Modern Aesthetics | Editorial Board Forum: Physician/Surgeon Autonomy
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Editorial Board Forum: Physician/Surgeon Autonomy

What are the greatest threats to physician/surgeon autonomy?

Jeanine Downie, MD: The greatest threat to my autonomy is the very aggravating regulation in medicine. Whether it is MOC, EHR, ICD-10, and/or increasing insurance regulation.

It appears that any prescription I write today is simply denied by the insurance company as if I have no medical training or expertise in my area. We do need to have a strong political action committee like SKIN PAC to argue on our behalf. We also all need to get involved.

E. Victor Ross, MD: The biggest loss of autonomy will be the ever-increasing burden of the EMR for short appointments for specific dermatologic problems. As part of a big institution, we are obligated to basically fill out lots of EMR blanks that are irrelevant to the nature of the visit (e.g., weight for a Botox visit).

Paul Carniol, MD: When performing cosmetic procedures we have the greatest autonomy compared to other practicing physicians. However, this still does not grant us immunity to the issues in the healthcare environment. Based on experience as President of the Medical Society of New Jersey, I believe there are multiple threats to physician autonomy. For example, different states have varying laws and regulations. These can include mandates for all physicians for certain CME activities, disclosures, and/or forms etc.

The greatest threats to autonomy in the immediate future relate to mergers in the healthcare institutions. These can involve hospitals, multispecialty groups, insurance companies, etc. As these become larger and more powerful, individual physicians are more limited, losing autonomy.

Joe Niamtu, DMD: “Threat” and “defend” are words for insecure people who are afraid of competition. You have to talk apples and oranges in this discussion. You can’t assume that all “non-core” docs do poor work and hurt patients and that all “core” docs are excellent. We all know that there are good injectors who are not typical cosmetic specialties and there are terrible injectors who are in the “core.”

The word “core” is accurate to describe the common specialties that receive certain training in their residencies. Beyond that, I think it is self-serving and self-anointed that a group of people got together and crowned themselves the chosen ones of injectable proficiency. It is not accurate. It is misleading, and it is economically driven. If we were talking about some Medicaid procedure, I don’t think that anyone would fight to control this domain. It happens that injectables are lucrative, and anytime you have profit involved competition enters the forefront.

What is important here is competent treatment with happy patients and low complications. I (oral and maxillofacial surgery/Cosmetic Surgery) am not considered “core,” but I am one of the largest users of neurotoxins and fillers in the entire southeast. Saying that only one type of person should inject is “professional discrimination”…Proficiency transcends the self-imposed barriers that people erect when profit is involved.

Gregory Buford, MD: I have been cash-based for over a decade and so, fortunately, am not affected by insurance regulations as are many of my peers. However, I see the government regulating medicine more and more in an attempt to hold accountable what they see as “greedy doctors,” when in reality many of the people making the greatest amount of money in the healthcare system never even attended medical school. These are the hospital administrators and those heading the large insurance companies. Greater regulation of the medical profession is not going to create better doctors; instead, it is going to frustrate those of us who are already practicing and deter those thinking of entering the medical profession from doing so. To add insult to injury, many of those in the press do not have the courtesy to even refer to us as doctors or physicians any longer. Instead, we have been downgraded to the catch-all term: “medical professionals.”

Joel Schlessinger, MD: The greatest threat is competition from inappropriate providers. Contrary to Dr. Niamtu, I do indeed feel the proliferation of wannabees is a threat to us. This is mainly due to inappropriate treatments and unethical treatments, which seem to be higher in the population of medispa providers than bona fide, core specialists. When individuals go to these fly-by-night places they generally don’t say that the provider was the problem but often think the injections were the problem and never do them again or have great difficulty considering them in the future.

Dr. Buford: To say that that a physician cannot inject Botox simply because they are not “core” is probably not going to work these days. Many of these physicians are getting trained and are seeking out these services simply because they can’t make ends meet in an insurance-based practice, and so this trend is not going away. However, the injection of Botox or fillers is completely different than some of the surgical procedures that these “Cosmetic Surgeons” are now offering. When I hear about an internist who is offering liposuction or breast augmentation despite the fact that that they have zero residency training in the area but just happened to shadow another doctor for a few days, it really surprises me. But what surprises me more is the fact that patients are choosing these practitioners not because of expertise but because of a lower price point.

I would like to see more transparency from all physicians (including me) regarding rate of complications.

I know of several such professionals who have had devastating complications and still practice “cosmetic surgery” simply because their patient base is not informed. And this is not right. I was taught that you should never offer a procedure without knowing how to both diagnose as well as treat potential complications associated with it.

With respect to facial injections, I am seeing more complications from inexperienced injectors who don’t recognize complications and simply brush them off and don’t treat them with urgency. I recently treated someone with localized necrosis who was told by her injector that this was simply a local infection that would go away with topical antibiotics. Luckily she was referred to me early on and we were able to limit the local tissue injury. Any program that trains injectors should focus not only on where to inject but also where not to inject and what signs and symptoms suggest that a complication has developed.

Dr. Niamtu: Some of the biggest “core bullies” that disdain a given specialty injecting have two or three nurses injecting in their office. There is a lot of hypocritical ideation with this core concept. To me “core” is a dynamic concept, as 20 years ago perhaps only derm and plastics were involved with cosmetic injectables. Today, injectables are core training for many specialties. In many areas many Family Practice, OB/Gyn, General Dentists, Nurses, NPs and PAs and other specialties also perform injections. Most probably do it pretty well and the ones who don’t will have negative consequences and shy away.

Does consumer misinformation threaten autonomy?

Jennifer Walden, MD: The Internet and more mainstream media have an effect on the quality and quantity of medical information that reaches the consumer. I counsel prospective patients asking for a specific procedure that they must come in for a consultation where I will perform an in-person physical exam and get to know what their goals and desires are, as well as determine if they seem to have realistic expectations. I will then give them the options in treatment, and let them know if they are a suitable candidate for the procedure that they desire. I also try to counter misinformation on the Internet and other forms of media by offering my own accurate content via my website, social media channels, and television segments/ magazine articles. I collect the information and make it presentable and readily available online. 

Dr. Downie: Some people who watch medicine on TV believe that they instantly become doctors. Additionally, patients underestimate the difficulty and expertise involved with cosmetic procedures. They think everything is easier than it actually is. I handle this by educating my patients. I talk to them about what to expect with every procedure.

How can core specialists ensure practice success, protect patients?

Dr. Niamtu: Education should be seamless and benefit all. Could you imagine anyone saying that “only core” should be able to use antibiotics? I am happy to teach anyone who wants to learn and has the background, training, and legal status to become competent. Am I worried about these people taking my business? Not really, most of them will just dabble in it and this is a free market economy so they are going have to work harder than I do to make a dent, and I work pretty darn hard.

Although injectables are controlled by a relatively small number of specialties now, I predict the future will be very different and like many other countries you will see a much more ecumenical dispersion of practitioners providing these services. Some of them will not be proficient and they will have outcome and legal problems. Others may become busier than the mainstream injectors because they are good and have predictable outcomes.

The only doctors who should fear competition are those who are not committed to excellence and allow others to overtake them by providing better patient service, experience and outcomes. None of us look forward to having 10 more offices next door doing what we do, but life is all about competition and upping your game. The elective medical and surgical business is no different.

Dr. Walden: Consistent messaging and public education about the training, credentialing, board certification, and recertification process that we as core providers/MDs go through is key. Our professional societies can also leverage their ability to reach a larger audience for us to further that message. ASAPS had done a great job with this via their Smart Beauty Guide campaign ( 

Dr. Buford: Education is key as is transparency. I emphasize to all of my patients how experienced I am with a particular procedure and what I have seen in my practice…I encourage them to ask me as many questions about my background as possible and encourage them to do the same with any other practitioner they are potentially working with. I find that many practitioners new to the aesthetic arena are not as transparent and certainly not as truthful. I also explain that it costs far more to fix a bad result than it does to get a procedure done right the first time around.

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