Watching over some doctor’s shoulders really is necessary

Medical doctors have to go through years of training and rigid examinations before they are certified as doctors. Surgeons are specialists and their training and examinations are even more intense and rightfully so. Despite that, there are surgeons who bungle their surgeries and their patients die as a direct result.

According to the College of Physicians and Surgeons of Ontario, cosmetic surgery involves incisions or significant alteration of the skin or underlying tissues and can involve many areas of the face and body. Common facial cosmetic procedures include facelift, brow lift, eyelid surgery, ear surgery, and rhinoplasty (nose) surgery. Less invasive cosmetic facial surgeries include facial liposuction, facial implants, micro fat grafting, and some laser resurfacing procedures. Common cosmetic surgical procedures done on the body include liposuction, abdominoplasty (tummy tuck), breast lift, breast enhancement (augmentation).

Although the term ‘cosmetic surgery’ is widely used, there is no such specialty designation by the Royal College of Physicians and Surgeons of Canada in cosmetic surgery and it is performed by doctors with different qualifications. “Cosmetic surgeon” and “cosmetic plastic surgeon” are general terms that are used by many physicians, including physicians who may not have had any formal training in cosmetic surgery. Presently, in Ontario, any medical doctor may perform surgical procedures, including cosmetic surgery however, cosmetic surgical procedures should only be done by doctors who have the appropriate training and experience in that field of medicine.

All surgery comes with possible risks of complications -- from anaesthesia, infection, and scarring, for example. Such complications can be minor or major and, in rare circumstances, even death can occur. Cosmetic surgery is no exception. It follows that patients who undergo cosmetic surgeries by doctors who have limited experience and training in cosmetic surgical procedures are putting their health and lives at risk.

A woman in England went into hospital to have her breast re-built. What should have been a simple operation went so horribly wrong. She was left in agonizing pain because her stomach literally exploded. Her body has been left so ravaged she had to undergo another 21 operations before the damaged was finally repaired.

When Lynn Dugan, went in for a facelift, she never dreamed she would wind up with a case of what was basically gangrene of her whole body. Nonetheless, Lynn spent two months, including one month in intensive care, in the hospital recovering from Necrotizing Fasciitis, the so-called “flesh-eating disease” after a botched cosmetic procedure.

Stanley Frileck, M.D., a Los Angeles plastic surgeon and member of the American Society of Plastic Surgeons, surveyed the practice and found about 25 percent of the practice involves fixing incomplete procedures. And, according to a survey by the American Academy of Facial Plastic and Reconstructive Surgery complications from inferior surgeons are so widespread that, of the more than 150,000 Rhinoplasties (nose jobs) done each year, nearly 21 percent are corrective procedures because of bungling by the original doctors who practiced in plastic surgery.

Family physicians in Ontario have been increasingly identifying themselves as cosmetic surgeons even if they have not received certification from the college to do so. Plastic surgery is an art and it must be done by trained cosmetic surgeons and not done by doctors passing themselves off as cosmetic surgeons qualified to do plastic surgery.

Let me tell of four such doctors in Ontario who practice cosmetic surgeries but at the same time, they are not certified as cosmetic surgeons. They are; Dr. Padma Jain, Dr. Eli Judah, Dr. Stanley Gore and Dr. Bruce Liberman. They are being investigated by the Ontario College of Physicians and Surgeons. They have refused efforts by medical investigators to observe them performing cosmetic surgeries. The college also wants to interview them, requests they have also rejected. The four doctors have attracted interest because they perform invasive cosmetic surgeries associated with high 'morbidity and mortality risks'. Two of the doctors – Judah and Liberman – cared for patients who died after cosmetic surgeries were performed by these two doctors, one as a surgeon and the other as an attending anesthesiologist.

Why are they refusing to let medical investigators who are certified surgeons watch these four doctors do plastic surgery on their patients? Are they afraid that their work is so substandard that they will be ordered to cease and desist from doing any more such surgeries or participating in such operations until they are properly trained and certified to do so? If that does happen, they will lose a great deal of money so I suppose, to them, a lot is at stake, both financially and with respect to their reputations.

Nina Bombier, who represents Judah (who performs liposuction on his patients) and Liberman, (who is an attending anesthesiologist) called the college's demands to observe her clients "an unprecedented power. There is no evidence of any imminent harm here."

I find that statement ludicrous considering the fact that two of their patients died because of the dangers that are inherent with invasive cosmetic surgeries associated with high "morbidity and mortality risks. Judah, for example, came to the attention of the college after a coroner's report found potential quality of care issues in the 2006 death of a woman who underwent a cosmetic procedure with him to remove hanging fat and skin from her abdomen. Liberman was the attending anesthesiologist during a liposuction procedure performed last September on Krista Stryland, a healthy, 32-year-old Toronto mother who died shortly thereafter.

Liposuction is art as well as a science, physicians say. But a practitioner who has taken only a short course before seeing patients for liposuction services often leaves, not a smooth contour in the body, but “divots” in the flesh, spots where too much fat was removed.

Most professional organizations recommend that such practitioners be board certified. That means he or she has had a year of hands-on experience at the side of an established, experienced surgeon trained and experienced in cosmetic surgery.

What really worries me about this is that the lawyers for the four doctors argue that their clients are in good standing with the college, have not breached medical standards and should not be subject to forced observation or interviews that could be used against them in future prosecution.

Andrew Matheson’s (who represents Jain and Gore) position is that the College doesn't have legal authority to compel doctors to co-operate with demands to observe their work or question them. He says that doctors have the right to protect themselves from self-incrimination.

To some degree, I agree with that premise. In Canada, no one can be forced to testify against themselves. However, if the investigator is asking them how they perform when doing liposuction, I feel that they must answer the questions and further, they should permit a certified cosmetic surgeon to watch them doing such surgeries to satisfy himself and the College that they know what they are doing.

Just because a patient dies during surgery, it doesn’t necessarily mean that the doctor bungled the operation. But if a doctor wants to practice cosmetic surgery of any kind, it behooves him to prove to the College that he is qualified to conduct such surgeries and answer questions about his procedures. If he refuses to cooperate with the College, then he should be prohibited from doing any form of cosmetic surgery until he is properly trained to do so and is certified by the College to do so.

Most hospitals are very picky as to what doctors they will permit to do any form of surgery in their operating rooms. This is why some doctors who do not have such privileges will do surgery in their own clinics.

Currently, doctors' biographies and some limited descriptions of their previous infractions can be found on the website. The new regulations come partly in response the College’s investigation into the work of Dr. Richard Austin, a Scarborough gynecologist who was allowed to continue to work after reporting significantly high rates of botched surgeries throughout the 1990s and 2000s. His patients were left uninformed of mounting complaints of medical incompetence that combined to millions of dollars in lawsuits.

As I see it, the College, Ontario's medical watchdog should have the right to interview and observe the work of cosmetic surgeons and any other physicians it suspects of incompetence. If the College decides that it has the authority to interview and observe the work of any doctor who does any form of surgery or participates in a surgical operation as an attending anesthesiologist, be the operation cosmetic or otherwise and the doctor or anesthesiologist doesn’t cooperate with the College, then they should not have the privilege of practicing as a surgeon or participating as an anesthesiologist in connection with any form of surgery in Ontario and if they continue to do so, then their licence to practice medicine should be taken from them.