New guidelines for cosmetic surgery

The Medical Board of Australia has recently issued a set of new guidelines for medical practitioners, with the aim to increase patient safety.

The new guidelines introduced by the Medical Board of Australia focus on consumer protection and patient safety, seeing pivotal changes to cooling-off periods for major procedures and for patients under 18 years old, and mandatory pre-treatment consultations, better price transparency and improved post-operative care protocols.

In March 2015, the Medical Board consulted with the profession, the industry and the community to draft guidelines in order to reflect professional standards, ethics and behaviour. The new guidelines will take effect on 1 October 2016 and will apply to all registered medical practitioners who provide cosmetic medical and surgical procedures.

Associate Professor Stephen Bradshaw is an inaugural member of the Medical Board of Australia and emphasises that the guidelines are not about imposing unreasonable regulations, but rather a reflection of good medical practice.

Cooling-off periods

One of the main points of discussion on release of the new guidelines was patient cooling-off periods. The guidelines suggest a seven-day cooling-off period for all adults before major procedures and a three-month cooling-off period before major procedures for all patients under 18 and a mandatory evaluation by a registered psychologist, general practitioner or psychiatrist. The guidelines also introduced a seven-day cooling-off period before minor procedures for all under 18s, and when clinically indicated, evaluation by a registered psychologist, general practitioner or psychiatrist.

Dr Bradshaw explains, “This cooling-off period gives people some time to consider the procedure. These are sometimes very major procedures that can be body- and life-altering, so there is a wide concern that some patients were going into procedures without knowing the risks, especially younger people.”

Mandatory psychological assessment

“Another major concern was that there was no psychological base and that some people may not have the maturity needed to make an informed decision,” says Dr Bradshaw.

The Medical Board combated this issue by introducing a mandatory period of psychological assessment for people under the age of 18.

The guidelines were then expanded to allow potential patients to have the option to see their general practitioner for this psychological assessment, not only a psychologist or a psychiatrist.

“Cosmetic surgery is a non-referred specialty outside what Medicare covers generally, and so patients don’t need a referral from their general practitioner,” Dr Bradshaw explained.

“As a result, the general practitioner has been taken out of the loop. I think the mandatory assessment from either a psychologist, psychiatrist or a general practitioner will help because there are a lot of young people that are probably having cosmetic procedures for the wrong reasons and are suffering from body dysmorphic problems and a whole psychological overlap. Now they’re having that time to pause and reconsider their choices.”

“We’re not preventing people under the age of 18 from having cosmetic surgery, we just want to make sure that they make the right decision. So it’s not about preventing; it’s about supporting people through it to make sure it’s the right thing to do,” he says.

Video consultations

One of the more controversial parts of the new guidelines was the altering of the in-person mandatory consultation guidelines to accommodate video consultations for doctors prescribing Schedule 4 (prescription only) cosmetic injectables.

The Board reiterated that these changes prioritise patient safety and reduce some of the regulatory requirements proposed in the previous draft guidelines, when either there was no evidence of improved safety or the costs significantly outweighed the benefits
of a proposal.

“Cosmetic practices shouldn’t ever prescribe without consulting. My understanding is that some practitioners were writing scripts for injectables without a consultation. That’s not good medical practice. You should not ever prescribe something without a consultation,” says Dr Bradshaw.

“We have altered in the final guidelines to say that consultations can be done by Skype or video – but it still needs to be a face to face consultation. It can’t just be a phone call, etc. The guidelines were very well supported across the industry – however this was the most controversial one,” he says.

Third party financing

Another controversial area was the role of third party financiers and the push for medical practitioners to provide patients with detailed, written information about costs.

The guidelines also prohibit medical practitioners from providing or offering financial inducements, either to patients or agents, and prohibit finance schemes being offered to patients (such as loans or third-party payment arrangements).

“The vast majority of practitioners want to do the right thing by their patients. However, sometimes the ‘business’ aspect of a practice can overtake the best interests of the patient. The issue of financing may be one of the more controversial things that may come out of these guidelines.”

“We don’t encourage or believe people should take third party finance arrangements. It’s fine to do it by credit card; it’s fine to say you can pay in instalments, but finance companies are not advisable and they do not comply with the guidelines. This is a big issue and there will be ramifications for some practitioners and some finance companies,” says Dr Bradshaw.

“We are also concerned that some patients were putting quite large deposits down even before they decided to go ahead. Patients shouldn’t be putting down any deposits until after that cooling-off period. Nothing should be paid for until the patient comes back and says, ‘I’ve been to my psychiatrist or I’ve been to my GP and we’ve discussed it and I’m still keen to have procedure X,” he says.

Care by other health practitioners

The new guidelines also highlight that the treating medical practitioner must take explicit responsibility for post-operative patient care and for making sure there are emergency facilities when they are using sedation, anaesthesia or analgesia.

“You are the doctor looking after this patient, you are responsible for that patient having a procedure done. We don’t want doctors coming back and saying ‘I wasn’t looking after that facility or I wasn’t in charge of how the facility runs’. The patient has the right to have good post-operative care.”

The Australasian Society of Aesthetic Plastic Surgery (ASAPS), the Cosmetic Physicians College of Australasia (CPCA) and the Australasian College of Cosmetic Surgery (ACCS) have all welcomed the guideline changes and have played an active role in the development of the new guidelines, in order to improve patient safety and informed consent.

“Patients will benefit particularly from the improved informed consent provisions. Cosmetic medicine and surgery are almost always self referred, and there is a greater need for the stronger informed consent guidelines announced by the Medical Board of Australia,” says Dr Ron Bezic, ACCS president.

Dr Cath Porter, of the CPCA says: “Although cosmetic injectables have become more common, people should not forget that they are still medical procedures that require supervision from a qualified medical practitioner in a safe environment and medical protocols need to be followed. The CPSA welcomes the MBA’s guidelines.” ASAPS also issued a statement, supporting the Medical Board recommendations. “ASPS and ASAPS are both committed to sensible and appropriate regulation of cosmetic medicine and surgery so we welcome the Medical Board’s new guidelines and its increased emphasis on patient safety,” from a joint statement Dr James Savundra, President of ASPS, and Dr Tim Papadopoulos, President of ASAPS.

Dr Bradshaw explains, “If we receive notifications about an adverse outcome then we will investigate and use good medical practice and the guidelines, to what we think is appropriate care. These guidelines are a subset of good medical practice and this will be a portion of good medical practice going forward.”