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Botox? Bollocks!

I had a little chuckle when I saw the Cosmetic Physicians getting upset at what they perceive to be the underhanded tactics of some Cosmetic Nurses.

For the benefit of those who have been living under a rock, there is a movement called Cosmetic Medicine. It is championed by the Cosmetic Physicians Society of Australasia the Australasian Society of Cosmetic Medicine and the so-called Australasian College of Cosmetic Surgery.

In a sense, many doctors practice cosmetic medicine in some way. Some skin lesions aren't likely to be cancers but are removed anyway at the patient's insistence. Some varicose veins are more a nuisance than a risk to life or limb and still get removed. Some footballers have surgery to speed their recovery and short term function when they would have healed on their own anyway. The line between what is truly deserving medicine and what is discretionary (or "cosmetic") is a very fuzzy one.

Nevertheless, cosmetic medicine is a booming industry. They like calling it Cosmetic "Medicine" because it is much more acceptable to pop a pill or have an injection than to have "Surgery" these days.

I have occasionally been caught at the dinner table between a plastic surgeon and a "cosmetic surgeon" having a good go at each other. The plastic surgeon (who, like me, undertakes a minimum of 5 or more years of basic surgical principles and practice after at least 2-3 years of general medical experience, followed by specialist surgical training in plastic surgical and reconstructive surgical techniques, and often further subspecialty fellowships locally or overseas) argues that cosmetic surgeons are not trained in the basics of surgery and surgical techniques, the care of the complex patient, the management of severe complications after surgery, and the wide range of techniques required in modern surgery.

The cosmetic surgeon (who could be from a wide range of backgrounds such as a doctor who has not undertaken any form of specialist training and just decides to set up shop, or a specialist in another field like a dermatologist or a GP who decides to extend their practice into cosmetic fields, or any of these people who choose to undertake a 1-3 year informal apprenticeship with another "cosmetic surgeon") argues that you don't need to learn how to do a microvascular anastomosis in order to inject collagen, do tummy tucks, perform liposuction, or do a boob job. Instead, they say that you need an "eye for aesthetics" which they say plastic surgeons lack, and you need experience in a dedicated cosmetic clinic where finer and more subtle work is done rather than a public hospital where plastic and reconstructive surgeons deal with major deformities and mangled patients.

Obviously I am a little biased, but cosmetic physicians are really in a much bigger mess because firstly they have failed to set common standards for themselves. This is inevitably because they come from very disparate backgrounds, and therefore any attempt to standardise a training program akin to surgical training runs the risk of rendering a whole generation of self-taught cosmetic physicians unable to meet their own standards, without very prolonged and generous "grandfathering" provisions.

Secondly, cosmetic physicians perform a wide variety of procedures, from Botox injections, Collagen or dermal filler injections, liposuction, abdominoplasties, breast enhancements, facelifts, dermabrasion, laser skin therapy, varicose veins surgery, and all sorts of procedures related only in the fact that their goal is to make you look better. There is no common set of skills. There is no fundamental "principle". There is, in short, nothing to base a training program upon other than learning a few tips and tricks here from as many other disciplines as possible. It's like taking a random factory production-line worker off the Boeing production line and saying "Why don't you ask everyone else in the factory a few questions, then we'll give you a building and you can build the new 787 Dreamliner for us?" From all the trouble that Boeing is having, perhaps that is really what is happening!

Thirdly, once you leave the moral high ground and start sniping at your own colleagues and lowering the standards of training necessary to perform these procedures, there is really no limit as to how low it can go. Cosmetic physicians standing up and saying that you don't need to be a surgeon to do cosmetic procedures is only step one. Step two (as described below) is cosmetic doctors supervising procedures done by cosmetic nurses in order to make more money. Step three (also described below) is for Cosmetic nurses standing up and saying that you don't need to be a doctor to do these procedures. Step four is beauticians standing up and saying that you don't need to be a nurse to do these procedures. Step five is some bloke in Mexico who does breast implants with a second hand diathermy machine and a spoon in his garage.

Just like Melissa Blandfort who is a travelling cosmetic nurse performing invasive procedures in patients for cosmetic purposes in various beauty salons, and without the review or approval of a doctor. Her website does not mention Botox by name, but clearly says that she performs:

Injectable wrinkle treatments
Injectable wrinkle treatments have now been in use as a cosmetic treatment for over 20 years. They relax a wrinkle causing muscles, to help improve the appearance of the wrinkle. It is extremely effective in treating crows feet, frown lines and other wrinkles caused by a muscle contraction. It is generally most effective in people aged form 25 to 55 years of age. It takes up to ten (10) days to have full effect and can last up to four (4) months.

Now, last I checked Botox and similar paralytic or neuromuscular blockade agents were prescription-only in Australia, so unless she takes a doctor around with her to write out scripts for these patients, I can't see how she can be legally injecting anybody with Botox. Her website says nothing about her being accompanied by a doctor, and I would hate to be the 20th patient receiving Botox out of her multi-dose vial that mysteriously appeared out of nowhere.


Links:

• Botox trend creating worry lines - Brisbane Times
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  Botox trend creating worry lines
  Jill Stark
  August 23, 2009
  
  DOCTORS groups claim nurses are putting patients at risk by illegally performing cosmetic procedures such as Botox, wrinkle fillers and fat-dissolving injections without supervision.
  
  The Cosmetic Physicians Society and The Australasian Society of Cosmetic Medicine say nurses are increasingly injecting the restricted drugs in beauty salons and at Botox ''parties''.
  
  They claim nurses should administer anti-ageing medication only after patients are assessed by a doctor. But they say people are often injected without medical checks and prescriptions are provided for patients doctors have not met.
  
  Complaints have been made to nursing boards in three states, including Victoria, amid fears that nurses lack the medical expertise to deal with infections, allergic reactions or nerve damage from injections.
  
  One nurse in Victoria is being investigated amid claims she administered Botox and fat-dissolving injections over a 12-month period at regional beauty salons without having patients checked by a doctor. The doctor she claimed to work for is only registered to practice in a neighbouring state.
  
  But nurses deny breaking the law and have accused doctors of a scare campaign to protect their own profits.
  
  The Sunday Age believes two nurses reported to the Nurses Board of Victoria have had cases against them dismissed.
  
  Botox is a schedule four, prescription-only drug. It cannot be advertised directly to the public and must be used under medical supervision.
  
  Nurses board chief executive Nigel Fidgeon said he could not disclose information on hearings but added: ''There is no legislative restriction preventing a nurse from administering Botox as long as they have a doctor's order. There is also no requirement for a nurse to be supervised by a doctor when administering such medicines.''
  
  Gabrielle Caswell, who heads the Cosmetic Physicians Society, said she had no problem with nurses administering the drug if a doctor had examined the patient. But she said: ''We are getting situations where nurses are now holding Botox parties. So you get together with friends and usually there's alcohol around, you have a bit of a drink, no medical history is taken, you just wait your turn, get your Botox and it's all just a bit of a laugh,'' Dr Caswell said.
  
  ''But the moment you've taken a drink, then you're not giving informed consent. There's no doctor there to check if you're psychologically or physically suited to Botox or fillers.''
  
  Melissa Blandfort, a nurse who has been visiting beauty salons across Victoria to inject clients with Botox for nine years, said the claims were nothing more than a ''turf war''.
  
  ''They [doctors] don't like nurses injecting Botox because it means less business for them. This isn't about patient health concern. You can actually have more of a problem taking too many Panadol than you can taking Botox,'' she said.
  
  Ms Blandfort conceded the law on cosmetic treatment was a ''grey area'' and said she would welcome regulation that provided more clarity.
  
  But Alicia Teska, board member of The Australasian Society of Cosmetic Medicine, said nurses were trivialising the specialty. ''These are medical procedures and they shouldn't be trivialised as being of no more importance than having a manicure or having your hair done,'' Dr Teska said. ''It's the standards that are not being met and people should be quite concerned about that.''
  
  Dr Caswell said patients might not have legal recourse if such a procedure went wrong.
  
  ''The nurse is not technically responsible for the treatment, it is the prescribing doctor. If you have never met the prescribing doctor and haven't undergone a medical examination and history-taking, it may be difficult to discover who the doctor is.''
  
  Ms Blandfort said she had full insurance with a reputable provider. ''All the nurses that I know who do this have indemnity as well … I've had people abuse me for not treating them because I thought they might be a high-risk person and I sent them away.''
  
  Victorian Health Services Commissioner Beth Wilson said Botox was a relatively safe drug if used responsibly. ''If a nurse is adequately trained and they understand infection control and they know how to get informed consent, then I can't see a problem with it. However, I don't think alcohol and medicine should ever be mixed and to have people come to a Botox party and get injected is asking for trouble.''

  
  
• Four Corners 2006 Episode "Buyer of Beauty, Beware" - MUST SEE! The reporter for this episode is Jonathon Holmes who currently fronts Media Watch. Watch out of the liposuction procedure gone wrong at about 40 minutes in.
  
  
• A death after liposuction exposes busy illegal clinic - The Boston Globe, 2006
  
  
• Ex-footballer Colin Hendry's wife dies after operation to repair botched cosmetic surgery - Daily Mail UK 10th July 2009
  
  
• Choice Magazine review of Cosmetic Surgery
  
  
• Patients at risk in ugly cosmetic surgery wars - SMH, 2006
  

Clubs and Cartels

The big news this week has been that the ACCC is on the prowl again. Medical work practices are not new ground here - the ACCC has previously stoushed with the RACS over surgical training, as well as Queensland obstetricians and more recently Adelaide heart surgeons (my previous posts ACCC Strikes Again and Bleeding Hearts in Private Hospitals). In fact the ACCC has so much interest in the medical industry that it provides an Info Kit for doctors.

The new case now concerns medical accreditation practices at St Vincent's Private Hospital in Sydney, in particular, the practice of limiting appointment of new anaesthetists to those who already hold appointments at the nearby St Vinnie's Public hospital.

In general, most private hospitals have Medical Accreditation Committees that review the qualifications of any medical staff that wish to work at that hospital. The majority of private hospitals are quite keen to have as many doctors on their books as possible and to make the accreditation or credentialling process as simple as possible, because generally more doctors means more patients (and more business).

In the case of anaesthetists, they generally provide a service at the request of a surgeon. With the exception of staff anaesthetists who are paid directly by a private hospital to be available full or part time for urgent or emergency cases, the majority of private anaesthetists are paid fee-for-service by the patient or their insurance fund. Patients generally choose their surgeons but not their anaesthetists, and therefore the surgeon-anaesthetist team usually comes as a single package.

A surgeon will choose to work with a specific anaesthetist in the private setting because they are competent, they work well with the surgeon and his team (often having worked together for years), and they are available to do a particular set of cases at a particular time. Usually if a surgeon moves to another private hospital the anaesthetist will follow, rather than the other way round. Therefore it makes sense that if a private hospital wants to attract a new surgeon to bring work over that they encourage simple, rapid accreditation by the associated anaesthetists.

In contrast, in a public hospital the surgeon has no say who their anaesthetist will be. It could be a junior registrar, or a seasoned consultant. It could be someone they have never met or worked with before. We have to trust that somebody, somewhere (usually the public hospital's appointments committee), has decided that this anaesthetist is up to the job. In most cases, there are no problems as many aspects of anaesthetics are commonplace and transferable. Having a pool of staff anaesthetists makes it easier to roster for emergency cover, or to squeeze as much work as possible from a smaller group of staff - essential in any cash-strapped public hospital - at the cost of breaking up the regular surgeon-anaesthetist team. Obviously for more complex operations there will be more in-depth decision making and efforts to pair experienced and familiar surgeons and anaesthetists (as well as other theatre staff) together.

So what is going wrong here at St V's? Well, to the frustration of the hospital management and the surgeons, an arbitrary rule has been applied to limit the accreditation of new anaesthetists. This means that otherwise qualified and capable anaesthetists are unable to work at that hospital and surgeons who go to that hospital must choose from the anaesthetists who already work there. It is effectively a closed shop and keeps those anaesthetists who already have appointments busy with private work, and potentially allows them to raise their fees above what might be market rates at a hospital with a more liberal accreditation process.

Unfortunately it means that surgeons are forced to work with anaesthetists that they may not wish to work with, as well as discouraging them from bringing work to that hospital, much to the disappointment of hospital management.

Sadly, this is not the only private hospital in Australia that engages in this type of activity. Sometimes it is instigated by the medical staff, sometimes it is instigated by management as a business decision (usually if they employ the anaesthetists directly). Sometimes the ACCC gets it wrong, but by my reading this is one that they have got right and things clearly have to change.

Links:

• ACCC demands answers from St Vincent's - The Australian
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  ACCC demands answers from St Vincent's
  The Australian
  via AAP | August 17, 2009
  
  THE entire team of anaesthetists at St Vincent's Private Hospital is under investigation by the consumer watchdog for acting as a cartel.
  
  The Australian Competition and Consumer Commission (ACCC) last week demanded the group of 30 doctors, who are allocated nearly all the hospital's anaesthetic work, justify its membership rules, the Sydney Morning Herald reports.
  
  The investigation comes after the hospital applied to the commission last year to rule it could continue the practice of preventing outside anaesthetists from working in its operating theatres, even when requested by a surgeon.
  
  Individual doctors face possible fines of up to $500,000 if they are found to have breached competition laws.
  
  The private hospital's pool is restricted to anaesthetists who also work at St Vincent's Public Hospital.
  
  The process is supposed to be competitive and to benefit public patients, but has been criticised for being skewed towards doctors trained at St Vincent's.
  
  The hospital withdrew its application in December, but the commission is investigating fresh complaints from anaesthetists who say they are still locked out of work at St Vincent's.

  
  
  
• St Vincent's a closed shop, said leading anaesthetist - SMH
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  St Vincent's a closed shop, said leading anaesthetist
  Sydney Morning Herald
  Julie Robotham Medical Editor
  August 19, 2009
  
  THE anaesthetist representing doctors in the St Vincent's Private Hospital cartel investigation told professional colleagues that work allocation practices there would not change, despite a deluge of adverse submissions collected by the competition regulator during its initial, later abandoned, inquiry last year into the scheme.
  
  Minutes of a meeting of the NSW branch of the Australian Society of Anaesthetists, obtained by the Herald, reveal Gregory Deacon's resistance to the idea that closed-shop anaesthetic rostering might breach the Trade Practices Act.
  
  According to the minutes, from February, ''GD reminded committee members that St Vincent's Hospital is a privately owned business and therefore has the legal right to appoint staff, including doctors, as it chooses … GD felt the appointment process at St Vincent's Hospital was unlikely to change as a result of the application to the ACCC.''
  
  At issue is the practice of allowing only the limited number of doctors with an appointment at St Vincent's Public Hospital to work at the private facility. The private hospital argued this ensured adequate anaesthetic cover for the public hospital. However, NSW Health, which funds the public hospital, told the commission that claim was specious because there was a surfeit of anaesthetists in the eastern suburbs willing to work with public patients.
  
  Other doctors told the commission the real intention was to keep lucrative private work within a select group of associates.
  
  The commission last December dropped its first examination of the arrangement when St Vincent's withdrew its application to be exempted from the law.
  
  Now the anaesthetists - who as a formal association manage anaesthetic staffing for the hospital - are again under ACCC scrutiny, following new complaints from doctors excluded from working there.
  
  Dr Deacon, as the public officer representing them, must respond by Friday to the commission's questions regarding the group's history, policies and reasons for refusing work to qualified doctors. He refused to comment last night.

  
  
  
  
• Elite hospital old boys' network targeted by competition watchdog - SMH
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  Elite hospital old boys' network targeted by competition watchdog
  Sydney Morning Herald
  Julie Robotham Medical Editor
  August 17, 2009
  
  THE entire team of anaesthetists at St Vincent's Private Hospital - more than 30 doctors - is under investigation for acting as a cartel.
  
  The Australian Competition and Consumer Commission is moving to end what other doctors claim is a decades-long history of restrictive behaviour by an old boys' network which is bent on protecting its exclusive access to some of Sydney's most lucrative private operating lists.
  
  The ACCC last week demanded the group - a consortium of doctors employed as independent contractors but allocated nearly all the hospital's anaesthetic work - justify its existence and membership rules and defend how its members set patients' fees.
  
  Other doctors said giving anaesthetic shifts to a limited pool of specialists could also compromise patient care, barring surgeons from choosing anaesthetists experienced in particular operations.
  
  The commission's move could see individual doctors hit with fines of up to $500,000 if they are found to have breached competition laws. It comes after the hospital last year applied to the commission to rule it could continue the practice of preventing outside anaesthetists from working in its operating theatres, even when requested by a surgeon.
  
  The private hospital's pool is restricted to anaesthetists who also work at St Vincent's Public Hospital - appointed through what the hospital describes as a, ''competitive process '' intended to benefit public patients, but which others say includes a system of patronage skewed towards doctors trained there.
  
  The application prompted a huge backlash, as individuals and specialists' groups told the commission the closed roster was unjustified and unique in NSW.
  
  In its submission, NSW Health, which funds St Vincent's Public Hospital, said public patients did not benefit from the exclusivity arrangement, because there was no, "current or foreseeable shortage of anaesthetists," in the eastern suburbs, and, "indeed if anything there is an oversupply''.
  
  The hospital withdrew the application in December and is understood to have told the doctors, who effectively run the anaesthetic department and charge some of Sydney's highest rates, to change how they allocate work.
  
  But the commission is now investigating new complaints from anaesthetists who say they are still locked out of work at St Vincent's Private.
  
  Early this year the hospital's executive director, Robert Cusack, signed a rejection letter saying there was, ''sufficient anaesthetic cover within the existing cohort of anaesthetists,'' and the candidate therefore, ''did not satisfy a business need of the hospital.''
  
  Despite this, Mr Cusack is understood to be furious with the anaesthetists' position and to have told them he will not pay their legal costs or any fines.
  
  An anaesthetist, David Bollinger, told the Herald : ''I've had a professional relationship with a surgeon I've worked with for 15 years, and he moved to St Vincent's and they won't let me work there. It's … mean-spirited, and bordering on unethical.''
  
  Another anaesthetist refused work said: ''St Vincent's is very highly regarded in the community [but] the way they do things is not necessarily in the best interests of patients … it's in the best interests of themselves.''
  
  Gregory Deacon, public officer of the St Vincent's Private anaesthetists' consortium, declined to comment, saying the matter was being handled by lawyers. The hospital also refused to comment, citing the ACCC proceedings.

10 Year Challenge

Seasoned readers may recall my previous post "10 Years in Limbo" about the 10 year moratorium placed on overseas-graduated doctors.

The 10 Year Moratorium applies to New Zealanders as well, as despite their special visa status they are not considered permanent residents even when enrolled in Australian Medical Schools, and the only way around this is to obtain permanent residency prior to commencing Medical School in Australia.

Well, Dr Mike Belich wants to do something about that, and he has challenged the validity of the 10 year lockout and is currently going through the courts, as reported in The Australian. To be honest, I don't really understand his argument for seeking an exemption from the current rules... but I guess this is how precedents are set.

No doubt all the New Zealander's over at Paging Dr will be all excited. I better go let them know...

GP goes to court fighting country duty - The Australian
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GP goes to court fighting country duty
The Australian
Adam Cresswell, Health editor | August 15, 2009

A NEWLY qualified general practitioner has launched a David and Goliath legal challenge to the head of Medicare, filing a Federal Court action over a ruling he says will force him to abandon his home and partner and spend the next 10 years working in the bush.

Byron Bay doctor Mike Belich passed his postgraduate exams to qualify as a GP three months ago but is on borrowed time in the northern NSW coastal resort because of a retrospective ruling by Medicare that he was an overseas student when he enrolled at the University of NSW in 1999.

The ruling means he is subject to a moratorium set up by the Howard government in 1996 that forces overseas-trained or foreign-origin doctors to work for 10 years in the outback before attaining the right to practise where they like under Medicare.

Belich could not apply for permanent residency when he first moved to Australia with his family at age 14 because as New Zealanders they were considered to be, effectively, permanent residents already. He became an Australian citizen while at university, but later found out that the day he started medical school was the cut-off point used to classify him as an overseas student. He's challenging the ruling as unfair and beyond parliament's original intentions.

If successful his case, lodged with the NSW registry of the Federal Court this week, could affect up to 100 other doctors of New Zealand origin who, it is understood, may be in a similar position.

Belich tells Weekend Health that while at university he was treated the same as a local student, to the extent that he graduated with a HECS debt.

He was first informed of Medicare's decision to classify him as an overseas student when he applied to join the GP training program, more than a year after he had qualified as a doctor and when an Australian citizen.

He says his case is a fight for "natural justice and transparency".

"They have gone against the intention of the law, and have acted in a way to get me and 100 other people into a 10-year binding contract where we had no idea (this would apply)," Belich says. "I'm not going to work where they want me to work ... the government has spent all this money training me as a GP, they are short of GPs and they need a GP here in Byron."

Belich, who has recently bought a house with his partner in Byron Bay, says subsequent attempts to overturn the decision - including direct appeals to then federal health minister Tony Abbott and his successor Nicola Roxon - have brought sympathetic noises but no practical concessions.

The situation has been in limbo during Belich's four-year period of GP training, when he was allowed to continue working in Byron Bay under a temporary exemption from the 10-year rule.

But with his GP fellowship secured, the exemption is due to expire on October 19. Belich says he cannot comply with the 10-year rural service order because his partner is unable to leave the area under the terms of a Family Court order granting her former partner access to their two children.

Belich's solicitor Adam van Kempen, partner with the Byron Bay law firm Bottrill van Kempen, says Belich is asking the Federal Court to make a declaration that Belich is not a former overseas medical student under the terms of the Health Insurance Act.

Further, the case, which cites the chief executive of Medicare Australia as the respondent, seeks a declaration from the court that the act does not prevent Medicare benefits being paid in respect of services Belich provides.

Other doctors who may be affected by the outcome of the case will be New Zealanders who study in Australia under the same conditions as Australian students but who later are told by Medicare that different rules will apply, van Kempen says.

"The contention is that the legislation has captured this group of people and it was an unintended consequence of the legislation," van Kempen says.

Given the October 19 deadline, van Kempen says he expects there will be an application for the case to be heard urgently.

In a letter sent by then Royal Australian College of General Practitioners president Michael Kidd to Abbott in July 2006, Kidd says it is "evident ... that the Department of Health and Ageing's classification of Dr Belich as a 'former overseas medical student' appears to be a contradiction to the information publicly available" from the Department of Family and Community Services,

Department of Education, Science and Training, Department of Immigration and Multicultural Affairs and other agencies.

Kidd concludes that the college believes the moratorium should not apply to Belich and requests Abbott "use (his) ministerial discretion ... to overrule this restriction and allow Dr Belich to practise freely".

A Medicare Australia spokeswoman says it would "not be appropriate ... to comment on foreshadowed legal proceedings".