Truth in Medical Education? Part 2

Armando Soto, MD, FACS
Article by
Orlando Plastic Surgeon

Okay, so in our last entry, I discussed how a combination of factors has led to a situation in which patients are routinely injured or deformed by providers unfit to perform procedures that they market aggressively.   I described these factors to include physician-independent factors, like our nation's growing appetite for new and exciting cosmetic treatments, and the very low ethical standard of medical device manufacturers who are looking for ways to expand profits by selling their machines aggressively to anyone they can- despite the risk to the population of selling their devices to untrained practitioners.   I also described the physician environment factors contributing to this problem, like declining insurance reimbursements for all physicians, the decline in respect and prestige the medical profession has experienced, and the almost inevitable (yet still reprehensible) resultant decline in the ethics and morals of these cash strapped physicians.   I described how this affects my practice daily- seeing women with preventable injuries and deformities that resulted from plastic surgery procedures performed by urologists, family practice doctors, eye doctors, and in some cases, by individuals who aren't MD's at all!   Today, I want to discuss the larger, societal problems this is going to inevitably lead to, and why, as a second generation surgeon, this is so disturbing to me.   Traditionally, and fundamentally, the practice and profession of medicine is based on public trust, and an implicit agreement between our society and those of us who make the choice to become its caregivers...     We as physicians understand that our course of education and training will be more rigorous than any other profession.   We understand that choosing to enter medicine will require us to largely sacrifice our youth to our dream of helping others, spending almost the entirety of our 20's and early 30's in a hospital learning and gaining experience that will help us be better doctors.   We even understand that in the United States, being a doctor means being constantly aware that the next person we try to help might know a lawyer and try to sue us if things don't go perfectly (what other group of human beings do you know that are expected to never make mistakes?)   We agree to do our level best to treat people and help them through illness or need.   In the past these sacrifices were well-compensated for most.   Being a doctor meant earning the respect of our patients, but on a larger scale, being a doctor meant you had earned society's respect.   You were viewed as an altruistic person who had studied and shown incredible devotion to help your fellow man and you were honored for this work and sacrifice.   For most, being a doctor also meant that you would lead a financially stable and comfortable (if not wealthy) lifestyle once your training was successfully completed.   Society agrees to hold us in high regard and assure our financial stability.   Somewhere along the way, providers of medical insurance (who in the United States are ALL for-profit companies beholden to shareholders and their bottom lines) figured out that doctors and their inherently altruistic natures could be taken advantage of... and Managed Care was born.     A history of managed care and the many ways it has affected doctors and patients alike is well beyond my point, but let's briefly understand the following:   By limiting access to care, managed care has caused the general level of frustration experienced by all involved in healthcare (from patients to nurses and doctors alike) to smolder and burn- to the detriment of the all-important doctor-patient relationship.   The CAUSE of the frustration is out of our hands as doctors, yet WE are the ones who have to deal with the frustrated patient. Their insurer is just a voice on the phone- and most often not even a real human voice.   This frustration, and the fact that the insurance company is "in the background", has caused the public perception of doctors to decline.   Managed care has led to dramatically reduced physician compensation.   The frustration, decline in compensation to physicians, and loss of societal status has led to physician frustration- and for some, a search for alternative financial gratification.   For these physicians, the fact that in their minds they have already lost the war with the insurers and the government and are being forced to accept ridiculously low compensation has created a hopelessness and lack of faith in the system.   It has also led these frustrated and underpaid physicians to question whether or not their agreement with society is still valid.   (I know a good general surgeon who is paid $550 to remove a gallbladder... that's for all of the preoperative visits, knowing how to make the correct diagnosis, successfully performing the operation, and all of the postoperative care... your plumber or electrician are paid much better...)   In other words, if being a physician no longer means prestige, the respect accorded a scholar, and financial stability, and if it also means daily life is filled with strife and frustration, why should I not do whatever I can to at least be paid better???   Even if this means that I need to call myself a liposuction expert- knowing that my training was in ophthalmology (treatment of disorders of the eye).       By giving up on the system and compromising their ethics and morals to make more money, physicians are themselves now ADDING to the factors causing our public standing to decline over time.   Every time a patient is injured irreversibly because she allowed an eye doctor to convince her he was an expert liposuction surgeon, her trust in our system of medicine as a whole diminishes. Her view of all doctors suffers.   And she is left with a very bad taste in her mouth which she remembers any time the topic of plastic surgery comes up.   And THAT is what is most disturbing to me... someone who went to the trouble of doing it right... Of actually completing an accredited Plastic Surgery Residency Program... Of taking and passing the American Board of Plastic Surgery Certification Examinations....   My reputation and that of my specialty is suffering because of the poor outcomes and injuries produced by non-plastic surgeons performing plastic surgery.     So what's the bottom line?   If you are interested in a plastic surgery procedure, please know that in the right hands you can be safe and have a very high likelihood of achieving your goal.   It is important to research you surgeon, the facility in which the procedure will be performed, and the anesthesia provider thoroughly.   Finally, if you DO choose to have your plastic surgery performed by a doctor without the training necessary to keep you safe and give you the best outcome, know that your Board Certified Plastic Surgeon is ready to offer you whatever help possible to correct your deformity.