In his opening speech at Plastic Surgery the Meeting 2024, the chair of the American Society of Plastic Surgery (ASPS) addressed an increasingly urgent issue: the protection of scope of practice. As a third-year medical student, I had limited exposure to this topic, but a Los Angeles Times article I read in the past year crossed my mind. In October 2020, a 28-year-old woman traveled from Las Vegas to receive liposuction from a physician (who was board-certified in pediatrics) in south Los Angeles. An hour into surgery, paramedics were summoned as she had stopped breathing. Four days later, she died at Good Samaritan Hospital. At the time, I thought this may have been an isolated incident. Learning that this physician had openly been performing surgical procedures for seven years was borderline unbelievable.
However, numerous incidents such as the aforementioned have warranted heightened vigilance and reflected the need to spotlight a topic that is both sensitive and, at times, uncomfortable to address. Not long ago, a physician with years of service lost his position shortly after publishing an op-ed on the importance of physician oversight for APPs. Although his article neither criticized nor undermined any professional group, his dismissal cited a breach of “mutual respect.”
Originally a project management term, “scope creep” has come to signify the expansion of practice boundaries for nonphysician professionals in health care. Out-of-scope practice, however, refers to actions outside what a licensed health professional is formally permitted to do. For instance, within internal medicine, any surgical procedure is considered beyond scope. Similarly, in a surgical specialty like otolaryngology, aesthetic procedures below the neck — such as abdominoplasty — are viewed as out-of-scope.
On the patient’s end, incomplete understanding of board certification and obtaining licensure facilitates the path toward out-of-scope practice. For instance, in the case of cosmetic procedures, the alternate pathway of becoming certified by the American Board of Cosmetic Surgery (ABCS) in lieu of the American Board of Plastic Surgery (ABPS) has added ambiguity to what the label of “cosmetic surgeon” means and entails. The prerequisite for ABCS certification is completing a residency in a “related” surgical specialty. Certification is granted after a one-year fellowship entailing at least 300 cosmetic procedures and passing ABCS-administered written and oral exams. Although not recognized by the American Board of Medical Specialties, those certified by ABCS can market themselves as “cosmetic surgeons” and gather a patient base with the significance of well-targeted and curated in the world of cosmetic surgery. A plastic and reconstructive surgery-trained physician has in-depth understanding of both gross anatomy and intricacies of neurovascular supply and structural composition of skin and soft tissue, in addition to years of experience managing postoperative complications pertaining to mentioned tissues. Such expertise acquired through a plastic and reconstructive surgery residency cannot realistically be replicated by a single year of training and 300 procedures, a fact that may be unbeknownst to those outside of the medical field.
Moreover, a study on the background of physicians performing cosmetic procedures in Southern California — ranging from minimally invasive procedures such as hyaluronic acid fillers to invasive procedures with potentially lethal complications (i.e., liposuction) — revealed that not only surgeons but physicians with nonsurgical specialties as well as APPs were performing these procedures. Primary care was the third most common physician specialty for provision of fillers and ranked fourth for liposuction, with many such specialists running practices exclusively offering cosmetic procedures. Radiologists, pathologists, psychiatrists, and anesthesiologists were also among physicians performing both minimally invasive and invasive procedures.
Following an uptick in unsafe and illegal cosmetic procedures, the “Do Your Homework” campaign by the ASPS was started, encouraging patients to validate their physician’s qualifications through either the ASPS or ABPS webpages. However, assuming that a patient clearly prefers care from a plastic surgeon, the responsibility falls on patients to ensure their physician has the appropriate credentials, which can be daunting given the complexity of certifications and titles.
The root of this problem is the presumed allure of cosmetic procedures as a fast and lucrative pursuit, as Robert M. Goldwyn, surgeon and author, aptly describes: “… plastic surgery theoretically offers the escape hatch of performing aesthetic surgery that is not financially regulated. This option is usually not available, for example, to pediatricians, pediatric surgeons, most surgeons, most internists, and medical specialists.” This perception causes downplaying of consideration for risk of adverse events, ultimately going against the principle of nonmaleficence.
In an ideal world, physicians would find satisfaction within their scope of practice and not feel compelled to venture into out-of-scope procedures. However, at this point in time, with legislation on scope of practice varying by state, the hope is for physicians to appreciate the magnitude of the out-of-scope cosmetic practice problem, especially given incidents such as the tragic death of a young woman during liposuction, ultimately reminding physicians to prioritize patient safety above and beyond all else.
Helia is a third-year medical student at Yale School of Medicine. When not learning medicine, she can be found sketching, collecting rare books, and bouldering. She is a 2024–2025 Doximity Op-Med Fellow.
Image by Alphavector / Shutterstock
