We learn new and reinforce the already learned constantly as medicine advances. Example; I perform hair transplants, the donor area can get large 1.8 cm wide x 15 cm long. Ihad experience in lesion removal and suturing prior. I learned this procedure (and several others) from an experienced general surgeon 35+ years. I would 1st assist then he would 1st assist me, when we were both comfortable he would observe, coach and teach. Now I am on my own with indirect supervision. My skills do not compare to your surgical expertise, but I think its the providers responsibility to be in their scope of education and training on what they do.

NP's are educated in the nursing model. There is obvious cross over when they reach the clinical training. NP's help me out here.

By 2015 all NP programs will be doctorate level, DNP's.

PA's have also breached the doctorate level. The first was about two years ago US Army/Baylor university put out it's first doctorate level PA's. Course included a rigorous 18 month EM residency. Interesting note; the PA's forego the title "Doctor" in order not to confuse the public of the gold standard of medicine.

Some articles of interest.

Greg

---

Greg:

No disrespect to you. I enjoy our conversations and respect your skillsas a PA. I took a look at a few of the surgical PA programs you listed - and they look like a good 12 month experience.

However, if we really compare things to a medical model, that's like completing a 12 month surgical internship after finishing med school.

It would certainly allow you to be proficient at relatively straightforward procedures, but even a good intern is not on the same level as the chief resident, or the attending.

My comment about ACGME-residency doesn't deny the possibility of postgraduate learning. It's just to state my opinion that taking a small number of weekend courses doesn't somehow "convert" a non-surgeon into a cosmetic surgeon or plastic surgeon-equivalent, as the AACS seems to think.

Tom

----

Hey Tom,

No disrespect taken. This is good dialogue! As always your comments are intelligent, well thought out and accurate. My disclaimers purpose was to be clear that I was not trying to offend or challenge anyone in our discussion group, only to educate and pass on information about the PA profession. There are still a good number of physicians (and others)that think a PA has no business with a stethoscope, rx pad, scalpel, laser, etc.... I think this opinion is largely based on a lack of information on PA education and training, or a misconception that PA's push for practice independent of physicians. My goal was to have those of this opinion take a second well informed look. NP's push and push hard for total independent practice very openly and looks like they will soon get it. The PA professions motto is "partners in medicine", and do not seek independence. The issue is, most allied health professions (nurse, pharmacist, physical therapist...)have a doctorate level of education available. PA's must follow suit to be competitive education and training wise, trying not to step on the toes of our greatest allies being physicians (MD, DO).

Your analogy of a surgical residency trained PA is excellent. I agree with you on the superior level of chief resident and attending. This is why PA's are dependent practicioners. I would describe my personal PA experience as a perpetual residency, I just get paid more.

I also agree with your opinion on the difference between CS and PS. "Weekend courses" do not give one expertise on anything. The AACS stance does not take into account the years of training in reconstructive surgery. I'm going to sit this one out, its an issue the physicians can argue out.

Greg

Wow -- an interesting discussion. I am Board Certified in both Family Practice, (and was even eligible in ER) and at no time in my training did I learn squat about cosmetic medicine. I was an FP practicing amongst the Amish in the late 70's with enough training to deliver babies, do C-Sections and if called on in a third world country could easily do old fashioned gall bladder surgery and appendectomies. But, my FP residency was tilted toward the surgical (my choosing).

As an FP I knew nothing about the organ called skin.
I would maintain (no offense) Plastic Surgeons know little about skin either (as an organ) beyond some basic and some even skilled surgical manipulation.

My derm training taught me everything I know about the skin, and CME keeps me abreast. I learned flaps from the renowned dermatologist Len Dzubow in Phila. (Several books on the subject of surgery of the head and neck.) I do them to this day.

Here's my big point -- those of us with experience (read = age) learned all of our cosmetic medicine at various courses -- some nonsense in quality -- others outstanding. I made a point of going directly to masters for mine so I could perform my art well. Sometime this meant going internationally.

I have a PA who does injectables under my supervision and as a technician she rivals many barely trained doctors. Reason? I trained her.

My staff of Medical Assistants, LPN's and RN's do laser work -- all taught by me -- with ongoing training as well. The repetition they do daily makes them expert -- and I supervise them. None of us in my office take a "cookie cutter" approach to laser settings -- varying them with subsequent setting changes based on client goals and response.
All of my staff know laser physics -- because with that knowledge they are less likely to do something stupid. It's my ass in the sling.

I daresay there are a lot of "non-traditionals" out there who have done as much due diligence as I -- and deserve their place amongst us -- but unfortunately I know a bunch who ought to stop -- now! I take care of their screw-ups -- so I know they exist.

We can't take the position of assuming formal credentials makes a perfect cosmetic surgeon -- we all know those with credentials who couldn't sew their way out of a paper bag without leaving dog ears or infection.

This is a tough issue. Responsibility lies with each of us to perform our art for the ultimate benefit of our clients. Turf wars based on degrees and memberships have little place here -- for those are indicators of interest -- not of skill or good judgement.

Respectfully submitted,
Jim

---

Tom,
You asked I take a stab at the categories:
Here're yours -- in blue -- with my thoughts in black following (special note -- for convenience I have reverted to the male, "he" rather than attempts to be politically correct -- no offense to the amazing women out there who should simply replace "he" with "she", etc.)

1. non-core physicians should not be performing cosmetic SURGERY, or any surgical procedure that they are not properly trained and credentialed in, regardless of the type of anesthesia used. "If you didn't complete an ACGME-approved residency in it, then don't do it".

Cosmetic surgery was a term defined by providers first -- then an academy formed to attempt quality control. There's a wide spectrum in this category ranging from the mundane (a tech could do it if adequately trained and supervised) to the extremely complex -- such as breast augmentation -- best left in the hands of but a few plastic surgeons (for many don't seem to have the 'art' of body symmetry in their heads.) Note I said, just a few -- for even their board certification hasn't saved many from 'bad jobs'.

Last time I looked, my license says "Medical Physician and Surgeon". Since much of what we do is learned over time as the onslaught of change and technology develops we need personal boundaries governing what it is we do to people -- our clients. I never just take a course, for instance. I like to find someone renowned for "doing it best" and get hands on (not look over the shoulder) training.

Understand -- even in the best of hands, "shit happens" -- but I'm not talking of this. One plastic surgeon I know went on regional TV showing his placement of contour threads in the dermis proved Contour threads didn't work, when , in reality he put them in the wrong place. His client had blue lines throughout her face -- on ABC TV. Must have used the original brand to boot. How embarrassing for him. But he wasn't -- being ignorant of the procedure's technique. Board certification doesn't help ignorance.

My point is a good "cosmetic surgeon" is one who has a personal interest and honest curiosity with firm knowledge about human facial and body anatomy, coupled with graceful and artistic surgical skills with an appreciation for pre-existing naturally occurring body/facial asymmetry. He then plys his craft effortlessly, constantly altering his approach as the tissue before him "talks to him" for the best alignment. There are lines he simply will not cross because of respect for the client and his own integrity. He bails before the fact -- referring before putting his client in trouble.

I would say the plastic surgeon's turf includes breast augmentation/reduction, and myocutaneous flaps -- plus anything else he has done repetitively in his training requiring his special expertise. For instance, brain surgeons have no problem with their turf.

Other surgical procedures safely done in office surgery set-ups can be done by those adequately knowledgeable of anatomy plus the necessary skills to deliver results well within the comfort zone of confidence garnered from adequate training. I do a modification of the S-Lift because I figured out a way to do it better via different flap closures. No biggy -- just illustrating the fact that what I call "listening to and observing living tissue" is what makes the difference between a good surgeon and one who consistently produces outstanding results.

The plastic surgeon who trained me in SmartLipo warned me not to do what his highly regarded Board Certified colleague did -- rammed the probe right through an abdominal hernia into the gut. Hmmm -- anatomy and a respect for the unusual (always a possibility) anyone?

Seems our dilemma is what kind of doctor do you want to be? And trust me -- Board certification won't save you or your client when things go south.

Tom -- here's my rule. I do what I know beyond a doubt I can do at least as well as anyone else -- or better. And I'm always looking for creative ways to do it better.
If I want to do something more, I go find a teacher who has done thousands of cases and can tell me the "insider secrets" for best results and keeping out of trouble. I never go just to the doc (no matter his certification) who's pimping for a laser company. One more step always is to find someone else who knows what he's doing cold.

2. Non-surgical, or medical procedures (injectables.) can often be safely performed by properly trained physicians of many specialties. But they need to know when they are over their head - and to refer to core-trained physicians in these circumstances.

Totally agree. Oddly enough, I've had frustrated clients from plastics come to me. There's this elusive thing called "the art of medicine". It a blend of Sherlockian curiosity coupled with hard science -- because just like flying a plane you must abide by the laws of physics or you'll auger in.

3. Physician extenders, valuable though they are, require medical supervision by a physician supervisor with more cosmetic experience, training and/or credentialling than the extender they are supervising. This should ideally be on-site supervision.

Total agreement -- and in most states -- the law.

4. Non-physicians, other than as listed above, have no business in cosmetic surgery or cosmetic medicine.

Cosmetic medicine includes many entry level "stuff': products (medical grade), facials, microdermabrasion, peels (both acid and laser) and many non-ablative laser procedures. I believe a properly trained staff person (RN, MA) operating under my supervision will provide higher quality results by the sheer fact of repetition (under supervision) with results matching or exceeding that of a physician doing it occasionally.
This is safe for the client -- often better (women dealing with women) with results from someone who does it daily being enhanced.

Quite frankly -- I'd rather fall on a sword than do bikini line laser hair removal. My esthetician and medical assistants have become expert in this -- and my time is leveraged to do what I want -- facial surgery, earlobe repair, laser lipo, etc.

Cosmetic surgery is a wide concept -- anything done to the skin or body to alter (for benefit or correction) by invasion of tissue. From what I've seen, results are all over the map on this -- regardless of credentials. There's "good guys", "bad guys" and total experts out there. Certified or self-taught doesn't seem to matter much here except for general quality (or standards) of care guidelines.

One of the best known, (internationally) published, and sought after eyelash transplantation surgeon lives in Mexico -- is self taught and very inventive. Nobody can match what he does.

What makes him so different? His love of what he does ... and his love for his clients.

That's what makes a great cosmetic surgeon.

Best to all as we add our two cents to this most stimulating and important conversation.

Jim

---
Jim:

Thank you for your thoughtful reply.

The problem is: for every person like yourself, who cares about their quality, and their patient outcomes, there are 10 who say, "don't restrict me - my licence says I'm a surgeon, so I'm gonna do cosmetic surgery, whether I'm trained / good / etc. or not, because I'm legally allowed to."

This doesn't help the patient in the end. Personal boundaries, unfortunately, are subject to abuse to egotists.

So, with this in mind, why don't you try writing a concise set of rules like I did. I think you'll find it's harder than you expected.

Best regards,
Tom
---

Tom,
Writing rules is a difficult exercise indeed and I give you credit for doing so. If rules such as yours were implemented I think a grandfathering clause for those who've proven merit would be necessary after which they too would be credentialed in some way.

I agree about the pollution of charlatanism within what is termed "Cosmetic Medicine" and "if we don't police ourselves ... etc." someone else may do it for us.

I can't write the rules -- you're correct -- too difficult.
Perhaps the answer lies with the public -- letting them know what's in store for them if they choose the wrong doctor/facility.

May I say to the MAPA/Epstein group -- to all who are PA's, estheticians and the like that you are not being targeted in this discussion -- for your interest in this forum indicates the dedication both you and your doctors share to the proper delivery of quality care to your clients. It's the poison without that is our common enemy and we must in some way differentiate ourselves from them.

Tom has shown leadership in this and his words have merit.
Lots to think about,
Jim

---
Thank you for your discussion. It appears you are quite experienced. Which courses and journals do you recommend? Who are the masters that you can go to for training? What do you think of the American Academy of Aesthetic Medicine, because they give out board certification? Their teachers are from all over the world. Which courses are good for Asian skin? I would also appreciate any reply for the group.

Sincerely,
Carolyn

---
I believe the best way to learn is one-on-one from very experienced physicians. GOing to courses can only take you so far. In regards to treating Asian skin, you must get the experience directly from treating the patients and sharing info with others of same practice profile. I have been treating Asian and Hispanic skin for the past 5 years and I still get surprised by certain skin reaction from patients

Kevin
---
ASLMS had a full half day on treating patients of color. It is GREAT! and a must for anyone serious about treating patients with lasers. If you can't go, you can order the CD from www.ASLMS.org and listen to it.

I have probably learned the most from reading the blog threads on MedicalSpaMD and talking to the experts there, like Kevin, Lornell, Greg, Tom, etc. I copy the thread and print it. I read it and underline and study what people are saying. Give this a try and your will learn more then you can learn at any conference!

I think the discussions we are having right now with our email list is a great way to learn. We will be taking these discussions to MedicalSpaMD for archiving and further discussion.

Jeff E

Jim:

Thank you for bringing rational thought to this discussion board. I've posted here before with my observations and opinions and have gotten nothing more than angry rebutal from irrate PS's. The truth is that ( I have performed over a 1000 tumescent lipos in the past two years) being board certified in a so-called "core" speciality matters little when it comes to cosmetic procedures such as tumescent lipo, fat transfers, and similar "surgeries". What does matter, however, is a thirst for knowledge, diligence, constant and never ending improvement, and a desire for perfection.
I've been the witness to some G-d awful results from very well respected "core" physicians over the past few years. And I have "repaired" a lot of "botched" surgeries. Perhaps it is a belief of theiir own superiority and self-rightousness that gets in the way, or perhaps the fact that having a piece of paper on the wall does not give one the artistic temprament to acheive superior results. Having the ability to perform a muscle flap or skin graft does not necessarily translate into the ability to carve a delicate waste with a canula. Don't get me wrong, I'm not deriding PS's in general, but those who think they get better results because of some piece of paper. In general however, it has been my observation that the best results are from those physicians who pay attention to detail, strive for perfect, and are committed to constantly improving their craft, irregardless of what school they attended, what residency they completed, or what association they are members of. And what I have observed is that patient's, for the most part, don't care either. They want to look good....period. We can all argue about who is better, who is more qualified, and who should and should not be doing which procedures, but the bottom line is that our patient's are really the one's making the decision for us. They are the consumers of our wares and services. If you get good results, you will get patients no matter what is written on the piece of paper on your wall. And if not, well...there is always insurance based medicine.

08.9 | Unregistered CommenterBotoxdoc

It's not the piece of paper per se that counts, Botoxdoc. It's all the years of training, the written and oral examinations, and the due diligence that go into being awarded the certificate that counts.

You are jumping up and down, shouting "I'm just as good as you". While that isn't for me personally to judge, it's certainly not becoming.

Thank you board certified for the debate. Obviously having completed a GS residency then a two year Plastics fellowhip is something to be respected, but it doesn't by default give one the innate ability or artistic temprament that many non-boarded cosmetic physicians also have. Nor does it exclude non-boarded physicians from acquiring those abilities.
I think we can all agree that certain PS and Derms are better than others when it comes to results. Likewise, there are those physicians who have initially been trained in another specialty but, who have a natural inclination and eye for the esthetic and are gifted in creating a pleasing outcome using the raw materials of hyaloronic acid and the like. A good analogy is the watercolor artist. It is very easy to dip a paintbrush in paint and put marks on paper, yet it is the talented few who can create a masterpiece with the same basic materials. And no amount of schooling or training can give one that innate ability.
One can argue that having completed a fellowship in plastics, and having studied the human form one would be better equipted, however, there are many non-boarded physicians who are capable of the same. And when it comes to cosmetics, our patients are the one's who make the final decision, not you or me or a medical board. One of my high school classmates is now the curator at a museum. She holds a PhD in art from a very prestigious university. Yet her work, although she is talented, remains unrecognized. Van Gogh on the otherhand had no formal training, and worked as a clerk in a bookstore.

08.10 | Unregistered CommenterBotoxdoc

For what it's worth, I worked at a well-respected university in Florida in the dermatology department. This university has a dermatology and dermatopathology residency program.
I am a PA and primarily performed all of the aesthetic procedures for the department --- all the injectables (botox, fillers), all the lasers (Nd:Yag, Alex, Fractionated CO2), the IPL --- and had an acne clinic where I would also sometimes incorporate aesthetic procedures.

The dermatology residents had little, if any, training in aesthetics as part of their entire dermatology residency. They were frequently asking me if they could hang out with me if they had any extra time to learn more about aesthetics. They told me that some programs had a little more aesthetics incorporated than they did, but of course to produce board certified dermatologists every program has to complete the same requirements.

I have to say, it made me angry.

Angry that Florida restricts satellite offices offering aesthetic services to dermatologists and plastic surgeons only when all the dermatologists that come from this program are less experienced and have less training than I do. Angry that forums like this exist where physicians bicker about who is qualified enough to do what when all of you are more "qualified" than me yet I'm willing to bet I'm more skilled than some of you. Angry that there are still physicians that have no idea what PAs are, and because "assistant" is part of our title, think the supervising physician should be standing right outside the door in case some horrible Botox injection accident should occur and the "1/2 trained" PA couldn't possibly handle it (though the law usually requires indirect supervision - the physician within reasonable distance and always available by phone, etc.).

The highest trained person always thinks anyone less trained than them cannot do the things he or she can do. That's just how it is.

A plastic surgeon thinks no other physician can do those procedures they do.
A dermatologist thinks no one should be messing with anything related to the skin.
Several physicians in general wonder why PAs write prescriptions; how can a PA possibly understand the physiology behind what he or she is prescribing?
PAs think that nurses probably shouldn't be injecting Botox (nurses can't in florida).

And then it goes in reverse:
Nurses who inject Botox think they can do it just as well.
PAs who do aesthetic procedures realize they can be just as well trained as a physician, when even supposed associated residencies don't even teach it.
General/other physicians think that they are doctors, of course they can learn/do any medical procedure.
Derms say that dermatologists pioneered liposuction in the first place, so it is not only for plastic surgeons.

The reality is, few residencies teach it. That means most all of us learn it outside of formal education.
Some people have a passion for it; a love, really.
Shady people want to take a weekend course to "try to make some extra money."

I think the only people who should be performing these procedures are ones who are capable of safely and effectively performing them, and most importantly, are able to recognize and treat complications should they arise.

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How did Kaan Keskin sneak in?

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