27 October 2021

We can’t leave cosmetic care to the cowboys

Comment Cosmetics

Like many of us, I watched the ABC Four Corners program “Cosmetic Cowboys” on Monday with growing dread and distaste.

Dr Daniel Lanzer, a dermatologist by qualification, was featured over allegations he had acted outside his scope of practice and failed to maintain hygiene and sterility. There were, in addition, a handful of complaints from patients over the years. He is now under investigation by the peak body for cosmetic surgeons, the Australasian College of Cosmetic Surgery and Medicine. UPDATE: and by AHPRA.

To judge from the website, it seems none of his three associates have trained for, nor obtained, a fellowship in any speciality. How were they trained to be doing what they are doing?

Dr Lanzer asserts that he has been misrepresented and is being lied about. He has denied the allegations about his behaviour, and says he has commissioned an independent assessment of the claims.

But it makes me recall my own experience with invasive procedures and the enormous, daunting responsibility they bring.

I undertook the diploma of O&G in 2002 while in a rural town before being accepted into the training program in O&G. Between 2004 and 2011, amid having my own children, when I ran out of training time, I spent years immersed in all things O&G including, in most weeks, one or two days of operating lists all day in addition to overtime, and 60-plus-hour weeks when I was the most senior doctor onsite after hours.

In 2011, when I reluctantly left, I’d logged more than 1,000 LSCSs in which I was the unsupervised operator, hundreds of forceps and ventouse deliveries, and probably thousands of perineal repairs on women soon after vaginal deliveries, mostly under local anaesthesia.

It is repetitive training over months and years as part of a structured training program and mentoring with oversight, checks and safety mechanisms for trainees and patients in place that create muscle memory as well as comfort and competence to handle the things that inevitably go wrong. These include ruptured ectopics with a shocked patient; endless numbers of postpartum haemorrhages, handled in theatre; the spontaneous uterine inversion in which I almost had my one and only maternal death; the fetuses we raced to deliver, only to have them not make it; shoulder dystocia in which I had to break a fetal bone to save a baby, and so much more.

My sense, in watching Dr Lanzer and his trainees, was of an astonishingly cavalier attitude. They seemed more focused on entertaining an audience on social media than in delivering adequate patient care to the person in front of them, who was often under general anaesthetic and therefore unable to advise of unexpected pain due to unexpected injury. In some videos, they seemed to be largely performing for the camera.

Additionally horrifying was the lack of dignity for the patients: the footage of a young woman with an arm across her bare breasts, being asked by two fully clothed men on video how much fat she thought they’d get out at liposuction of her abdomen – why was she not afforded more privacy and dignity?

Then there were the before and after photos on display on social media profiles of entirely naked people with blacked out genitalia and nipples; and the way one of Dr Lanzer’s associates begins his YouTube videos as though he’s an auctioneer at a sale rather than a doctor, before proceeding to parade an undressed body (head out of camera shot) with markings to describe what he is about to do to her, sometimes moving flesh for the camera.

None of this, for the most basic doctor, would qualify as appropriate, patient-centred care behind closed doors, much less for edutainment.

ALL doctors have complications, we all know this. With invasive procedures and entirely elective procedures, this risk rises exponentially. It is our job therefore to inform patients of this, and to ensure, as best we can, that they understand this.

Equally ingrained is the job of maintaining our patients’ dignity and their privacy as best as possible, and to not fall into the trap of thinking they are part of a procession line – even when we have their generous consent to share the before and after pictures, or to show “live procedures” on social media, especially if the patient is not awake and unaware of what is being done to them on film.

It is entirely possible that the truth is somewhere between what Dr Lanzer is asserting and what the ASAPS plastic surgeons – who have their own interests to protect – are saying.

At the same time, pictures of human fat stored in domestic fridges, and of dried blood on surfaces, do not need staff with a vendetta against him to tell the story.

Every single training program in a speciality offers the structure of mentorship, of supervision till a trainee is capable of being left unsupervised or from a distance; as we rise up the ranks in skill, we are then tasked the job of supervising junior trainees ourselves, all the while being mindful of patient-centred care, ideally. In my limited viewing of this episode and correlating it to my years in a surgical training program, I saw none of that.

As far as I can tell, Dr Lanzer works in Melbourne and has his associates working interstate in his day surgeries, presumably independently. Medical qualifications are hard enough to come by that when we have them, we like to advertise those letters every chance we get, yet none of these men have letters beyond MBBS that I can see.

I’m a GP with an interest in cosmetic medicine. Watching the episode and having seen his videos in my feed on occasion even prior to this, and being dejected by them, I have to ask if this is truly the way medicine is headed, with a race to the bottom, especially in the cosmetic industry, which is largely unregulated.

Many in “real medicine” say that this is why we should “leave beauty to the beauticians” and people who allegedly lack the ethics of our job. But in doing so, it is entirely possible that we leave a vacuum that less scrupulous practitioners will rush to fill – a look at the non-surgical industry is proof enough of that.

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