Editorials

Will the Real Plastic Surgeon Please Stand Up? I received an interesting phone call from an old friend recently. Now in her early thirties, she was considering some aesthetic surgery. Since I am a resident in a combined general surgery/plastic surgery training program, she approached me with a list of four local plastic surgeons her friends had advised her to consider. “Do you know any of them?” she asked. “One is even a plastic surgeon where you work. Who's the best at face lifts, and who's the best at tummy tucks?” I was puzzled. I had not heard of any of them. I asked around. To my surprise, I discovered that of the four people on my friend's list of plastic surgeons, only one was actually a plastic surgeon. The other three were a dermatologist, an ENT, and an ophthalmologist. These days there are numerous examples of non-plastic surgeons performing plastic surgery. As a resident, I receive an interesting and varied array of junk mail. Lately, the majority of my junk mail is about one thing: easy routes to becoming a plastic surgeon. A brochure explains that I can become the holder of a “suitable for office display” certificate in liposuction, for example. The requirements are a oneday didactic course followed by a complete “residency.” The “residency” consists of providing the gynecologist with 20 patients on whom to assist him in performing liposuction in his office and for which he will bill. “Ideal training for all types of physicians interested in performing plastic surgery,” the brochure assures me. When I was in medical school I knew a resident in oral/maxillofacial surgery. He recently completed his residency, and we are still in touch. A few months ago he told me he returned to the dental school through which he did his residency to give a lecture to his former colleagues. The title of the talk intrigued me: “Becoming a Plastic Surgeon.” He described his 6-month cosmetic plastic surgery fellowship-taken in the office of another oral surgeon without a plastic surgical residency-where he learned to perform rhytidectomies, rhinoplasties, abdominoplasties, and reduction and augmentation mammaplasties. The majority of his current practice is in breast surgery, he noted. What is going on here? Oral surgeons doing breast surgery without plastic surgical residencies. Gynecologists doing liposuction. Dermatologists and ophthalmologists doing rhytidectomies. How could this happen? In the era of managed care, physicians are being squeezed from all sides. Plastic surgery, it seems, appeals to physicians as the last vestige of fee-for-service medicine. So they join the ranks of plastic surgeons; they take a weekend course or a fellowship in “facial plastic surgery,” “laser plastic surgery,” or “cosmetic plastic surgery.” In some cases the transformation appears to entail little more than putting one's hand on the Bible, staring up in the sky, and intoning, “I am a plastic surgeon.” Amazingly, these other specialists have fooled just about everyone. The public believes that these people are plastic surgeons. My friend who approached me with the names of four “plastic surgeons” is a young professional in a high-powered job. Not a lazy or uneducated consumer. And when The New York Times needs a quote about increased plastic surgery during the holiday season, to whom does it turn? An ENT.1 Other specialties are deliberately and systematically encroaching on the field of plastic surgery. They are calling themselves plastic surgeons, performing plastic surgical procedures, and charging fees that match or are greater than those of plastic surgeons. With the current financial climate in medicine, this trend will only increase. While I have seen no studies to confirm it, I would bet that their surgical results-even for simple cosmetic procedures-are inferior to those of plastic surgeons. All the while, the image of plastic surgery is tarnished, negative stereotypes of plastic surgeons are reinforced, the specialty is cheapened, and plastic surgeons' ability to gain funding from managed care plans for reconstructive surgery and from the government for research is diminished. Make no mistake: In the long run, dermatologists doing aesthetic surgery will limit the opportunities for microsurgeons to do free flaps. The response from organized plastic surgery has been, as far as I can tell, essentially passive. Its only move to combat this trend was to reject the American Board of Otolaryngology's request for subcertification of ENTs as “facial plastic surgeons” under the aegis of the American Board of Plastic Surgery.2 But what active steps can really be taken? After all, by law, any physician with a valid medical license can practice any field of medicine without government or legal interference. There is plenty that can be done. Plastic surgeons can present public education campaigns through the mainstream media explaining what a real plastic surgeon is. How the training is broad and long and rigorous and thorough and that the skills and techniques of plastic surgeons reflect it. In fact, the American Society of Plastic and Reconstructive Surgeons has begun an ad campaign to encourage cosmetic surgery and to associate the organization with cosmetic surgery in the minds of consumers.3 However, the ads miss the mark in an important way. While they focus on the benefits of the procedures, they do not clearly explain the distinction among those who perform them. To accomplish this vital next step, the ads' catch phrase might be, “Don't go under the knife until you know your plastic surgeon is really a plastic surgeon” or “Accept no imitations: Make sure your plastic surgeon is a diplomate of the American Board of Plastic Surgery.” Perhaps the term plastic surgeon can be trademarked by the American Board of Plastic Surgery, to be used only by board-certified plastic surgeons. This would curtail the use of “plastic surgery” by all the various imitation plastic surgery boards and academies and societies that are springing up. Perhaps some investigative reporters should be notified of the problem; they might be interested in doing an exposé on dentists performing breast surgery while calling themselves plastic surgeons. The days of complacency in medicine are over. Sitting on laurels and in ivory towers will mean the demise of the specialty as a vital and creative force within medicine. Imagine if accountants started proclaiming themselves attorneys and focused their sights on performing high-profile and lucrative types of legal work. I find it hard to believe that lawyers would be as passive as plastic surgeons have been in responding to this analogous challenge. However, if the specialty is resigned to doing nothing, I hope someone will let me know. I still have three more taxing years of residency. If the value of being a real plastic surgeon is going to be completely marginalized by then, perhaps I'll consider resigning from my program. I hear there's a dermatologist with slots available in his 2-week plastic surgery training course. Lloyd M. Krieger, M.D., M.B.A. Department of Surgery; Division of Plastic Surgery; UCLA Medical Center; Los Angeles, Calif. 90024