The recent ABC Four Corners program has ignited the ongoing debate over who should be permitted to formally use the term ‘surgeon’.
The Australian Medical Association (AMA) insists the title ‘surgeon’ should be “reserved for medical practitioners who have obtained specialist medical college accreditation” – and objects to the use of the term ‘cosmetic surgeon’ where “a practitioner is not recognised as a surgical specialist”.
Immediately following the Four Corners expose, the AMA issued a ‘warning’ for the “urgent need to tighten rules on use of ‘surgeon’ to protect public safety”, and declared the program “highlights the risks of surgery” and need for specialist accreditation.
The AMA said only medical practitioners with a Fellowship from an Australian Medical Council (AMC) accredited specialist medical college “whose training program includes a surgical component relevant to their field of expertise” should be allowed to use the ‘surgeon’ title.
The AMA emphasised “patients can be misled by the term ‘cosmetic surgeon’ or ‘podiatric surgeon’, believing they are dealing with a medical practitioner who has formal and specific surgical qualifications when in fact they may not”.
AMA President Dr Omar Khorshid said the loophole needs to be closed, but action is required from health ministers.
“Many Australians will be shocked to know you can call yourself a cosmetic surgeon without any specific surgical training whatsoever, as there’s no restriction on the use of the term ‘surgeon’ by doctors or by other health practitioners,” Dr Khorshid noted.
Health ministers have been consulting on reforms to the regulatory scheme governing all health practitioners in Australia since July 2018. They supported restrictions to the use of titles ‘surgeon’ and ‘cosmetic surgeon’ but announced further consultation would need to occur. (See accompanying box.)
The AMA stressed that it “supports this reform and urges health ministers to finally complete the work they began over three years ago”.
Dr Khorshid said: “Safe surgery requires high levels of training – there are no short cuts.
“To protect the public, anyone using the term ‘surgeon’ must be a medical practitioner who has had the appropriate qualifications and credentialling that guarantees a minimum level of training and expertise as well as oversight of standards of practice and ethical behaviour.
“Surgery is as successful as it is because of the education and training processes, the regulatory processes, and because Colleges set standards and hold their members to account.
“That’s why we need to close the loopholes that allow practitioners to call themselves surgeons without necessarily meeting the necessary standards.”
The AMA announced it formally “supports changing the National Law to make it clear to patients that anyone using the title ‘surgeon’ can only do so because they are a medical practitioner who has met and continues to meet the standards necessary for Fellowship of the relevant surgical college”.
Update
In mid-December, 2021, the federal and state governments launched a landmark review aimed at overhauling laws into who can call themselves a cosmetic surgeon, increasing the penalties for deceptive advertising and social media abuses, according to the SMH.
Federal Health Minister Greg Hunt has asked state health ministers to make new laws a priority.
On December 12, the states and Commonwealth released a 108-page Regulation Impact Statement (RIS) into the use of the title ‘surgeon’ and ‘cosmetic surgeon. It will be open for public consultation until April 1, 2022, with the public invited to anonymously provide feedback about their experiences and submissions.
According to the statement, an anonymous survey and direct submissions would help devise policy responses to reform the cosmetic procedures industry.
The consulting document canvasses a series of options, including restricting the title ‘surgeon’ under National Law and undertaking major public information campaigns. Other options include strengthening the existing framework through administrative rather than legislative mechanisms and increasing provider liability for non-economic damages.
A fourth option is to maintain the status quo, but this seems unlikely.
The consulting document said ministers were ‘particularly’ concerned that the practice of cosmetic surgery and widespread use of the informal title ‘cosmetic surgeon’ may be strongly and disproportionately associated with these risks and harm. It said there was an information and power asymmetry between patients and practitioners, which was contributing to the risk of consumer harm.
‘It can be difficult for the public to obtain information from neutral and informed sources, particularly as most cosmetic surgery consumers obtain information about prospective procedures from the practitioners that perform those procedures and from social media,’ the report says.
‘This RIS is interested to discover how widespread cosmetic surgery resulting in significant harm and complications [might] be, and whether medical practitioners’ qualifications are contributing to potential harm.’
It said advertising and marketing material must comply with a series of laws. Breaches of the law for advertising offences can incur financial penalties of $5,000 for each advertising offence for an individual and $10,000 for a body corporate.
Public consultation for the review began on 21 December, 2021 and closes on 1 April, 2022. A report is expected around the middle of the year.
The survey can be found here: https://engage.vic.gov.au/medical-practitioners-use-title-surgeon-under-national-law
‘MANY AUSTRALIANS WILL BE SHOCKED TO KNOW YOU CAN CALL YOURSELF A COSMETIC SURGEON WITHOUT ANY SPECIFIC SURGICAL TRAINING WHATSOEVER, AS THERE’S NO RESTRICTION ON THE USE OF THE TERM ‘SURGEON’ BY DOCTORS OR BY OTHER HEALTH PRACTITIONERS.’ – AMA President Dr Omar Khorshid
ASAPS demands action from AHPRA
Under the headline ‘When will Australia’s regulator start protecting patients?’, the Australasian Society of Aesthetic Plastic Surgeons (ASAPS) released an equally robust statement declaring it “demands immediate action” from Australia’s health regulator AHPRA to “ban the use of the title ‘cosmetic surgeon’ by those who are not in fact specialist surgeons”.
ASAPS President Dr Robert Sheen emphasised: “The issue here is one of transparency. Transparency is central to patients making informed choices about their healthcare provider.”
ASAPS describes itself as “the peak body for plastic surgeons in Australia and New Zealand, whose focus is aesthetic plastic surgery” with membership “exclusively composed of registered specialist plastic surgeons with world-class expertise in cosmetic surgery and aesthetic medicine”.
The ASAPS statement noted the AMC is “the benchmark that provides a nationally consistent standard of care that patients can rely on for specialist treatment. It decides what specialist training is accredited, recognised and safe.”
ASAPS said AMC accreditation “provides independent oversight of both standards of specialist education and ongoing compliance with ongoing professional education. Only practitioners who have successfully completed AMC accredited training can use legitimate approved specialist surgical titles.
“However, most practitioners who use the title ‘cosmetic surgeon’ are not registered surgical specialists. This is currently allowed by AHPRA.”
ASAPS declared the “use of the title of ‘cosmetic surgeon’ is a free for all – it can be used by any medical practitioner without AHPRA registration as a specialist surgeon and without AMC-accredited surgical training.
“It means doctors with no more than a basic medical degree can call themselves a ‘cosmetic surgeon’.”
ASAPS highlighted a recent survey “has shown 81% of Australians agree the title ‘cosmetic surgeon’ implies the doctor is a registered specialist surgeon. There is therefore a real issue whether patients understand their surgeries are not in fact being carried out by a specialist accredited surgeon.”
Dr Sheen added: “There are practitioners who self-label as ‘cosmetic surgeons’ yet do not have specialist surgical registration, and do not reveal this important detail to their existing or prospective patients.
“It is AHPRA’s job to regulate anyone who would perform procedures on a patient. Part of that regulation should be to enforce transparency and honesty about titles that clearly communicate assumed levels of education and expertise.
“The National Law that already exists even mandates transparency in Section 118: ‘to protect members of the public to ensure they are not misled’.
“The terms ‘cosmetic surgeon’ and ‘plastic surgeon’ are used interchangeably, and people wrongly assume both titles reflect the same level of expertise.
“The difference is this: only practitioners who have completed an additional 8-12 years of AMC accredited specialist plastic surgical training, beyond their medical degree, can lawfully call themselves a registered specialist plastic surgeon. Whereas the title ‘cosmetic surgeon’ is a free-for-all; it is not backed up by AMC accredited training.”
ASAPS also noted that in November 2019, Australian State and Federal Health Ministers voted “unanimously to restrict the use of ‘surgeon’, including by those using the title ‘cosmetic surgeon’ without the other appropriate specific training, in order to prevent causing confusion among members of the public.
“However, practitioners carry on every day using the term ‘cosmetic surgeon’ when they are not specialist surgeons.”
ASAPS advocated that “action needs to immediately be taken to rectify these issues in order to protect patients and ensure they understand the qualifications of the medical practitioner carrying out their surgery.”
Since October 2020, ASAPS has led a campaign badged as ‘Know The Difference’ which “urges the public to know the difference between those who falsely claim to be registered surgeons by using the fabricated title of ‘cosmetic surgeon’, and the only practitioners who are appropriately qualified to be performing cosmetic surgery and registered as specialists in plastic surgery.
“The campaign informs and educates about the differences and the importance of making the right choices about who they can trust with their cosmetic procedures. These procedures should be performed safely by a surgeon with appropriate plastic surgery qualifications.”
ACCSM call for ‘new national accreditation’
The Australasian College of Cosmetic Surgery and Medicine (ACCSM) called upon federal and state health ministers “to adopt urgently its proposal for a new national accreditation standard for all doctors performing cosmetic surgery”.
ACCSM describes itself as “the national peak body for cosmetic surgery and medicine” and a “not-for-profit, multi- disciplinary fellowship-based body of cosmetic surgeons, cosmetic physicians, plastic surgeons, general surgeons, maxillofacial surgeons, ear nose and throat surgeons, ophthalmologists and other doctors and health care practitioners who practice in cosmetic medicine and surgery”.
ACCSM said revelations made Four Corners highlighted both “dangerous and unacceptable practices and the consequences for patients” and President Dr Patrick Tansley said “patients need to be protected”.
Dr Tansley added: “Patients need to be able to identify easily those practitioners who are trained and safe in cosmetic surgery, so they are protected before they undergo surgery and not just having to make complaints after they have been harmed.
“Currently that is not the case, as any medical practitioner can currently call themselves a ‘cosmetic surgeon’.”
ACCSM said the AMC, as the “independent national standards body for medical education and training”, recently found “plastic surgeons trained by the Royal Australasian College of Surgeons had a ‘deficit’ in their experience of cosmetic surgery and qualify with ‘a gap’ in this area of practice”.
And ACCSM intensified the debate by commenting: “Tragically, the only death of a cosmetic surgery patient in Australia where inadequate surgical training was a causal factor, occurred at the hands of a specialist plastic surgeon whose liposuction patient believed he was competent because he was a specialist plastic surgeon.
“In contrast, the Victorian coroner who investigated her death noted that ‘irrespective of a practitioner’s provenance or primary qualifications, there was a need for specific training and experience in performing liposuction surgery’.”
Dr Tansley said: “This is why all doctors, plastic surgeons and cosmetic surgeons alike, need to have to meet a national competency standard based on essential training, qualifications and recertification in cosmetic surgery.
“This would ensure all doctors, including specialist plastic surgeons, who call themselves cosmetic or aesthetic plastic surgeons would need to have achieved an independently assessed benchmark of relevant training, qualifications and experience specifically in cosmetic surgery. They would also be subject to ongoing recertification requirements.
“The ACCSM has also proposed an AHPRA-Register of all medical practitioners performing cosmetic surgery who have met and maintain the Standard. Only those on it would be able to use the title ‘cosmetic surgeon’ or ‘cosmetic or aesthetic plastic surgeon’.”
ACCSM presented this solution to the COAG Health Council in early 2021 and to the Senate Inquiry in September 2021; it means “all doctors performing cosmetic surgery would have to meet a National Competency Standard based on essential training, qualifications and re-certification specifically in cosmetic surgery”.
ACCASSM said “despite the AMC’s concerns about their lack of cosmetic surgery training, plastic surgeons opposed this solution in the Senate Inquiry. Instead, their suggested solution is to ban the title ‘cosmetic surgeon’ – and approach which was tried and failed in Queensland a decade ago”.
Dr Tansley summed up: “In the interests of patients, we ask the plastic surgeon societies to drop their opposition to the National Standard and work cooperatively with other surgical groups and regulators to make it happen.
“No trained and competent doctor concerned about patient safety should object to a formal Accreditation Standard.” AMP
2019 NSW Inquiry recommended title ‘restriction’
In February 2018 the Parliamentary Committee of the NSW Health Care Complaints Commission (HCCC) conducted an Inquiry into cosmetic health service complaints in NSW “in response to concerns raised by the Minister for Health, the HCCC, the media and the community” to investigate whether “the HCCC and other Government regulatory frameworks could improve outcomes for the public who use cosmetic health services”.
The Committee delivered its Report – including 16 Recommendations – in November 2018 and the NSW Government tabled its formal response in June 2019, including “details surrounding three particularly controversial issues”, one of which was “whether the use of the title ‘cosmetic surgeon’ should be restricted” (Recommendations 2, 3 and 4 below).
On that issue, the NSW Government noted that COAG Health Council “will be considering any needed legislative action” arising out of a consultation paper on this subject in the second half of 2019, and “depending on the outcome of the COAG Health Council processes, the Minister for Health and Medical Research will consider whether any changes should be made to NSW specific legislation”.
In the Parliamentary Committee’s report and recommendations, Chair Adam Crouch commented: “The Committee recommended a review of the HCCC’s powers and functions to ensure the HCCC is able to protect patients using health services, and assist in resolving their concerns.”
Of particular focus, he highlighted the Committee recommended “the title ‘cosmetic surgeon’ be restricted or protected nationally, or at the very least in NSW, so doctors using this title meet certain minimum criteria in terms of education, training and experience”.
Crouch explained the Committee “heard that at present a range of doctors may use this title – from GPs to plastic surgeons – and this can potentially mislead the public”.
The Parliamentary Committee’s Recommendation 2 stated: “The Committee recommends the Minister for Health continues to make representations to the COAG Health Council to protect or otherwise restrict the title ‘cosmetic surgeon’ at a national level under the Health Practitioner Regulation National Law.”
The NSW Government Final report responded: “Supported in principle. The COAG Health Council released a consultation paper on the future of the regulation of health practitioners earlier in 2018. The paper, among other matters, sought submissions on whether the use of the titles ‘cosmetic surgeon’ should be restricted. It is expected the COAG Health Council will be considering any needed legislative action arising out of the consultation paper in the second half of 2019.
The Parliamentary Committee’s Recommendation 3 stated: “The Committee recommends that, if the COAG Health Council does not protect or otherwise restrict the title ‘cosmetic surgeon’ within a reasonable timeframe, the Minister for Health considers whether separate legislation should be introduced in the NSW Parliament to place restrictions on the use of the title ‘cosmetic surgeon’ in relation to doctors practising in NSW.”
The NSW Government Final report responded: “Supported in principle. Depending on the outcome of the COAG Health Council processes, the Minister for Health and Medical Research will consider whether any changes should be made to NSW specific legislation.”
The Parliamentary Committee’s Recommendation 4 stated: “The Committee recommends the Minister for Health considers whether it is in the public interest to support protections and restrictions on the use of the title ‘surgeon’ either at a national level or for doctors practising in NSW.”
The NSW Government Final report responded: “Supported in principle. The COAG Health Council consultation paper also sought submissions on whether the use of the titles and ‘surgeon’ should be restricted. It is expected the COAG Health Council will be considering any needed legislative action arising out of the consultation paper in the second half of 2019.”
COAG promised ‘surgeon’ restriction in 2019
In December 2019, the Australasian Society of Aesthetic Plastic Surgeons (ASAPS) announced on its website: “Rogue and unregistered doctors are set to face tougher regulatory oversight with Australia’s Health Ministers agreeing to pass new legislative amendments to the Health Practitioner Regulation National Law at the last Council of Australian Governments (COAG) Health Ministers’ meeting on 31 October and 1 November.
“The communique from the COAG meeting stated: The use of the title ‘surgeon’, including by way of ‘cosmetic surgeon’, by medical practitioners, non-specialist surgeons or those without other appropriate specific training can cause confusion among members of the public.
“ASAPS President Dr Naveen Somia has received the following letter from the (Federal Health minister) Hon Greg Hunt MP confirming this move.”
In his letter, Minister Hunt said: “I note consumers are often not aware that health practitioners who perform cosmetic surgery have widely varying levels of qualifications, training and expertise.
“At the November 2019 Council of Australian Governments (COAG) Health Council meeting, my state and territory colleagues and I approved changes to the Health Practitioner Regulation National Law (National Law) to restrict the use of the title ‘surgeon’. It was agreed the use of the title ‘surgeon’ by medical practitioners, non-specialists surgeons or those without other appropriate specific training can cause confusion among members of the public.
“I note that further work will be required prior to the changes being made to the National Law to determine which medical practitioners should be given the right to use the title ‘surgeon’. This will include consultation with community consumer groups and medical professions.”
