Health investigates how the cosmetic-surgery boom is changing the face of doctors’ offices everywhere.
When
her mom’s gynecologist mailed a postcard announcing she was adding
cosmetic procedures to her practice, Kristen Cortland* didn’t hesitate
to see her about the prominent bags under her eyes. “She’s a really
good gynecologist, so I assumed she’d be good at anything she did,”
says the 29-year-old Chicago-based realtor.
Right after being
injected with something called a “natural fat burner” (it was actually
a substance called Lipodissolve that has not been approved by the Food
and Drug Administration) by her mom’s OB-GYN, Cortland felt unbearable
pressure in her eyes. “Before I left her office, my eyes blew up really
big,” she says. “At home, my face got so puffy that, in profile, you
couldn’t see my nose.” Cortland kept calling the doc’s office, and kept
being told that there was no need for a follow-up visit. “Honestly, I
don’t think she knew what to tell me,” she says.
Six weeks later,
when her features finally reemerged, Cortland still had the original
problem, plus a new one: a prominent indentation between her lower
eyelid and cheek that will need to be surgically corrected. Still, she
was one of the lucky ones, says her new physician, Julius Few, MD,
associate professor of plastic and reconstructive surgery at
Northwestern University’s Feinberg School of Medicine in Chicago: “She
could have gone blind.”
If your doc hasn’t gone cosmetic yet,
it may just be a matter of time. As the cosmetic business booms
(noninvasive procedures—including microdermabrasion, lasering,
injectables, and chemical peels—are up 747 percent since 1997), more
and more OB-GYNs and general practitioners (GPs) are branching out into
aesthetic procedures. In fact, so many OB-GYNs have added lipo, Botox,
and the like to their offerings, that they’ve even created a society:
the four-year-old International Society of Cosmetogynecology.
This
trend could mean easy one-stop shopping for you, or it could mean a
really bad, even disfiguring, experience like the one Cortland had.
Here’s what you need to know to face this new in-thing safely.
What’s
fueling this boom in noninvasive cosmetic surgery—and the rise in MDs
working outside their fields of training? Two things. One, we’re a
nation obsessed with looking as good and as young as possible. Cosmetic
surgery without going under the knife is appealing to many—so many, in
fact, that 9.1 million minimally invasive treatments were performed in
2006 (the most recent year for which we have statistics). The other:
money. Botox Cosmetic (the leading cosmetic procedure) brought in
around a half-billion dollars in revenue for its maker Allergan last
year.
This new trend means quick loot for docs, too. When a
patient comes in for wrinkle-smoothing rather than a urinary tract
infection, not only does she pay a higher fee, but she pays for it on
the spot. This means that the doctor isn’t stuck chasing down an
insurance check, says Mitchell Chasin, MD, medical director of
Reflections Center for Skin and Body medispas in Livingston and
Bridgewater, New Jersey. “Many physicians are doing it because of the
effect of managed care on their practices, and all the hassle
factor—they’re running to where they think the grass is greener.” In
fact, an article on the American Academy of Family Physicians Web site
encour-ages members to add cosmetic services. The title? “Better Your
Bottom Line: Aesthetic Cosmetic Procedures Can Be Boon to FPs.”
Some
happy customers see this as the ultimate in one-stop medical shopping
(“Women want to go to one place where they can do it all,” says Beverly
Hills, California, gynecologist and cosmetic surgeon Delores Kent, MD.)
But as the number of hybrid practices has grown, so have the problems,
according to alarming new research. An August 2007 study by the
Physicians Coalition for Injectable Safety found that 38 percent of its
plastic surgeon members have seen complications due to injectables
administered by poorly trained providers.
Another recent report,
this one by the American Society for Dermatologic Surgery (ASDS), found
that 59 percent of its members (derms who do surgery) have seen an
increase in the last two years in complications caused by physicians
who were not dermatologists performing dermatologic procedures. The
number-one problem they have encountered? Misdiagnosis of skin cancer
as age spots (one in four of the derms has seen this screwup). “The
nondermatologists think it’s an age spot. And, unfortunately, they’re
not trained enough to know it’s a cancerous legion, so they’ll remove
it,” says an ASDS spokesman. The only problem: You can’t laser off skin
cancer, so it returns, generally at a more advanced stage.
This
boon for physicians, then, may be a bust for patients, says Kathryn
Hinsch, founder of the Women’s Bioethics Project, a public-policy think
tank in Seattle. “A big problem is that any doctor with very minimal
training can perform these procedures, so the potential safety issues
are high,” she says.
Brent Moelleken, MD, a plastic surgeon in
Beverly Hills, California, adds, “If patients heard about a plastic
surgeon expanding his practice to include Pap smears and
hysterectomies, they would be horrified. But they think little of
having laser procedures or liposuction done by a gynecologist. And
there is no law against either.”
The scary truth is, many
generalists who add aesthetic procedures may actually be winging it.
They often have just one day of training—if that, says Omaha
dermatologist Joel Schlessinger, MD, president of the American Society
of Cosmetic Dermatology and Aesthetic Surgery (ASCDAS). He gets
requests almost every day from docs: “They want to watch me work for
one day and then start doing cosmetic procedures.”
The classes
themselves are multiplying, too. At this year’s American Academy of
Family Physicians meeting, how-to courses on lasers and fillers were
offered alongside diabetes management and colonoscopy training.
One
of the biggest problems with quickie courses is they don’t teach what
to do when something goes wrong. So a barely trained doctor may not be
aware of simple fixes, says Krista Ramonas, MD, a San Francisco–based
ophthalmologist who sees medical and aesthetic patients, including more
and more women who come in with droopy lids from bad Botox jobs they
received from nonspecialists. “We have eyedrops that can lift the lid
after an improper injection,” temporarily fixing the problem so that
the Botox wears off evenly, she says. “But many doctors don’t even know
these drops exist.”
What continues to surprise Ramonas is the
number of her medical colleagues who are willing to take a crack at
someone’s face without knowing facial anatomy 101. “My mother’s OB-GYN
recently told her he’s doing Botox. He said, ‘We have the patient
population—women in their 40s.’ But they don’t have the experience! In
ophthalmology, we have a saying: We don’t go below the clavicle. Well,
OB-GYNs shouldn’t go above the breast.”
“Complications can happen
with a dermatologist, too,” acknowledges Flor Mayoral, MD, a
Miami-based derm. But that’s where years of study and experience come
into play, she says. A dermatologist, plastic surgeon, or
ophthalmologist has completed at least two or three years of surgical
training and has learned how to manage complications. But a
nonspecialist who doesn’t know how to spot a red flag could forge on
with horrific results—and Amy Sanders* has the scars to prove it.
Sanders,
a 35-year-old woman from Omaha, Nebraska, went to a medispa owned by a
“skin-care specialist” for hair removal. The spa’s medical director was
an MD and a specialist, but not in skin care; he was an emergency room
doc. Sanders never saw him, anyway, because a layperson manned the
laser. “She was in terrible pain during the procedure, and she said so,
which should have been the tip-off to stop,” Schlessinger says. As a
result, Amy suffered second- and third-degree burns on her legs and
stomach. And this isn’t a rarity. In many cases, the so-called trained
doctor isn’t the one injecting your face or operating the laser
machine, Schlessinger explains. “That doctor trains staff members, and,
while he’s busy seeing patients for coughs and colds, the secretarial
person is busy administering the Botox.” There are derms and plastic
surgeons guilty of handing off tweaks to support staff (which is
perfectly legal in many states), but they’re less likely than
generalists to do so because their reputations rest on you looking
great, Schlessinger says.
Bad
cosmetic surgery aside, where does this trend leave the woman who just
wants to see a dedicated MD? “Part of the fundamental trust between a
patient and doctor is the idea that the doctor has the patient’s best
interest at heart, and that there is no financial incentive for the
doctor to perform any procedure,” Hinsch says. “When doctors start
adding cosmetic procedures, which they’re adding because they’re big
moneymakers, there’s a corruption of that basic trust.” Many physicians
sidestep this ethical quagmire by never directly hawking their
fat-blasting, wrinkle-smoothing, and hair-removal services. But even a
stack of brochures in the waiting room, Hinsch insists, sends the
message to patients that looking younger is a matter of good health.
Even
if you aren’t swayed by the literature, that stack of pamphlets may
make you wonder: Am I still a priority around here? If your internist
gets $20 co-pays from you and $500 cash from the patient he treats with
Restylane, whose call will he return first? Who will he spend the most
time with during appointments?
Some docs avoid becoming “jacks of
all trades, masters of none” by slashing their patient loads or opting
out of their original fields, which causes another problem. It’s a
brain drain that could have major reverberations throughout women’s
health care, Hinsch says. “There’s already a huge crisis in the
shortage of obstetricians.” (Many OB-GYNs stopped delivering babies in
the past 10 years, unable to keep up with sky-high
medical-malpractice-insurance premiums.) Now, as the rejuvenation
business surges, obstetricians may soon become more of an endangered
species.
James Fairfield, MD, a derm in Lansdale, Pennsylvania,
teaches newbies how to use lasers and fillers—and he counts
gynecologists among his best customers. “The cost of
malpractice-insurance premiums causes them to look elsewhere for
money,” Fairfield says. “They drop the OB portion of their practices,
buy a laser, and start doing Botox and fillers.”
(Health contacted the American College of Obstetrics and Gynecology (ACOG), but
the organization declined to comment for this story. In their only
statement on OB-GYNs doing cosmetic procedures, the group takes no
position: “Because they are not considered gynecological procedures, it
is inappropriate for the college to establish guidelines.”)
So,
let’s say your doctor is hopping on the beautification bandwagon.
Should you find a new doc? It comes down to a gut feeling. Do you sense
that she’s focused on you—or that her head is somewhere else, say, on
her burgeoning medispa down the hall? Here’s a big red flag: Your MD
tells you she could do something about those bags under your eyes,
turning your medical appointment into a beauty consultation. That may
be a signal to change doctors.
If you are considering a cosmetic
tweak your doc offers, remember, “It’s buyer beware,” says
Northwestern’s Julius Few, MD, a leader of the Physicians Coalition for
Injectable Safety. “If you go outside the classic specialty group,
there is no guarantee that you’ll get someone who has any experience,”
he says.
(To help assess a doctor who is practicing cosmetic medicine out of his or her scope, see Do You Own or Rent That Laser?, and How Quacks Give Themselves Away)
Yes,
there are GPs who’ve done hundreds of cosmetic procedures and do
high-quality work, Fairfield says, “just as there are plastic surgeons
and derms who don’t take enough care and produce bad results.” But
unless you find that rare primary care provider who is truly a
subspecialist in aesthetics, you’re taking a risk.
That’s a
gamble that Cortland—the woman who received Lipodissolve from a highly
regarded OB-GYN—will never take again. “I wouldn’t go to my dentist for
a gynecological exam,” she says now. “From now on, whatever a doctor
specializes in is the only thing I’ll see her for.”
