Have you ever asked yourself about your patients' perception of what "board-certified" means to them? What do your patients think when they see the term “board-certified?” Do they understand its implications? Do they even care? Knowledge is power and patients appear to be lacking in both when it comes to this issue. We will delve into just how much patients truly understand when they see this term and why this understanding is of particular importance in the medical aesthetics industry.
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Have you ever asked yourself about your patients' perception of what "board-certified" means to them? What do your patients think when they see the term “board-certified?” Do they understand its implications? Do they even care? Knowledge is power and patients appear to be lacking in both when it comes to this issue. We will delve into just how much patients truly understand when they see this term and why this understanding is of particular importance in the medical aesthetics industry.
British journalist and classical music aficionado Norman Lebrecht once proclaimed that classical music should embrace its elitism. During his infamous talk, “Reframing the Classic Music Experience,” he explored the perceived elitism that lingers in the classical music industry.
“Why shouldn’t we be elitist?” he asked.
He argued that a lifetime of work from some of the finest talents on earth should be a selective and elite experience that is celebrated. He viewed the ideal classical performance as long pieces of music, expensive tickets and sophisticated audiences. Elitism and secrecy can share the same air when traditional views on how things should be done develop a stranglehold over innovative and nonconformal thinking.
Of course, this concept spreads beyond classical music to any medium that encourages intellect, competition and profit, including plastic surgery. Cosmetic surgeons devote their professional lives to elective procedures with an established notion of patient dissatisfaction and therefore, risk to reputation and livelihood, unlike any other field of surgery.
Richard C. Webster, M.D., a historic practitioner of cosmetic surgery, wrote in a 1984 article on the history of cosmetic surgery, “The more elective a surgery is, the less tolerance of error or inadequate improvement there will be…when patients must pay themselves for their treatment, every item of expense is scrutinized carefully and, at times, rationalized into being unjustified.”1
When surgery is performed to eradicate disease, preserve life or diminish physical pain, its medical value is indisputable. The need for the procedure typically originates from an unpredictable circumstance, and in many cases, the patient is only accepting the surgery because of its necessity.
The uniqueness of cosmetic surgery is in the subjectivity of its results. That subjectivity is why third parties, like insurance companies, can choose to value cosmetic surgery differently than general surgery. The discussion is more about individual patient desires than medical necessity.
Obtuse Opposition
While in its infancy, the plastic surgery discipline was openly opposed by the medical community at large. The need for reconstructive surgery facilitated the creation of the specialty, but since the field of plastic surgery involved utilizing techniques that, for the most part, already existed in other previously established surgical specialties, the growth of the plastic surgery industry was seen as coming at the expense of those original disciplines.
According to Dr. Webster, those interested in cosmetic procedures were considered everything from “tinkerers, watchmakers and panderers to the rich” to “dollar-hungry incompetents who would not know what to do in a belly, who could not operate their way out of a box in ‘necessary’ surgery and who, at times, were nothing more than quacks or outright charlatans preying on a gullible public.”
“Nobody believed plastic surgery should exist,” said Alex Sobel, D.O., FAACS, current president of the American Academy of Cosmetic Surgery (AACS) and past president of the American Board of Cosmetic Surgery (ABCS), as well as the owner of Anderson Civil Cosmetic Surgery. “They had to battle so hard for their own existence that they would hide their interests from peers for fear of ridicule or getting run out of a hospital.”
The need to work in the shadows led to a pattern of anti-collaborative behavior and jealousy among peers that is commonly associated with the medical industry. “Your tricks were your ability to differentiate yourself from somebody else, and if you could execute a great facelift that no one else in town could, then you had all the business,” Dr. Sobel said.
As medicine progressed and specialties emerged, disagreements about who should or should not perform a procedure became commonplace. Doctors began to protect their own turf.
“An internal medicine doctor may develop and then insert the first several thousand pacemakers,” Sobel said. “Then suddenly a few years later, when there's a specialty called cardiology that didn't exist beforehand, they say internal medicine doctors shouldn't be putting in pacemakers – and that's how the medical community kind of is.”
Cut-throat competition might be less prevalent today, but the philosophy that doctors should be placed in “board-certified boxes” persists and often grows within certain segments of the medical community, including cosmetic surgery. Sobel provided an example from his time as an Ear, Nose & Throat (ENT) surgeon. He was testifying in front of the Medical Board of California on why cosmetic surgeons should be able to advertise what they do when a surgeon tried to dismiss his credibility by saying that ENTs have no training outside of the face.
“ENT surgeons invented most of the microvascular free flap (techniques) where you can take off part of somebody's leg, plug it in somewhere in the face and reconstruct the jawbone out of it,” Sobel said. “Nobody had a problem with ENTs inventing that, and for a while, they let ENTs perform it. That's a huge reconstructive industry that was brought to the public and eventually brought to plastic surgery by ENTs who had a need for it.”
The Benefits of Board Certification
As Dr. Sobel pointed out, only those trained and experienced in certain procedures should be allowed to perform those procedures. All doctors take an oath to only do what lies within their education, experience and training. There is a need for terms like board certification to ensure public perception of expertise.
“You want to be board-certified because that's your stamp of approval from the medical education system that you've accomplished your specialty and you now have a right to practice,” Sobel said. “That gets a little dangerous when doctors say, ‘Well, I'm entitled to practice within the scope, even the parts that I'm not really trained or accomplished in. And since I took a test, nobody can really argue with me.’ Not everybody does that.”
Sobel described how doctors can lean on certification titles to either restrict competition or expand their capabilities. Board certification does not implicitly imply extensive experience and training in all elements of a specific surgical discipline.
“Physicians could tell patients, ‘You should come to me because I'm board-certified and that means I have the gold standard to do what you need done. You are at peril if you go see someone else,’” Sobel said. “I think, from the inside, that’s what physicians think, from their training to whatever they ended up doing, that’s how they see board certification and how they want the public to see board certification.”
Hospitals can benefit from using terms like board certification to bolster the credibility of their staff and potentially shift any medical malpractice blame to the certification board. State governments can also use certification as a catch-all term to allow doctors to work in different states.
“States have a lot of interest in board certification because they want to be able to credential people for working and moving from one state to another quickly,” Sobel said. “When they were figuring that all out, one of the basic standards was board certification, because it's just such an easy commodity.”
Sobel suggested the purposeful vagueness of the term board certification offers patients a simplified explanation, because ultimately, they don’t care about the specifics. They just want someone who will properly perform their surgery. But does board certification prove that a surgeon is safe or just well-trained?
“It’s a discussion of the scope of practice for mid-level practitioners, physician associates, nurse practitioners who present themselves as doctors and others,” Sobel said. “Is it commercial free speech or is it confusing to the public and harmful? If you actually drilled somebody on it from the medical community and asked, ‘Does (being board-certified) really mean they’re safe,’ they would say, ‘Well, no, not really, but it means the doctor got far enough to take a test.’”
Public Definitions of Plastic & Cosmetic Surgery
A 2017 study2 in the Journal of Plastic Reconstructive Surgery by Ajul Shah, M.D., et al., tried to better determine public opinions on titles like plastic surgeon and cosmetic surgeon and whether patients feel confused when searching for providers of cosmetic surgery.
For the study, researchers analyzed responses to a 19-question survey from 5,135 patients. Predictably, patients believed surgeons needed extensive training to perform surgery to improve cosmetic appearance, with 77% of respondents suggesting at least five years of training. In reality, it takes 10 to 14 years on average to become a doctor or a surgeon in the United States. When broken down into its different components, this includes a four-year undergraduate degree, four years of medical school and three to seven years of residency.3
Residency length can be dependent on the surgical discipline and typically involves five years of general surgery residency, plus integrated experience in the specific discipline. Plastic surgery includes two to three years of residency/fellowship in plastic surgery, while dermatology includes three years plus the PGY-1 Transitional/Preliminary program and cosmetic surgery requires four to six years of residency in a related discipline and one-year fellowship.4
The survey found that 87% of respondents either thought surgeons must be appropriately credentialed to legally advertise themselves or were unsure if they needed to be. Only 10% of respondents said board certification was not important if the surgeon had a good reputation. A significant number of respondents were uncomfortable with obstetrician-gynecologists (92%), dermatologists (68%), general surgeons (74%) and family practice physicians (93%) performing surgery to improve their appearance.
Another takeaway from the survey was the apparent confusion among patients on the differences between plastic surgery and cosmetic surgery. A small percentage of patients (6%) believed that board certification in cosmetic surgery required more training than plastic surgery, while 29% believed that plastic surgery required more training and 11% thought cosmetic surgeons and plastic surgeons had equal training. Most respondents (54%) answered by saying they were unsure of the difference.
Board certification from the American Board of Cosmetic Surgery requires spending a full year training exclusively and comprehensively in cosmetic surgery, passing a two-day oral and written exam and completing a minimum of 300 individual cosmetic surgery procedures of the face, breast and body, as well as additional training in non-surgical cosmetic procedures.5
American Society of Plastic Surgery members need to have board certification from the American Board of Plastic Surgery, or if practicing in Canada, certification by the Royal College of Physicians and Surgeons of Canada. They also must pass oral and written exams and complete continuing medical education (CME) requirements annually.6
The Engaged Modern Patient
According to Dr. Webster’s 1984 article, the original distinction between plastic and cosmetic surgery was that plastic surgery was focused on reconstruction and cosmetic surgery was done solely to improve one’s appearance for cosmetic reasons. Dr. Sobel suggested that in modern medicine, the terms are essentially interchangeable. There is less of a stigma about a desire to improve one’s appearance for purely cosmetic reasons, which has perhaps created a lack of public distinction between the surgeries.
The 2017 study indicates that patients do care about the phrase “board-certified,” they just don’t know what it means due to medical marketing, recognized and unrecognized boards and varying categorizations of surgeons. The authors of the study concluded, “This confusion makes it increasingly difficult for a patient to interpret the necessary information to decide which physician can safely perform surgery to improve one’s appearance.”2
More information is needed to truly understand how much patients want to know or should know, about their surgeons. The biggest concern of patients is likely always going to be their own safety, and the term “board-certified” next to their surgeon’s name can create the seal of approval they need to agree to the procedure.
While Dr. Sobel believes that ultimately patients want some kind of reassurance of the credibility of their doctors, he also thinks there is a desire for some to go deeper with their level of understanding.
“So much of what we do, the way we practice and the way these certifying boards function, is in the absence of public opinion,” Sobel said. “I think most of us can agree that modern medical care involves an informed or pseudo-informed public that seeks their own information, their own diagnosis and their own treatments. They are asking more questions and becoming more engaged.”
References:
1. Webster RC. Cosmetic Surgery: Its Past, Present, and Future. The American Journal of Cosmetic Surgery. 1984;1(1):3-14. doi:10.1177/074880688400100102
2. Shah A, Patel A, Smetona J, Rohrich RJ. Public Perception of Cosmetic Surgeons versus Plastic Surgeons: Increasing Transparency to Educate Patients. Plast Reconstr Surg. 2017 Feb;139(2):544e-557e. doi: 10.1097/PRS.0000000000003020. PMID: 28121896.
3. International Medical Aid, www.medicalaid.org/how-long-is-medical-school-in-2023
4. American Board of Cosmetic Surgery, www.americanboardcosmeticsurgery.org/patient-resources/cosmetic-surgery-vs-plastic-surgery/
5. American Board of Cosmetic Surgery, www.americanboardcosmeticsurgery.org/patient-resources/choose-abcs-surgeon/
6. American Society of Plastic Surgery, www.plasticsurgery.org/news/articles/the-differences-between-plastic-surgery-and-cosmetic-surgery-and-why-board-certification-matters
