The final report from the ‘Independent Review of the Regulation of Medical Practitioners Who Perform Cosmetic Surgery’ announced 16 recommendations ‘to improve patient safety in the sector’ – and all have been accepted by both AHPRA and the Medical Board.
The independent review was commissioned by the Australian Health Practitioner Regulation Agency (AHPRA) and the Medical Board of Australia (MBA) in November 2021, ‘in the wake of media reports that raised various concerns about alleged conduct of some medical practitioners in the sector’.
The purpose of the independent review was to examine the existing regulation and regulatory practices in use by AHPRA and the relevant National Boards to ensure they have kept pace with rapid changes in the cosmetic surgery industry and to make recommendations for any required changes.
The Review noted: ‘Today cosmetic surgery is a significant commercial industry. Concerns have been raised that practices and methods of promotion by some registered health practitioners within this industry may be creating both ethical dilemmas and significant patient safety issues.’
It also emphasised that ‘regulation of cosmetic surgery is multifaceted, involving multiple state, territory and national regulators. Effective regulation requires clarity of roles and responsibilities and efficient information sharing.’
Overall, the review made 16 recommendations for action that AHPRA and the MBA ‘can take to improve patient safety, within their sphere of influence, including by setting minimum standards about the education, training and qualifications expected of medical practitioners who perform cosmetic surgery, improving the way in which AHPRA and the MBA manage cosmetic surgery notifications, strengthening regulation of advertising, and using guidelines to set clearer expectations for medical practitioners who perform cosmetic surgery’.
Key Findings: enforcement & oversight
In its Key Findings, the independent review declared bluntly that it has ‘highlighted unsafe practice, misleading advertising and substandard marketing across the cosmetic industry’.
As a result, AHPRA has set up a targeted Cosmetic Surgery Enforcement Unit – with an immediate injection of $4.5 million for extra resources – to ‘accelerate action and step-up enforcement’ as well as a separate Cosmetic Surgery Oversight Group. (See Breakout Boxes for details)
In addition, AHPRA announced it ‘will enforce the ban on testimonials in cosmetic surgery advertising as they are likely to mislead, deceive and trivialise the risks’.
AHPRA and the Medical Board also ‘welcomed any action from Health Ministers to protect the title ‘surgeon’.’ And AHPRA chief executive Martin Fletcher pledged to act immediately, in partnership with Medical Board of Australia.
Fletcher noted: ‘I am appalled by the tragic stories of patients who were harmed by doctors taking advantage of them – the situation is totally unacceptable and must change.
‘I respect the courage of people harmed by cosmetic surgery who shared their story with the Reviewer.
‘We want everyone who chooses to have cosmetic surgery to be better informed and protected. We want doctors who undertake cosmetic surgery to be trained to a safe standard. We want the public to feel confident they are going to be well looked after and, if things go wrong, that they will be supported and that their concerns will be acted on.
‘We will use our legal powers in full to better protect consumers who choose cosmetic surgery. Registered practitioners in the industry can expect a relentless focus,’ he said.
Minimum training standards ‘non-existent’
The review found that for cosmetic surgery ‘universal minimum standards for education, training and qualifications are non-existent in Australia.
‘It is therefore possible for any medical practitioner to offer and perform invasive cosmetic surgical procedures without having undertaken appropriate training or having amassed sufficient supervised experience to reach an acceptable level of competency.
‘In these circumstances, consumers are largely left on their own when it comes to selecting a practitioner to perform cosmetic surgery, having to sift through a plethora of advertising and marketing material and try to make sense of numerous qualifications, in an attempt to identify a qualified and competent practitioner.’
The review recommended AHPRA and the MBA use the ‘endorsement’ process provided in its governing legislation (the National Law) to establish minimum qualifications for medical practitioners wishing to perform cosmetic surgery.
An ‘endorsement’ recognises that a person ‘has an extended scope of practice in a particular area because they have obtained a specific qualification approved by the MBA’.
The training programs leading to the qualification ‘also must be accredited by an independent accreditation authority’. Once established, it ‘will be easy for consumers to identify whether a practitioner is qualified to perform cosmetic surgery’ (as the endorsement will be listed on the AHPRA public register).
A public education program about endorsement ‘will also be necessary; however, conveying that consumers should ensure their practitioner has an endorsement is a much simpler message to communicate than the current unacceptable situation’.
The review emphasised ‘cosmetic surgery, like any other form of surgery, is invasive and carries risks. It should only be performed by highly trained practitioners. The standards set for an education and training program by the MBA, in consultation with the AMC, will have to be very high.
‘Only rigorous and robust programs that appropriately train practitioners in the necessary aspects of surgery should be accredited.’
Significant ‘under-reporting’ of safety issues
The review noted one of AHPRA and the MBA’s key functions ‘is to receive and manage notifications about the performance, conduct and health of medical practitioners, including taking disciplinary action against them when it is necessary to protect the community’.
But to take disciplinary action, they ‘must first receive notifications’ – and notwithstanding that the National Law places an obligation on registered health practitioners to make notifications in certain circumstances (including where they observe that a medical practitioner is placing the public at risk of harm), the review found there is a significant under-reporting of safety issues by registered health practitioners and employers in the cosmetic surgery sector.
The review recommended AHPRA and the MBA ‘review and enhance its educational material for practitioners about making mandatory and voluntary notifications, and undertake a targeted education campaign in relation to making notifications aimed at the cosmetic surgery sector, including other health practitioners who may subsequently treat cosmetic surgery patients (eg, emergency department staff).
To ‘handle and respond to notifications about cosmetic surgery matters’, the review
also found ‘some improvements to the way cosmetic surgery notifications are assessed and investigated are necessary’ and made recommendations aimed at enhancing the regulatory response – including ‘development of training and guidance material for staff specifically about the management of cosmetic surgery notifications to enhance consistency and rigor in the handling of these matters’.
Information flow between regulators
The review noted AHPRA and the MBA are part of a complex and multi-jurisdictional system that regulates cosmetic surgery in Australia.
It found that to appropriately manage notifications that are received, those bodies ‘need
to understand the roles and responsibilities of all the regulators in this space and be able to work effectively with them’.
The review recommended AHPRA and the MBA ‘take steps to improve the flow of information between regulators’.
Advertising risks & regulation
The review observed that ‘owing to the unique nature of the cosmetic surgery sector – including that it lacks the protective measures found in other parts of the health system that inform consumers and direct them to qualified practitioners – advertising poses risks not present in other areas of medical practice and needs to be well regulated’.
The review was ‘concerned with tactics employed by some practitioners, particularly on social media, including using images of models who are unlikely to have had cosmetic surgery, to promote a particular surgical procedure, content that actively encourages people to pursue what is promoted as a socially accepted or perfect body type and the use of influencers to promote procedures.
‘This is particularly concerning when regard is had to research suggesting a connection between social media use and the increasing incidence of body dysmorphia and other body image concerns – particularly among young women’.
To safeguard against some of the concerning impacts of cosmetic surgery advertising, the review recommended:
- that stronger enforcement action be taken about high-risk matters;
- an industry-specific audit be undertaken to inform future proactive auditing of such advertising, including using technology to assist with this;
- that AHPRA and the MBA revise its Advertising Guidelines and/ or produce additional material specifically about cosmetic surgery to clarify the standards expected of practitioners.
MBA codes/guidelines ‘not adequate’
The review also examined the MBA’s codes and guidelines – a way the Board ‘can seek to influence good medical practice by making their expectations clear to practitioners and the community of the standard expected of doctors’.
The review found the MBA’s Guidelines for registered medical practitioners who perform cosmetic medical and surgical procedures ‘are not adequate and should be strengthened’.
The review recommended these guidelines are ‘updated, with improved clarity in relation to matters such as pre-operative screening, informed consent and post-operative care’.
State variations in facility regulation
The review also noted the ‘state- by-state variation in approach to facility regulation – a matter outside of the control of AHPRA and the MBA – potentially exposes patients to undue risk’.
However, the review considered there is ‘an opportunity for AHPRA and the MBA to take a lead in seeking to facilitate reform in areas outside its powers and responsibilities, where patient safety issues have been identified.
The review concluded ‘the cosmetic surgery sector has become somewhat of a market disrupter, as it sits outside existing traditional health system frameworks that tend to ensure patients access appropriately qualified medical practitioners.
‘Regulatory responsibility is dispersed through a patchwork of national and state/territory agencies, all with different roles to play to address consumer safety issues present in the sector.
‘In these circumstances the unique nature of the cosmetic surgery sector poses regulatory challenges not normally experienced in other areas of medical practice and calls for more unique solutions.’ AMP
Cosmetic Surgery Enforcement Unit
AHPRA will establish a Cosmetic Surgery Enforcement Unit to work with the Medical Board to achieve 7 goals.
- Set clear standards to make it easier for consumers to know who is trained and qualified to do cosmetic surgery safely. AHPRA will create an area of practice endorsement in cosmetic surgery. A doctor’s registration on the public register will show if they have met clear standards in cosmetic surgery set by the Australian Medical Council and the Medical Board of Australia. If Ministers change the Law to protect the title ‘Surgeon’, then only doctors with AMC- accredited qualifications could be called Cosmetic Surgeons in future.
- Crackdown on advertising to enforce a ban on testimonials that mislead and deceive consumers and trivialise risk, by cracking down on advertising and social media used to promote cosmetic surgery. AHPRA will update and enforce advertising restrictions and use new technologies to audit social media, backed by tougher regulatory action.
- Tackle under-reporting – not one of the serious matters featured in recent media coverage was reported to AHPRA by a medical practitioner before it was broadcast, even though many doctors and nurses provided patients with much-needed follow-up care. Silence allows poor practice to go unchecked and this harms patients. No doctor wants that. AHPRA will encourage reporting of patient harm in the cosmetic industry so they can act more quickly to keep patients safe. It will also write to every doctor in Australia so they know what to report and when, and why it’s the right thing to do. Patients will be safer when doctors, nurses and other health practitioners understand their professional responsibility to report unsafe practice.
- Strengthen patients’ voice by targeting the misuse of non-disclosure agreements (NDAs) to gag consumers in the cosmetic industry. AHPRA will launch a campaign to remind consumers that honest disclosure to regulators is legal and their right when things go seriously wrong. It will also set up a confidential hotline for cosmetic complaints, to make it safe for people who are currently too scared to report harm.
- Reinforce and strengthen existing guidelines. The MBA will strengthen its guidance for medical practitioners performing cosmetic procedures and surgery by stepping up scrutiny and enforcement of the requirements in the Board’s code of conduct and other guidance for medical practitioners who work in the cosmetic industry. It will require practitioners to inform their cosmetic surgery patients of their registration type as part of the ‘informed consent’ processes. This will ensure patients are aware if their doctor does not hold specialist registration.
- Changing the way to deal with complaints. AHPRA will change how cosmetic surgery complaints are handled in a bid to remove dangerous doctors more quickly. It will centralise experience and establish a national team of regulatory experts to investigate complaints and make decisions about cosmetic complaints. National decision-making will be led by the Chair of the Medical Board Dr Anne Tonkin, supported by an expert investigative team of AHPRA staff, backed by co-opted external regulatory expertise in forensic investigation and social media scrutiny.
- Working with others. AHPRA will work with state and territory health authorities to close current loopholes and address inconsistencies in areas such as facilities licensing and drugs and poisons rules, which are outside our authority and control. These problems are outside National Scheme or practitioner regulation powers and remit and are contributing to patient harm. We look forward to action from jurisdictions to address these issues.
Cosmetic Surgery Oversight Group
AHPRA will also establish a Cosmetic Surgery Oversight Group to ‘sharpen the governance and oversight work’ of the new Cosmetic Surgery Enforcement Unit.
This Group will ‘report publicly on progress and assure the community, governments and professional stakeholders that we are doing what we have committed to do, as quickly as possible’.
The Oversight Group will be established by AHPRA Board Chair Gill Callister and will include an independent member who is a ‘recognised champion and expert in consumer protection’.
MBA Chair Dr Anne Tonkin said it was clear that ‘stronger action was needed now’ and committed the Board to action, noting ‘a number of practitioners in the cosmetic
surgery industry have forfeited the trust of the community and the respect of the medical profession.
‘An ‘area of practice endorsement’ will set standards and make cosmetic surgery training and qualifications clearer. It will empower consumer choice, by identifying who is trained and qualified, and who is not.’
Tonkin warned ‘setting the standard would be hotly contested’ and emphasised: ‘There are fiercely different opinions about what qualifications guarantee safe care. Patient safety will be our core focus as we consult with our stakeholders and develop the endorsement.’
The cosmetic surgery ‘area of practice endorsement’ will complement any action by Health Ministers to restrict the use of the title ‘surgeon’.
Independent review:
844 responses
In November 2021, the Medical Board and AHPRA commissioned an external review of patient safety issues in the cosmetic surgery industry, including how to strengthen regulation of practitioners in the industry.
The independent review was led by former Queensland Health Ombudsman Andrew Brown and an expert panel: Australian Commission on Safety and Quality in Health Care chief medical officer Professor Anne Duggan; CHOICE chief executive Alan Kirkland; and National Health Practitioner Ombudsman Richelle McCausland.
A public consultation period from 4 March-14 April 2022 generated 595 public survey responses and 249 submissions.
In addition, 2 advisory groups were established to assist the review:
- Consumer Reference and Advisory Group: membership included consumer organisations as well as representatives with expertise in marketing and psychosocial aspects of cosmetic surgery;
- Technical Advisory Group: membership included clinicians from a range of specialities and areas of practice.
‘Urgent action’ against 5 practitioners
The Medical Board of Australia announced it has taken immediate action against all practitioners mentioned in recent media coverage:
- Daniel Lanzer ‘is no longer registered to practise. This means he can’t practise as a medical practitioner anywhere in Australia.’
- Mohammad Reza Ahmadi ‘cannot practise cosmetic surgery’.
- Daniel Aronov ‘cannot practise cosmetic surgery’.
- Ryan Wells ‘has been suspended (so cannot practise medicine)’.
In addition, the MBA noted ‘active investigations continue on all these matters as more people come forward’.
The Medical Council of NSW ‘has also restricted Adam Najem’s registration, limiting his ability to perform cosmetic surgery’.
AHPRA and the MBA also noted that ‘in response to calls to ban all cosmetic surgery, we clarify we do not have the legal powers required to ban cosmetic surgery either temporarily or permanently.
‘There are only three areas of legally restricted practices in our legislation; they are restricted dental acts, optical appliance prescribing and spinal manipulation, and any addition to these can only be achieved through amending the legislation.’
