New Cosmetic Surgery Regulations: In Practice

Cosmetic surgery reforms set by the Medical Board of Australia (MBA) and Australian Health Practitioner Regulation Agency (Ahpra) came into effect on 1 July 2023. We asked doctors around the country how the new practitioner guidelines have impacted their practice.

Dr Gabrielle Caswell

Eyra Medical and Skin Clinic, Moree, NSW

In medicine, the regulator’s position is to provide practitioner guidelines for safe delivery of medicine. It is important that positions are considered on the history of cosmetic surgery in Australia.

At the same time, it is important to recognise the autonomy of adulthood, in that adults who can provide informed consent without coercion or other factors at play should be able to access the type of care they would like to receive.

I think that most surgeons operate on the philosophy of multi-consult scenarios before cosmetic surgery, and again this needs to be balanced against the patient’s own research and motivation. The highly motivated patient is a concern in all areas of medicine; ACAM has structured an examination for members called The Motivated Patient for this reason. However, we need to be aware the impact of social media and behavioural norms which surround the ‘selfie’ culture and not misdiagnose individuals as sufferers from BDD.

In addition, we need to consider in the equation travel medicine and procedures that individuals may seek overseas if they cannot access treatment in the Australian system. There are multiple case studies and examples of exotic infections, etc, which are then dealt with within the Medicare system, and may have been avoided if treatment was conducted in Australia.

If we examine the referral restriction, it is, I believe, more about inappropriate and informal referrals that may involve ‘in house’ or clinic staff referring to surgeons based on personal financial reward, rather than who is the best practitioner for a patient. From a cosmetic medicine perspective, this is akin to piecemeal or incentive payments, for example, increased amount of dermal filler used in a day. This could have the effect of incentivising injectors to increase filler recommendations for patients on the basis of how the injector will be financially rewarded.

There are positives and minuses to the referral restriction; being a rural practitioner, where waiting times for a general practitioner can extend to 3 months, I can foresee some issues around waiting periods and knowledge of who to refer to for what procedures, as well as taking up valuable appointment space.

Educating patients as to the skill base and training of their chosen practitioner is in part behind the new advertising guidelines, which requires practitioners to display their medical registration. There is also an open database that patients can now check to ascertain the doctor is registered to practice in Australia (again we should reflect how this may have been prompted). Education and qualifications matter, as does knowing who your treating doctor is. Technological-based consultations in cosmetic medicine have come under firm review in this process. I think it is great that a patient who is receiving injectables from a person other than their treating doctor should be able to actually name their treating doctor (who has an obligation to the patient and responsibility for their treatment).

Australian regulatory guidelines and health acts have not had a history of dealing with commercial medicine. At the end of the day, it comes down to practitioners running

honourable practices, safeguarding the best interests of the patient as a core pillar of their practice. Having said that, this needs to be balanced against the concept of informed adult consent. Some concerns are raised about certain conditions (such as BDD), but these concerns need to be balanced against the requests of a consenting adult who chooses to undergo a procedure, to their own body, when they are capable of providing informed consent.

From a cosmetic medicine point of view, the guidelines are mostly positive and all that we ask of ACAM members. To help ACAM members become their best clinical self, ACAM provides a range of tools and education that are specifically pointed at meeting their cosmetic and MBA registration requirements.

Dr John Flynn

Cosmedic & Skin Clinic, Gold Coast, Qld

The recent regulatory changes have come in with some fanfare and as a knee-jerk type response to current media issues with cosmetic surgery. This is not to say they are not well intended but just not really well thought out. I am always supportive of sensible regulation which helps to improve patient safety.

The two-consultation requirement does not really have much effect on my practice at all since most of our patients would have at least two consultations anyway. If the patient decides to proceed with a surgical option, there will also be a ‘pre-operative’ consultation with the clinic nurse in addition to the other consultations. This provides another opportunity for reviewing consent and answering questions and revealing any potential gaps in understanding from the patient. Further, when the patient is booked into a facility for the procedure, the facility will also conduct a ‘pre-admission’ assessment of the patient, providing yet another opportunity to check all elements. I realise that not all practices will follow this model and so I am supportive of this element in the new regulations.

The GP referral is a more difficult issue. In my practice, we always like to have the patient’s GP informed of planned procedures and I usually write to the patient’s GP when there may be other health issues such as asthma, hypertension, etc. But, in this era, many patients do not have a regular GP, or indeed may not have a GP at all and their preferred health practitioner might be a naturopath or chiropractor or Google. The ideal would be that this circumstance might encourage the patient to develop a relationship with a GP which will always be beneficial to them. If, however they just attend ‘any’ GP just to get a referral then it may not mean much in the order of things. Particularly, if that GP does not know the patient and any of their past history. What happens when a patient does not want their GP to know they are having a cosmetic procedure? So, all of those things really just make the referral issue sometimes irrelevant and don’t provide any assistance to the patient.

There is also the issue of coercion. The Medical Board is forcing people into a course of action in order to have a medical procedure. This is just fundamentally wrong when viewed as a Human Rights issue. What about the GP? They are generally very busy and often have long waiting lists for appointments. How pleased are they going to be about random patients ringing up for ‘urgent’ cosmetic surgery referrals?

While, in my view, a patient having a regular GP is a good thing, and maintaining contact between GP, cosmetic surgeon and patient is also good medical practice, the regulatory framework is flawed.

The BDD screening tool has been accepted by most patients as a necessary evil or an irrelevance. Any aware patient will be able to strategically answer the questionnaires so that they pass. An experienced practitioner will do better in determining a patient with BDD than the questionnaire. Nevertheless, identifying this cohort of patients is important and they do need to be managed carefully.

Cooling-off periods do not really impact our practice since there is always a waiting list for surgery that allows sufficient time for patients to reflect and reconsider their plans. That the cooling-off period is mandated is really not a practical issue, just an in-house administrative one.

I don’t expect there will be any long-term impacts on my practice from these regulations since we manage most of these issues already. However, the ‘TikTok’ type of practice with the social media heavy marketing approach are likely to encounter some practical issues which might disrupt their business model. That’s not necessarily a bad thing!

Dr Steven Liew

Shape Clinic, Sydney, NSW

The new regulatory changes have been implemented quite successfully in the office because the team has been working hard to ensure that we are compliant.

The two consultations prior to surgery is something that Shape Clinic has been incorporating since its inception about 20 years ago, so that really has not impacted us too much. The new changes that took us some time is more of the BDD screening, working out which tool is most effective.

The GP referral takes a while to get used to, but all patients were primed about six weeks prior to the regulations taking effect. I think the bit that impacted us and takes the longest to get used to is the timing of consent as well as the timing of booking the patient with a deposit. But, like everything, once a protocol and policy have been implemented, the patients are certainly coming on board. And after about three weeks, we are getting used to this process.

The extra measures have not affected any surgical bookings at all. Shape Clinic has been established for a long time and with our efficient administrative staff working extremely hard behind the scenes, now it’s almost like we’ve been doing this for a long time.

Patients are very resilient. Obtaining the GP referral and undergoing BDD screening have not caused any concerns or complaints from our patients, including our existing patients who are seeking new surgical procedures.

I don’t foresee any significant impact to our practice. Ultimately, while we may not necessarily agree with a lot of things being required in the names of patient protection, we still have to comply with it.

Dr Anh Nguyen

Dr Anh Plastic Surgery & Medispa, Perth, WA

From my perspective as a specialist plastic surgeon, it is effectively business as usual. We will continue to care for patients with plastic, reconstruction and cosmetic concerns with the highest level of care and ensure the values I hold dear are never compromised – excellence, integrity, compassion and respect.

Our patients have always been recommended to obtain a GP referral to see myself. All our patients are screened with validated screening tools for body dysmorphic disorder prior to their consultation and see our in-house counsellor and nursing team for pre-operative education and counselling to prepare them for surgery and manage any anxieties in regards to their surgery.

We would normally already recommend a cooling off period for our patients to consider their options, get a second opinion, organise their finances and family/personal commitments and go ahead with surgery when they are ready.

The new guidelines have helped to deter the patients who are unrealistic and wanting to rush ahead with their surgery. We have found our patients are very informed and accepting of the new requirements. They feel confident and informed in their decision when they are at the stage of going ahead with their surgery. Our patients know that the new guidelines are in the best interests of the patient and protect them.

Looking at a longer-term impact, we anticipate that our patients going ahead with surgery are more educated, informed and realistic.

Dr Jayson Oates

Academy Face and Body, Perth, WA

We book new patient consults 4+ months out, so as soon as we knew about the new rules
we started informing patients of the new requirements. Using our practice management system, we had to plan for the extra consult and use the SMS system to remind patients they needed referrals even for purely cosmetic procedures.

Generally, it takes several months to go from consult to theatre anyway, but with multiple consults and cooling off it removes the ability to provide something more quickly if the situation arose.

We already were using a BDD screening tool so that did not change anything for us.

In terms of extra measures affecting appointment scheduling, we did have one day in mid-July where we had a number of patients who did not have referrals despite multiple reminders. They could not present on the day which was frustrating for them and us.

Most of my patients are fine about the new regulation. There are a few grumbles, especially that they cannot get a referral from their cosmetic physician. Some have found they want to discuss a second concern but the referral only covers one and we now need the referral to cover the specific concern/area before we can discuss it.

I don’t envisage too much change in the longer term. We don’t know what happens if our patient gets a referral from a GP who does some cosmetic work that we don’t know about. If we accept a referral from a GP who does cosmetic work, have we committed some offence?

Dr Naveen Somia

Naveen Somia Plastic Surgery, Sydney, NSW

We have incorporated all the recommendations and have communicated well with all our patients that this is the new norm and what they must do in order to obtain cosmetic surgery.

I reviewed our website visitor numbers, calls and appointment bookings for the month of July. And, yes, there was a small downturn, but it is too early to see whether if this was primarily due to the regulations as significant changes were made to our website during this period to comply. We will closely monitor this for the next 3 to 6 months to see if there’s any short, medium or long-term impact.

The patient journey – once they make contact until they have surgery – has slowed down due to the regulations and this has added an additional complexity to the practice. Fortunately, our patients have been understanding and supportive.

Dr Michael Zacharia

Dr Michael Zacharia, Sydney, NSW

I have incorporated all the new changes, including requesting a GP referral for all new patients and previous patients who have already had surgery before July 1. We do the first consultation and then have the patient reviewed at least one week later, either in person or by phone. We emphasise to the patient that there has to be at least one week from the first consultation for the second consultation to occur. All patients are required to complete a BDD form that we assess at the time of consultation and this is one suggested by the Australasian College of Cosmetic Surgery and Medicine. The consent process is considered after the second consultation, however at the time of the first consultation, I go through all the potential complications of surgery.

There is no doubt there has been an increased administrative process within my practice, however it has not affected us negatively. I think it is a good idea to have a GP referral, especially in my practice because a lot of the surgeries are functional in regard to the rhinoplasty aspect of things.

I always feel that when the patient has a second opportunity for a consultation it gives them time to really consider their options in the surgeries they’re looking to proceed with. For example, today I saw a patient who is having a rhinoplasty, brow lift and cheek augmentation. Originally at her first consultation she was considering even further surgery which I did not feel was necessary, so the extra consultation and cooling-off period gave her time to gather her thoughts based on the extensive information we gave the patient at the first consultation.

Our patients seem to be quite happy with the new process, and in fact most probably don’t know that there is a new process! The main issue is achieving a GP referral, with some patients frustrated with this.

From a long-term perspective, I think this is going to have a positive impact on my practice rather than a negative impact. Probably the most time-consuming administrative aspect has been the need to change our website and Instagram posts to comply with the new Ahpra rules and regulations. AMP