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« Botox & The "Spock" Look | Main | Interview: Dr. Mark Mofid, A Plastic Surgeon In San Diego, California »
Friday
Aug312012

The Value Of Board Certification In Cosmetic Medicine?

Board Certified Plastic Surgeon

Is it better and safer to get Botox injected by a family physician who has been injecting patients for 15 years or a newly graduated plastic surgeon who just finished his residency last week?

In Cosmetic Surgery, the term "Board Certified" is the most highly used term for marketing purposes today. Thirty years ago, many doctors were "Board Eligible" or non boarded and their value came from their training and their experience and their expertise, not just a label. Today, doctors are expected to be board certified in something. That something is the topic of heated battles and debates and many of our colleagues are just as confused about it as are our patients and the public and the media. Insurance companies and third party payor and even hospitals require board certification and may use it for determining reimbursement. 

The American Board of Plastic Surgery (ABPS) and The American Board of Facial Plastic Surgery (ABFPRS) have had many decades of heated nasty all out warfare. For the most part, on the surface at least, the war is over but small battles and skirmishes are still waged amongst these two specialties here and there around the country. But cosmetic surgery is no longer being offered purely by Plastic Surgeons or Facial Plastic Surgeons, Oculoplastic surgeons, Oral surgeons, otolaryngologists, & dermatologists are a significant part of the cosmetic surgery providers. More over, family physicians, ER doctors, Radiologists, OBGYNs, and other doctors whose specialty is not traditionally associated with cosmetic surgery are now the fastest growing population of cosmetic surgery providers with Botox and fillers and lasers as their entry to the more involved mini facelifts and blepharoplasties and liposuction. The American Board of Cosmetic Surgery and the American Board of Laser Surgery has given this large heterogonous group of non-cosmetic surgeons an umbrella to gather under and a label to use for marketing and validation.  

The American Board of Plastic Surgery and The American Board of Facial Plastic Surgery have now joined forces in order to "protect the public" and inform the media and public about the lack of proper residency or fellowship training by many of these new non traditional providers.  Protecting the public is a noble endeavour and a great cause but I ask who is going to protect the public from less inept members of the American Board of Plastic Surgery and the American Board of Facial Plastic Surgery?  There is no doubt that the vast majority of poor cosmetic surgery with bad outcomes are being performed by Board Certified doctors, most of which are actually certified by these two esteemed Boards (ABPS and ABFPRS). 

Then what is the true value of "board certification" and how will the public be protected? We must police and control our own profession as a whole before we are controlled by outside forces. In Ontario Canada, a deal between the society of Plastic Surgeons and the Department of health posed a new regulation where no one other than a plastic surgeon could use the term "plastic surgery" in their advertising! So, is it better and safer to get Botox injected by a family physician who has been injecting patients for 15 years or a newly graduated plastic surgeon who just finished his residency last week or even from a nurse who works at a plastic surgeons office? This is a tough question that needs to be answered by us doctors before it gets settled for us by external forces. 

Reader Comments (27)

Great question, but one that I would think would be easy enough to answer. In damn near every cosmetic procedure that I can think of, it's expertise that counts, not paper. I can't see how anyone can keep a straight face and claim that Botox should only be injected by boarded docs. Liposuction maybe... but trying to tell an ER doc that he can treat trauma and not crows feet because it's 'unsafe'? Common...

08.31 | Unregistered CommenterINDMD

Two things:
1. what matters is the training obtained by the MD to perform the procedure. Too often, the primary specialty is what is "used" to rule in or rule out a doc from doing a procedure. One of the best laser practitioners in the world who is extremely well respected is a nurse practitioner and I know one of the worst is a "board certified" MD by a plastic board I will not name. One can be great at some procedure, but that does not lessen the amount of training required to pick up a new procedure. The problem is when an MD from any specialty starts offering botox or a laser procedure without seeking the proper training.

2. I may have misunderstood the authors comment about the ABLS (and I apologize if I did), but as the Executive Director of the American Board of Laser Surgery, I disagree with the statement about the "umbrella to gather under and a label to use for marketing and validation." The ABLS has a rigorous written and oral exam, an extensive qualification package of education, training, experience and number of procedures to apply, does not discriminate regarding primary specialty, and is the most well respected laser board internationally. The ABLS does not allow any certified practitioner to improperly advertise and it only certifies the most highly trainied and experienced laser practitioners. How the practitioner performs, acts, and advertises after certification is, like all boards and certifying programs, beyond the control and responsibilty of the boards. Practitioners should individually be held responsible for their own actions.

"...who is going to protect the public from less inept members of the American Board of Plastic Surgery and the American Board of Facial Plastic Surgery", indeed.

While every one of my boarded colleagues is very fond of trotting out a slew of the "didn't know what he was doing and I had to fix" stories about non-boarded docs injecting Botox or fillers or whatever, we all know that it's the application of skill and experience that provide safety, not board certifications.. especially when it's their RN or PA who's the 'injector' in their office.

I appreciate that this thread was posted, but I have yet to see the surgeon who would rather inject than cut.

09.3 | Unregistered CommenterCSL MD

What matters is training and expertise. Without training expertise is dubious. Training is obtained independent of titles, board certifications or the name of your residency.

Training is what matters most for patient safety.

This has and continues to be one issue close to my heart. The Facial plastic surgery organization has accepted a "treaty" offered by the (general) plastic surgery organization whereby the facial plastic's will never condone their members operating outside the head and neck, and will state that the only acceptable surgeons for facial plastic treatment are those certified by either the ABFPRS or the ABPS. The (general) plastic organizations are suppose to accept the facial plastic folks as properly trained in plastic surgery of the head and neck. However, nasty anti-competitive comments and back - biting statements and actions about the superiority of (general) plastic surgeons continue. This "divide and conquer" philosophy has placed the facial plastics (and even dermatologists) into the snake pit with with their self-proclaimed enemies intent on eliminating or severely limiting the oppositions influence, and influencing law makers to pass rules and make regulations that prohibits or restricts competition, under the guise of protecting the public interests.
This policy is manifested in many ways. Lobbying efforts with state and federal elected legislators, infiltration into state medical boards, control of hospital credentialing and privileging committees, state political action committees formed to aid
members into doing their part in putting out the "correct" message to the public in each members website, at public presentations, and on media interviews, national PR firm involvement to spread the "gospel", and of course, large annual "voluntary contributions" to fund this effort.
Board certification does not mean "Proficiency", only that a physician/surgeon has passed a test representing some fraction of knowledge felt to be indicated for a particular specialty. The bottom line is the public will always need to research a physician's training, experience, and results, and no piece of paper will substitute for that due diligence.

A newly minted plastic surgeon may have just graduated from a residency but during his or her training has gone through rigorous education, practice, and examination to pass board exams. They should not be discounted as someone who has no clue what they are doing. As to
The ER doc that treats major trauma... Yes, he could cause major hat treating crows feet if do e improperly. There is a reason why we have specialists. You wouldn't want an orthopedic surgeon doing your facelift, and you don't want a cardiac surgeon doing your hip replacement (at least not if you care about the results)

09.3 | Unregistered CommenterMartin

I am willing to bet that any graduating plastic surgery resident will be better at doing Botox, fillers or laser than any ER, FP, or OB-GYN graduating resident (i.e. same amount of time following residency). The PS residents now get quite a bit of training in these areas during residency. Let's do a real honest study: any takers?

09.3 | Unregistered CommenterTF

Is cosmetic medicine even recognized as a specialty?

@Martin, I wasn't discounting boarded docs as having no clue, but I am suggesting that passing a board in one of the cosmetic specialties doesn't impart skill or experience outside of that specialty. (It is, after all, just a test.) Many of the common cosmetic treatments are entirely nonsurgical. Suggesting that one of the surgical specialties (which are needed) has some innate control over everything cosmetic is just hubris, and the same thing that has been going on since the 70's between the derms and the plastics. Anyone with a lick of sense can see that it's more about marking territory and the wallet than anything else.

This is not to say that the specialties are not needed. They are, but being boarded doesn't impart a blanket halo outside of that board certification.

09.4 | Unregistered CommenterCSL MD

Very interesting discussion. One that we've all been involved with before of course and I don't see it ending in the near term.

I'd be curious as to what the author - and the other authors on this site - have to say about these comments.

09.4 | Unregistered CommenterDermgal

Great topic that has been in debate for a very long time. I’ve been involved in the Cosmetic, Plastic and Reconstructive business for the last 12 years in a non-clinical capacity. I admit I had been brainwashed by those certified by the ABPS or involved with them in some way. I’ve been the Fellowship Coordinator for a world renowned board certified plastic surgeon and have seen 6-8 physicians who had just completed Residency come in to our program and have very little “cosmetic” surgery experience from school. I’ve since worked for a board certified cosmetic surgeon and although that board is not recognizable by the American Board of Medical Specialties, his Fellowship was more intense than any Fellowship approved by the ABPS. He, like physicians sitting for their plastic surgery boards took both written and oral exams.

It comes down to putting responsibility on the patients to do their research on the doctor. Admit it, there are “bad” doctors whether they are board certified or not and whether it’s with the ABPS, ABCS or any other board.

Concerning Botox…I personally would go with someone with experience no matter what their title is as long as they are approved over someone who just got out of school. My Botox and Fillers have primarily been done by a RN Injector and she’s done a better job over some physicians that I’ve seen do it.

I interviewed at several plastic surgery fellowship programs, and I can tell you that one of the main reasons I ultimately decided against pursuing a fellowship in plastic surgery was that almost all programs had cosmetic/aesthetic surgery as only 10% of their curriculum and that was during the last year. The other 90% was dedicated to reconstructive surgery.

09.4 | Registered CommenterZMD

This is an issue with medicine in general, not just cosmetic treatments. The de facto standard of board certification has evolved from several dubious foundations. There is turf protection, of course, with the anointed ones closing ranks to bar encroachment by others taking "their" procedures. Aggrandized ego plays a role, with certified docs feeling superior to non-certified docs simply on the basis of certification regardless of actual relative skill and experience of the individual. The ubiquitous use of "Board Certified" as a marketing tool has drilled the idea into every patient, giving the public the impression that a non-certified doc is automatically less qualified. Attorneys play on that perception, using certification for defense and lack thereof as an assault. Privileging committees are lazy, preferring to more-or-less rubber stamp allowable procedures based on certifications rather than vet candidates for individual experience and skill. They are also aware that attorneys will make use of non-certification in the event of a suit.

What is missing is actual data supporting that certified docs actually provide better care. Some studies suggest they do, mostly in regard to specific, very narrowly defined treatments. Others have shown certified docs have higher rates of complications even when adjusted for the patient's clinical status, perhaps because they are more aggressive. Others show no significant difference.

The fact is that doctors on the whole are very intelligent, academically capable, and professional. Most have had broad enough experience in training to have developed at least basic multi-disciplinary skills applicable to expanding their scope of practice. Bad apples exist with and without certification, but few physicians undertake treatments for which they not made an effort to become reasonably proficient.

09.6 | Unregistered CommenterJillD

This section of comments has been very good. As the Executive Director of the American Board of Laser Surgery, part of my job is to work with state medical boards, societies and licensing agencies to help improve these issues, for the sake of proper patient care. If any of you are interested in helping me with your individual state regulations, read below and contact me. I am basically looking for someone in each state who can help me determine current laws and potentially work to improve them if needed.

The Board is highly interested in the promotion of standards for the efficacious and safe use of lasers in medicine. We are currently engaged in a fact-finding exercise to better understand the landscape of current and pending regulations for use of medical lasers across the United States. To that end, we are seeking members who would be willing to assist the Board by contacting their local state medical board, health department, cosmetology board, and/or radiation/laser regulatory board and obtain copies of current and pending regulations.

In addition, we also seek to understand the state of regulations internationally.

If you are able to assist, please contact me at drseiler@seilerskin.com.

Thanks very much for your consideration and kind regards,

Warren B. Seiler, MD
Executive Director
ABLS

http://abcnews.go.com/Health/oregon-doctor-charged-death-botched-cosmetic-surgery/story?id=17104454#.UE_PAq5418E

09.11 | Unregistered CommenterLP

The turf war continues through the authority of the medical board especially here in Texas. Doctors who are not "plastics " but have many years experience in Liposuction (over 2000 cases) as well as in injectibles are being brought before the board under ridiculous premises such as incomplete medical records and "lack of training" for their job. Not looked at are the low complication rates and ability of the docs but the Plastics are winning since fighting the board cost upwards of 20k not reimbursed by malpractice. Anyone else see the conspiracy?

09.20 | Unregistered Commenterdocfrog

TF: It could be a splendid idea to compare the results of core and non- core physicians. But I would go even further; why not to make the results an absolute requirement for practicing aesthetic medicine? Aesthetic, I mean.
I wonder, the multitude of monstrosities we "admire" on the streets and TV screens, celebrities and wanna-be celebrities....do you think the majority of those anti-aesthetic masterpieces" come from the offices of core or non-core physicians?
You see, Plastic Surgery is a wonderful specialty, requires years of practical education and can deliver fabulous results. Of all "aesthetic" specialties Plastic Surgery deserves our utmost admiration...because it can, technically, deliver results that could be magical. It can! But does it? Do all Plastic Surgeons deliver what they should...the aesthetic results? Do majority deliver or only a small percentage? Assuming the training is comparable in all Plastic Surgery residency programs why some results are great and some truly pathetic?
Plastic Surgery training teaches how to perform many procedures in many variations. They teach how to enhance breasts and cheeks but not the need for these . You may learn the best techniques for face lift but...how many hours of training is devoted to the art form? To reals meaning of "Aesthetic"? There is no semiological research in the sense of asking questions: “what are the ideal breasts for a given woman?", "what are ideal buttocks?", “ideal legs”? what is ideal nose?”, “which lines and folds need not to be corrected?", “what are ideal lips for a given face?”
The “ideal”, for clarification, is not the subjective concept of “the most beautiful”! It is the sum of many anatomical, cultural and artistic components that may give rise to admiration.
In any cosmetic procedure, artistry is paramount. There is a large degree of medicine, science and technology involved in the Aesthetic Medicine, and this is what we as doctors are taught and must learn. Knowledge, experience and continuous learning are extremely important, but we must not confuse these with the term “skill”. Without the artistic skill, without the passion and, above all, without understanding of the art form the beauty is void and the end results are left to the gamble of chance.
In Art, the knowledge of art and experience with looking at it, without the artistic skill may produce, at the best, a very knowledgeable and experienced art critic rather than artist. Unfortunately in Aesthetic Medicine, it is immaterial whether one has skills or not. There is no artistic scrutiny at any level or at any stage. Edgar Degas explained this very simply:
“ Painting is easy when you don’t know how, but very difficult when you do”. Almost anyone with minimal training could remove tattoo using the newest and most sophisticated lasers. But very few indeed, would have a skills to create one.
The most important aspect of Aesthetic Medicine is a simple awareness that although lasers, Botox, fillers, implants and scalpel may bring about the most amazing and artistically pleasing results, these are just raw, passive, and obedient tools without built-in recipes for beauty or guarantees for aesthetic magic. These may come only through skills and knowledge of those who use them with artistic responsibility regardless of individual taste.
And this is the reason I like the TF's idea of challenging the skills of physicians practicing Aesthetic Medicine in general.
The "controversy" related to who should and should not use the lasers, injectables etc. has nothing to do, whatsoever, with the ultimate results of these procedures. It is a silly, childish chest-thumping posturing that has no place, nor weight, in the real world of Aesthetic Medicine.

If you haven't completed several years of training and didn't take the board, you are not a plastic/cosmetic surgeon. That's how simple it is.

I am a "non-core" physician boarded in internal medicine. I switched my practice exclusively to cosmetics and probably do more laser treatments and injections that 90% of the practicing dermatologists. I have no interest in doing facelifts or treating skin cancer, so even if I could, there is no point in going back to residency to meet the requirements to sit for a plastics or dermatology board certification. It would be nice if there was a board of cosmetic medicine which would certify practitioners based on meeting extra training requirements and testing relevant to the field of aesthetic medicine.

There is a board for laser that not many know of. Please see www.americanboardoflasersurgery.org the ABLS was established in 1984. I am the Executive Director and a Board Examiner. Email me if you have any questions at drseiler@seilerskin.com

Very interesting discussion thread. I am a member of the American Academy of Cosmetic Surgery, and on the Board of Trustees for the California Academy of Cosmetic Surgery (CACS.) We, together with our parent organization, (AACS) have been fighting a battle for equivalency for a decade. Our requirements are no less stringent than those of the ASPS, and yet the AMerican Board of Medical Specialties has yet to recognize us, in spite of several judicial mandates to do so. I agree with all the comments that reflect that Board Certification, in and of itself, is not a guarantee of either a skilled practitioner, nor a good outcome. Non-invasive procedures (Botox, fillers) were done previously exclusively by non-plastics practitioners, because the Plastic Surgery community turned their backs on these procedures as being ineffective and beneath their status. Now they have recanted, and have embraced these modalities, having seen their value (both to patients and to practitioners.) Although I am not a plastic surgeon, I attend many of their conferences. A highly respected plastic surgeon and leader of the plastics community, Dr Foad Nahai, made these statements himself at the 2011 ASPS conference.

All this infighting is a shame and discredits our profession. There is plenty of work for all of us. Turf and territory wars, in the end, hurt us all.

11.21 | Unregistered CommenterAlex Denes

I am encouraged to see a healthy debate among my pears in the above postings. I believe the argument resides in a political, territorial dispute rather than one of skill and competency. From my own experience, it is clear to me that board certification in Plastic Surgery does not in and of itself assure competency or safety. Yet, the traditional media is seemingly fixated on it. The argument that BC PS's use recurrently that they had to "fix" a bad outcome by a non-boarded physician is stale and entirely inaccurate. In my experience, the opposite is true. I have repaired at least a dozen or more "botched" liposuction cases. Botched not by non-boarded PS, but by BC PS's. My clinic is based in Florida, yet patients have come to me from as far away as Saudia Arabia, central america, and the carribean. I have performed over 3000 lipo cases in the past five years with only 5 minor complications. Yet, according to Florida Board of Medicine I'm practicing outside of my scope. And current legislation is being enacted to limit me. While the wording of the legislation is seemingly innoccuous, in practice, I am finding it very difficult to comply with their regulations eventhough my clinic is fully ACLS compliant. I hold an unrestricted license to practice medicine. I guess that doesn't mean anything anymore.

12.20 | Unregistered Commenterlipodoc

"Board certification" is a marketing gimmick and turf battle. Ultimately, it is a battle that the societies cannot win entirely because patients are not stupid. Most understand that artistry is not something that can be certified or awarded by a board of gray haired luminaries. I have been surprised at how eagerly the media have swallowed this pseudo distinction, but its partly because there is no voice effectively championing the other side. A site that is inclusive of non core docs competing with Real Self to provide information to the public does not exist (Make me Heal used to provide such a forum, but seems to be fairly inactive lately). AACS has not effectively challenged the idea that only core docs should be doing cosmetic procedures in the public forum. There is no unifying slogan that non core docs say that is equivalent to "Board Certified." There should be! Until we stand up for ourselves, we will get run over again and again. Until we stop bowing our heads in submission to core docs and believing that we are second rate practitioners we will be treated as second rate by them and the media. If AACS and the other organizations are serious about promotion of qualified non core aesthetic practitioners, they will set up an online patient forum to compete with Real Self and seriously discuss pushing back against the existential assault of the core establishment.
alexander rivkin md

I think it is all overdone, and really it is just a way for the boards to make money and try to exclude others from a particular area of medicine. Most of the recent advancements don't come from plastic surgeons, and in general they are the last to embrace less invasive techniques. As for liposuction, their own journal (Aesthetic Surgery Journal, Vol 31, #2, Feb 2011) in reporting about liposuction and trends indicates that most complications occur in the hands of ASPS members when using laser lipo.

Training DOES matter, but it does not have to be from these groups to produce good outcomes. I am not a member of either, yet I have had the privilege of giving several lectures at large national aesthetic meetings on liposuction, fat transfer, and stem cells. Bottom line - the training program is probably good, but it is the individuals who make the difference in outcomes. This is exactly the same for those of us not "board certified".

As to public protection, forgive me for sounding pessimistic, but I believe these are really just code words for "protect our turf".

02.25 | Unregistered CommenterM Johnson

I am oculofacial plastic surgeon, and I can tell you that I am much more qualified to do eyelid procedures or face compare to a general plastic surgeon. But they are the one that have board certificate for these procedures! And people think they are the qualified surgeons for these procedures!!!!!
I asked one of my plastic surgeon friends, when was the last time you did any eyelid gold weight surgery for a patient, and he said I only did one during my residency.
These procedures are routine for oculofacial plastic surgeon along with many other eyelid procedures.
So as you can see the boards are based on old specialties. My specialty did not even existed at the time of the creation of these boards.
I believe the board certification at this point is a way of controlling other specialties that are new by the older specialties. I don't believe it has anything to do with patient safety!!! It has become very political as well. Yes, we need new classification of board certification and new requirements! Unfortunately this has been delayed for many years for as I mentioned for political reasons and nothing more. The boards need to be changed!!!!!!!!!!!!
Please if you know anything different let me know.

02.27 | Unregistered Commenterrostami

Board Certification is a Marketing tool used by people who are poor physicians. Granted it is a standard set by your peers and this holds weight, but to be used as the only criteria people should use to choose a physician is non-sense. Too much importance is given to this. It is only 1 piece of the puzzle. The cream always rises to the top most lay people realize this. Unfortunately people are beginning to equate certification with skill level, not true.
I am currently triple certified.

I firmly believe this whole issue has become one of prejudice. There is no difference between the certified and non-certified doctors argument than racial prejudice.

03.3 | Unregistered CommenterSessa,A

It is unfortunate that the term board certified does not mean the same it did a decade ago and mostly because of the explosion of cosmetic activity. The American Board of Medical Specialties only recognizes certain boards as authentic; however some societies eg this one requires very stringent activities to become board certified. unfortunately not all do and some board certification is granted to weekend courses. it is also true many doctors market themselves as cosmetic surgeons which they may not be and claim board certification--but the patient must be aware that he may not be board certified in what they think. some doctors simply open cosmetic practices without any training whatsoever thinking they can perform such "simple" procedures. basically the patient really needs to adhere to a strict caveat emptor.

03.29 | Unregistered CommenterElson, MD

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