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Is it ethical for Physicians to add cosmetic procedures to their core practice?

*Do You Tip Your Doc for Botox?
In the last few years, an increasing number of General Practitioners, Family Practitioners and OB-GYNs in the United States, Canada, and Australia have added revenue-enhancing cosmetic procedures to their core practice. Because 91 percent of cosmetic procedures are performed on women, OB-GYNs have a ready-made client base—but is the integrity of the physician-patient relationship, the practice of medicine, and ultimately the care of patients compromised when physicians offer cosmetic procedures and products that don’t increase the health and welfare of their patients?
“We are physicians who limit our practice to women,” writes David Levine, MD in the Journal of Minimally Invasive Gynecology, an OB-GYN and outspoken proponent of the practice, “and these same women are responsible for the bulk of the $6 billion per year spent on cosmetic treatments, it seems natural for us to consider offering these treatments.”
Levine’s argument seems logical on the surface, but in medicine, what makes sense financially is not always what makes sense ethically. We must face the fact that there are deep ethical implications of the rapidly increasing trend of General Practitioners (GPs) Family Practitioners (FPs) and OB-GYNs adding revenue-enhancing cosmetic procedures and products such as skin rejuvenation, Botox®, Radiesse®, liposuction, breast augmentation, and mesotherapy to their core practice.
This quandary is situated in the context of a broader debate on the moral distinction between what constitutes appropriate medical treatment and what constitutes treatment that is non-curative. Cosmetic surgery itself is an explosively contested practice. Because cosmetic procedures are not treating or preventing disease, injury, or malady, many argue they do not serve the goals of medicine and potentially risk or cause problems that are not outweighed by the perceived benefits. That said, at least when a woman steps through the doors of a cosmetic surgeons office she is making a choice. When her GP, FP or OB-GYN start offering these services, the line between appropriate medical treatment and elective, non-curative treatments becomes blurred.
Yet the trend is gaining momentum. In January 2004, the International Society of Cosmetogynecology was founded to educate and support OB-GYNs who are actively performing these procedures. Six years ago there were few resources to help GPs and FPs add cosmetic procedures to their practice, now there are a plethora of seminars, educational materials, and consultants available to transform one’s medical practice. The American Academy of Family Physicians itself offers continuing education courses on injectable cosmetic fillers, cosmetic lasers, chemical peels, microdermabrasion, and more.
To understand what’s driving the trend, we must look at why GPs, FPs and OB-GYNs would want to expand their practices to include cosmetic procedures. Over the last decade there has been downward pressure on physician income, dissatisfaction with managed care oversight, decreased job satisfaction, and increased liability concerns leading to some OB-GYNs to drop their obstetric care and others to leave the fields they were trained in all together. According to the American Medical Association, the effect of this discontent on the patient-physician relationship and the practice of medicine is yet unclear, but is cause for some concern.
The allure of revenue-enhancing procedures is seductive, notes Julie D. Cantor, MD, JD in her Virtual Mentor column, “Everyone wants a piece of the cosmedicine world, a ‘happy’ place where a full-time anesthesiologist can become a part-time aesthetician and ‘make a few bucks’ by wielding a laser at a beauty salon.”
Adding cosmetic procedures might be a ready remedy for a physician’s salary boost, but the potential ethical issues it raises are alarming: conflict of interest, exploitation of patient trust, and demeaning the practice of medicine to name just a few.
The fundamental trust between a patient and a physician is based on the principle of beneficence; patients are confident that their doctor has their best interest at heart and there is no incentive, financial or otherwise, for their physician to perform any particular procedure. The Hippocratic tradition calls upon physicians to hold their duty to their patient’s welfare above consideration of personal advancement because any activity that creates a conflict of interest casts doubt on the physician’s ability to fulfill fiduciary obligations and undermines patient trust. The addition of cosmetic procedures to a GP, FP or OB-GYN’s practice is solely driven by financial incentives, which brings the personal interests of the physicians into the therapeutic relationship.
Ethically, it is important to distinguish how the practice of medicine differs from the world of business. Franklin D. Miller, MD in the Cambridge Quarterly of Healthcare Ethics writes, “From the time of the ancient Greeks to the present, medicine as a professional practice has been distinguished from business. Governance by an internal morality underlies this distinction. Business, to be sure, does not lie outside the domain of morality. But medicine is subject to specialized and more stringent ethical constraints than are characteristic of and appropriate to business enterprises. Medicine is not a morally neutral technique. Rather it is a professional practice governed by a moral framework consisting of goals proper to medicine, role-specific duties, and clinical virtues. The professional integrity of physicians is constituted by loyalty and adherence to this internal morality.”
“I will not deny that there is a monetary incentive to performing cosmetic procedures,” admits Dr. David Levine. “There is no insurance coverage for any cosmetic procedure offered, and demand dictates fees. Those of us who have watched our fee schedules free fall over the years are looking for areas where we will be compensated for the work we do without discount.”
Not all OB-GYNs share Levine’s enthusiasm. Paul D. Indman, MD, challenges the idea that adding cosmetic procedures is just a natural extension of the practice of gynecology. In an op-ed piece in the Journal of Minimally Invasive Gynecology Dr. Indman wrote, “The American Association of Gynecologic Laparoscopists’ vision is to serve women by advancing the safest and most efficacious diagnostic and therapeutic techniques...Fundamental to all these procedures are the existence of gynecological disease or problem that requires surgery… How does liposuction, Botox, breast augmentation, or vaginal rejuvenation fit into our vision? We can try to extend the definition of gynecology beyond that of the dictionary’s ‘medical specialty concerns with diseases of the female genital tract, as well as endocrinology and reproductive physiology of the female.’ It is curious, however, that all the newly proposed additions consist of lucrative cosmetic procedures…”
Daniel Frank, MD, an internist in Seattle, established his primary care practice in 2002. At the time other primary care practices were starting to offer cosmetic procedures, but he rejected the idea, “When setting up the practice, we were called upon by a number of sales people who wanted us to offer cosmetic procedures. I believe if there is too much of a financial incentive to offer a procedure or service, then my objectivity could be comprised, and even the best and most diligent and objective among us can’t help but be swayed by the economic factors, particularly in primary care. We did not want to detract from our primary mission, which is the care of our patients, so we declined.”
There is no prohibition against physicians earning a living, so when do financial incentives become ethically problematic? The American Medical Association suggests that it is “the size of the financial reward or penalty associated with certain practice can help distinguish appropriate from inappropriate incentives. All other factors being equal, a direct correlation exists between the size of a financial inducement and the degree of influence it exercises.”
In the case of cosmetic procedures, the financial inducement is considerable. The AAFP suggests that a family practitioner can easily bring in an additional $10,000 to $20,000 a month, more if they are willing to devote more time it.  In light of this, the AMA urges that the medical profession “must strive to preserve the trust patients hold in their physicians. It can not abandon ethical standards to economic forces.”
Financial incentives often compromise clinical objectivity, including increasing the possibility of misdiagnosis. According to the American Society for Dermatologic Surgery, the primary misdiagnosis by GPs is identifying cancerous lesions as “age spots.” Instead of referring patients to a specialist to have the suspicious spots checked out, as they may have in the past, GPs are removing them with lasers. Unfortunately, skin cancer cannot be removed this way so the cancer returns at a more advanced and dangerous stage.
Sam Nacify, MD, a facial plastic surgeon, has been involved in numerous cases where melanomas were treated improperly and lead to diagnostic delays. “Just as I may be more likely to miss signs of ovarian cancer if I performed a gynecological exam,” he says, “a delayed diagnosis is more likely to happen when a practitioner is not properly trained in diseases of the skin.”
Beyond financial conflict of interest, we also have to explore how these procedures exploit the already established doctor-patient relationship. Patients have the right to expect the highest level of medical professionalism when they come to their physician ill and vulnerable. Unfortunately, many are being prepped for a sales pitch of the physicians’ latest offerings. When a patient sees advertisements and brochures in her GP, FP or OB-GYN’s waiting room, or thumbs through before-and-after photo books, or experience longer waiting times to see the physician for non-cosmetic related issues, a subtle messages sent: feeling better is not enough; looking younger is a matter of good health.
“These norms of appearance are directed mainly at women, and specify what they ought to look like in a way that demands significant investments of time, energy and money,” writes philosopher Sara Goering, PhD in the Philosophy & Public Policy Quarterly. “Since most normal women cannot meet the societal ideal, even those with otherwise healthy, well-functioning bodies believe they have aesthetic ‘deficiencies’ and feel dissatisfied with their corporeal lots.” All this undermines a patient’s perception of clinical objectivity and the physician’s ability to practice medicine solely as the advocate of the patient.
More than just clouding professional judgment, adding lucrative cosmetic procedures to a physician’s menu of services can breed resentment towards patients who require extensive and challenging care that does not result in much financial gain. According to the AMA code of ethics, the potential to affect objectivity of physicians is not only cause for concern associated with financial resources. Inducements that are based on the use of resources across physicians’ practices compound the conflict between the interests of the physician and those of the patient by introducing conflicts between patients.
There is also risk of exploiting the inherent imbalance of power in the patient-physician relationship. Patients who are ill are more vulnerable and exploitable as they rely on the expertise and compassion of their physician. Other patients may lack the expertise and independent judgment needed to make a proper determination about a cosmetic procedure and can believe that if their physician offers a procedure, it must be appropriate for them. For example, a patient may worry that a routine examine pelvic exam would reveal flab that could be medically “cured” by the physician’s new cosmetic offerings.
As more GPs, FPs and OB-GYNs offer procedures they may not be adequately trained to perform, the ethical considerations of non-malfeasance cannot be overlooked. Again, this comes down to trading on the trust inherent in the physician-patient relationship; while a patient may see that their GP, FP or OB-GYN is listed as “Board Certified,” it’s doubtful that she is going to check with the ABMS to see whether their practitioner is certified by The American Board of Plastic Surgery or merely by the board of their own field.
Traditional lines that separated specialties are now blurred. Fredric Stern, MD, FACS, is a nationally recognized educator on a number of cosmetic procedures including Botox® and Radiesse®. He believes that safety risk posed by inadequately trained physicians is a real threat. “I feel so strongly about the issue that I only train physicians from specialties that I think are adequately prepared to perform these cosmetic procedures and deal with the potential complications,” Says Dr. Stern. “Generally, family practioners and OB/GYNs do not fall into that category.”
There is also the matter of medical resources. Physicians have specialized knowledge and extensive training, much of it from public resources. With that knowledge and training comes an obligation to steward medical resources. GPs, FPs and OB-GYNs who focus on cosmetic procedures rather than their fields of expertise rob the community of those scarce resources.
In addition to adding cosmetic procedures, some physicians are adding cosmetic product lines. This is problematic on a number of levels: selling products trades on the physician-patient trust, not disclosing the financial arrangements with distributors may lead the patient to believe this is a non-profit venture, and patients may feel pressure to buy products in order to curry favor with their physician. Patients do not generally contest prescriptions recommended by their physicians, so if that same physician recommends a certain skin cream, the natural inclination would be to buy it—patients have an implicit trust in their doctor’s judgment and believe he or she is acting in their best interest.
Not surprisingly, sales of physician-dispensed skin products are growing at a double-digit rate. A spokesperson from cosmetics giant Estee Lauder explains why it’s working so well, “By placing the line for sale in doctor’s offices the company hopes to benefit from the growing number of consumers who wish to buy their skin care products from trusted specialists.” This is clearly a marketing strategy that leverages the trust inherent in the physician-patient relationship.
However, this practice may violate the AMA code of ethics, which states that physicians “should not sell any health-related products whose claims of benefit lack scientific validity. When judging the efficacy of a product, physicians should rely on peer-reviewed literature and other unbiased scientific source that review evidence in a sound, systematic and reliable fashion.”
As GPs, FPs and OB-GYNs continue to add cosmetic product lines and menus of cosmetic procedures to the general fare of PAP smears and annual checkups, they risk demeaning their profession by creating a public image that physicians are mainly businesspeople working to increase their income. This trend makes it easy for patients to wonder whether their health and safety is the priority or whether the physician’s income is the priority.
Until the medical community does something about this trend, we as consumers of healthcare need to raise awareness in our GPs, FPs and OB-GYNs. We need to let them know of the potential moral harms of adding cosmetic procedures to their practice, and we need to lobby for reform. Trust is central to the patient-physician relationship and little is more destructive to patient care than a widespread degradation of the public trust in the medical profession.
Former chair of the President’s Council on Bioethics, Dr. Leon Kass, proposed a novel solution to this ethical quagmire, saying he’d feel much better if they had some kind of “body technicians” instead of physicians to perform cosmetic surgeries. “It is a kind of corruption of the art to put it in service of satisfying people’s desires,” he said, “even when some of those desires are reasonable. I’m somewhat old-fashioned on that subject. If medicine is not guided by some kind of commitment to wholeness or healing, it’s reduced to being a simple body shop where technicians for hire perform.”
The integrity of the physician-patient relationship, the practice of medicine, and ultimately the care of patients is compromised when physicians offer cosmetic procedures and products that don’t increase the health and welfare of their patients. Let’s work to make this trend-line spike down. 
* Question on Yahoo! Answers forum:  Do you tip the doctor who does your Botox? How much?  Answer:  Docs are not supposed to get tipped as it conflicts with their Code of Ethics.
Author:  Kathryn Hinsch
Editor:   Christy Raedeke
April 2009

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