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Become an Advocate for the practice of Ethical Aesthetic Medicine

A Q&A with Charles E. Crutchfield III, MD and Neil Shah, MD
By: Charles E. Crutchfield III, MD and Neil Shah, MD


Charles E. Crutchfield III, MD is a Board-Certified Dermatologist and a Clinical Professor of Dermatology at the University of Minnesota Medical School. He is also Medical Director of Crutchfield Dermatology.

Neil Shah, MD is a Board-Certified Dermatologist, a diplomat of the American Board of Dermatology, a Fellow of the American Society for Mohs Surgery, and a member of the American Society for Dermatologic Surgery.

While many physicians agree that maintaining a strong code of ethics is key in the practice of aesthetic medicine, determining how to achieve that can be a great challenge. Moreover, establishing the extent of a physician’s responsibility regarding the broader upkeep of ethical standards in aesthetic medicine can be a slippery slope. Obviously, there is only so much a physician can control, but the widespread abuses of cosmetic procedures in the US may demand that physicians do more than take stock of their own ethical codes. Ahead, Charles E. Crutchfield III, MD and Neil Shah, MD answer questions on the major ethical issues facing aesthetic clinicians today and how to take action.

How important is a strong ethical center in the practice of aesthetic medicine, and how does it differ in the cosmetic world from the strictly medical world?

Ethical integrity is critical whether a physician performs aesthetic or non-elective medical procedures. We are physicians first. Although the practice of aesthetic medicine seeks to optimize a patient’s health and appearance, our obligation to do what is in our patient’s best interests always overrides all other considerations, including financial interests. Aesthetic patients are often vulnerable financially and, at times, emotionally. Where medical patients seek the objective result of restoring health, aesthetic practitioners must keep this vulnerability in mind when treating those who want to make subjective improvements to their already good health to avoid harming those who seek the physician’s help.

It is very simple: In all situations, physicians must maintain the highest ethical standards and, as we learned during our training at the Mayo Clinic, always do what is best for every patient.

What’s your read on the current state of nonphysician based cosmetic services? How do regulations vary, and how are some practitioners findings ways around them?

The expansion of businesses offering non-physician based cosmetic services over the past decade has been mind-numbing. Many of these shops, commonly known as “strip mall spas,” offer services that many states literally define in statutory law as the practice of medicine, even though they have no medicallytrained staff on site. The danger of untrained and unlicensed practitioners is real, and people are being injured as a result.

For instance, an esthetician on our staff came to us after a short stint with a strip mall spa where, on her second day, the lead esthetician called in sick. The spa had two very lucrative ablative laser cases scheduled for that afternoon. The non-physician owner asked the employee over the phone if she was comfortable performing the laser treatments by herself. She told him that she had never used a laser, did not even know how to turn it on, and did not feel comfortable. He insisted she would do just fine and asked her to locate the laser’s manual so he could talk her through the procedures. Fortunately for her and the two patients, she resigned on the spot and left the spa.

A major reason strip mall spas and other non-physician based facilities have become so numerous while operating this way stems from shortcomings in the regulation of aesthetic medicine. Many states have vague laws regarding medical directorships and obligations of licensed physicians. Laws that do exist are easily abused, leading to a number of licensed physicians “renting out” their medical licenses to permit medically untrained personnel to purchase and use lasers and to perform injections of prescription medications. While these aesthetics-only companies name a medical director, that director is typically not onsite, does not individually see patients, and rarely interacts with or trains the staff who will end up dealing with potentially serious complications that may arise.

Just as troubling, even when states have reasonable regulations to protect aesthetic patients, those laws and regulations are often not adequately enforced or have penalties that are merely road bumps for unscrupulous owners pursuing profits. Any fine they face is minor compared to the money the strip mall spas can rake in by having poorlytrained, low-wage employees perform risky aesthetic procedures that truly require a physician’s training and expertise.

These enforcement failures are beginning to yield an increase in scrutiny of and pressure on state medical practice boards and attorneys general to respond to a rise in patient injuries at businesses that ignore state laws. It has also resulted in the overdue creation of credible organizations like “Doctors for the Practice of Safe & Ethical Aesthetic Medicine” to work with state agencies to inform the public of the importance of seeking care from competent, properly-trained personnel for aesthetic medical care.

How can board-certified physician practitioners compete with the low prices and cheap services provided at a medispa down the street? How can physicians win the “information wars”?

The race to the bottom is not a competition we should engage. Competent physicians do not seek “bargain basement” shoppers as patients. If a patient is more concerned with price than with results and safety, every week a different strip mall spa will have a lower price, and that group of patients will go there. It is a never-ending downward spiral. I tell patients fixated on price of a sign hanging on the wall in my grandfather’s shoe repair shop: “The bitterness of poor quality lasts much longer than the sweetness of low price.”

Although cut-rate, non-physician providers claim to offer the same services as board-certified, core-aesthetic physicians, any similarity is superficial. True service implies the ability not only to perform a procedure, but to do so safely, competently, and with the ability to deal with potential complications. This last area is where non-physician practitioners especially lack the training to ensure that their patients have comprehensive start-to-finish aesthetic care.

We recently wrote an article entitled, “The most important component about any aesthetic procedure is not price, but the person performing it,” and we provide a copy to every patient who expresses an interest in aesthetic procedures, with an emphasis on those who refer to a Groupon or other special they may have seen. We are interested in serving patients who value quality, service, and safety first, with price of services being an important, although distant fourth consideration.

Doctors for the Practice of Safe & Ethical Aesthetic Medicine is also dramatically changing the aesthetic medicine landscape by providing patients with critical information about the level of care one should require before entrusting their health to a facility offering aesthetic procedures. The number of physician-operated clinics requesting and displaying the Doctors for the Practice of Safe &

Ethical Aesthetic Medicine seal has grown exponentially over the past couple years, including international inquiries for membership in recent months.

What about clinicians who practice aesthetics but are not certified by the appropriate boards? What can/should a clinician do, not only in their best interest for the sake of competing, but for ensuring patients are receiving ethical treatment?

If your health is at risk, would you seek a dermatologist for a colonoscopy? A cardiologist to treat skin cancer?

The purpose of board-certification in a medical specialty is to identify rigorous training in a specific set of diagnoses and procedural skills. An OB-GYN is no more qualified to perform aesthetic laser surgery than a dermatologist is qualified to deliver a child. Although aesthetic procedures may appear deceptively simple (and some are fairly routine) the skill of appropriate patient selection and the ability to treat complications are why an appropriately trained aesthetic physician is essential. Only those physicians who hold board-certification in dermatology, plastic surgery, oculoplastic surgery, and otolaryngology/facial plastic surgery have adequate training through their residencies and board-certification process to ensure total competence in aesthetic procedures. We know that patients have a choice; our goal is to provide them with the best information about physicians most qualified to perform their aesthetic procedure so they can make the best choice.

With so many specialties and certifying boards for aesthetic medicine, have the lines become so blurred that patients ultimately lose out?

Although many certification boards exists, none are more rigorous than the American Board of Medical Specialties. ABMS accredited specialty boards, such as the American Board of Dermatology and the American Board of Plastic Surgery, require that accredited physicians have graduated from an accredited residency program, have passed the rigorous specialty board examination, and continue to maintain accreditation via Maintenance of Certification programs.

If a physician is not certified by an ABMS member board, he or she is not appropriately trained in his or her specialty. That is why a legitimizing organization like Doctors for the Practice of Safe & Ethical Aesthetic Medicine is so vital. It assists patients in identifying physicians certified by legitimate certification boards established by the ABMS who are committed to ensuring patients have the best possible outcomes. The key is to educate patients that Doctors for the Practice of Safe & Ethical Aesthetic Medicine is the appropriate designation to look for when considering an aesthetic procedure.

Based on trends you see now, both locally and on a national scale, what do you think the future holds for sound ethical practice in aesthetic medicine?

Aesthetic medicine may move towards a two-tiered system, similar to what is happening in other areas of medicine. ABMScertified physicians in the core aesthetic fields will provide safe, competent aesthetic care to those patients who recognize their expertise. These qualified physicians will offer higher value aesthetic care with fewer complications. Unfortunately, patients drawn to low initial prices, with the trade off of decreased safety, higher complication rates, and poorer outcomes—lower value care, will still seek non-certified, non-core aesthetic practitioners to the extent state medical boards and attorneys general permit them to continue operating. This second group of patients will continue to suffer poorer outcomes, including injuries, unless we are able to educate the public and enact and enforce legitimate protections.

Until protections are enacted and enforced, we must educate the public to require that any clinic offering aesthetic medical procedures, including specified laser treatments and aesthetic injections, always have a physician personally and appropriately examine the patient before the initial treatment. They should also require the clinic to disclose the level of licensure of anyone performing or supervising their procedure, including a credentialing board recognized and approved by the ABMS. They should look for the name and valid contact information of its medical director and require that this information be provided in printed form before any treatments or procedures, and they should make the clinic guarantee it will provide a timely personal examination and consultation with the clinic’s medical director-physician if any complications or major concerns arise in relation to a performed procedure.

What is your take-home message to colleagues about the importance of practicing ethical medicine and how to combat unethical practices?

While state medical boards, legislatures, and attorneys general move to protect the public, physicians can make progress in improving the practice of aesthetic medicine by becoming a member of Doctors for the Practice of Safe & Ethical Aesthetic Medicine (www. SafeAndEthicalDoctors.org) and providing this information to all of our patients and potential patients. A widescale marketing effort designed to educate patients about the group is already resulting in an informed public moving toward responsible care, even in the face of low-cost, low-value competition.

We must remember our duty as physicians to do what is best for the patient, not our individual interests. If we put the patient’s needs first, we are each rewarded with an economically successful practice, healthy and happy patients, and a clear conscience.