Although state laws on the issue vary, a licensed physician in the United States (including the state of California), is not required to commit to the field of medicine he or she studied during residency. As such, under current law, a gynecologist, for example, may elect to perform cosmetic procedures—including cosmetic surgeries—without having been specially trained to do so. The California Medical Board dictates only that licensed physicians may practice any subspecialty of medicine, if they do so in a competent manner that complies with the law. Likewise, in California, any licensed physician can legally open a private cosmetic surgery practice regardless of which specialty that physician completed his or her residency.
To date, all instances in which physicians have been barred by state medical boards from performing cosmetic surgery have been after a patient dies or sustains injury/harm as a result of the practice. A nationwide study of physicians marketing themselves as cosmetic surgeons revealed that 12% of physicians practiced outside their scope of expertise, including gynecologists, urologists, anesthesiologists, and at least one non-physician, phlebotomist.
Distinctions in Plastic Surgery and Training
Generally, plastic surgeries can be subcategorized into two distinct types of procedures: cosmetic and reconstructive. Cosmetic procedures enhance a person’s overall appearance by adjusting his or her anatomy in a way that makes him or her more visually appealing. (An example of a cosmetic procedure is a surgeon injecting Botox into a patient’s forehead to reduce wrinkles, or performing liposuction to assist in the removal of unwanted fat.) In contrast, reconstructive surgery is used to restore function and appearance in certain circumstances such as birth defects, or to mitigate the impact of medical conditions such as breast cancer, or trauma caused by accidents/injuries.
Frequently, there is a significant degree of overlap between reconstructive and cosmetic procedures. However, the scope of cosmetics spans beyond minimally invasive procedures (such as cosmetic injections), and includes complex surgeries, such as facelifts. Plastic surgery training is largely completed through a post-graduate residency program. Physicians who become board certified in plastic surgery are required to complete six years of training in general and plastic surgery. Plastic surgery residency programs generally include cosmetic surgery as a portion of the required training. In contrast, cosmetic surgery training alone is generally completed through a one-year, post-residency fellowship training program specifically tailored toward cosmetic surgery.
The Confusion with Board Certifications
The American Board of Plastic Surgery (ABPS) provides the most notable board certification for plastic surgeons. To be ABPS certified, a surgeon must complete approximately six to eight years of specialized training through a plastic surgery residency program with accreditation in the United States. Additionally, ABPS certified surgeons are required to recertify every ten years through a rigorous oral and written examination process, as well as satisfying continuing education requirements. In contrast, the American Board of Cosmetic Surgery (ABCS) provides certification to cosmetic surgeons in the United States, but cosmetic surgeons are allowed to call themselves as such regardless of whether they are certified with ABCS.
There is no law that requires a physician to be “board certified,” but in California, unless a physician is certified by a specialty board, they are prohibited by California Business and Professions Code §651(h)(5) subsections (A) and (B) from using the term “board certified” when advertising. A physician may still advertise as being a specialist in a given field in spite of the fact that the physician is not board certified in that field as long as he or she completed a residency in that field.
The Appeal of Cosmetics
Most cosmetic procedures are not considered “medically necessary,” and as such, most are not covered by insurance. The effect of this is that cosmetics tends to be a lucrative and out-of-pocket practice, which draws many physicians to it.
Much of cosmetic surgery is performed outside of the hospital setting, and this allows physicians to avoid the tedious hospital credentialing process—designed to ensure the competency of the physician seeking admitting privileges. Physicians who perform aesthetic procedures in their own offices avoid this tedious vetting process altogether.
Likewise, whereas a plastic surgeon must have at least six years of surgical training in a board eligible program to perform surgery, a board-certified cosmetic surgeon is only required to have approximately one year of fellowship training prior to performing procedures. That single year can be the only form of surgical training that the cosmetic surgeon has ever had.
Easily Sidestepped Safeguards
California Health and Safety Code (HSC) § 1248 et seq., requires that anytime a medical procedure is performed under anesthesia that puts patients at risk of “losing their life-preserving protective reflexes,” that said procedure must be done in a licensed, certified, or accredited setting. Although California law requires outpatient facilities where physicians are using enough anesthesia to put patients at risk to be accredited or otherwise vetted in the way described in the HSC, some physicians circumvent this requirement by using local anesthesia for surgical procedures that would otherwise require full sedation.
Enacting Meaningful Change
Rather than allowing any licensed physician to practice cosmetic surgery, I would propose that plastic surgery residencies should create more spots for residents interested in specializing in integrated plastic surgery. At present, plastic surgery remains one of the most competitive specialties to match into in the United States, and this fact deters competent candidates from applying for and achieving a career in plastic surgery. The Match process is the process whereby residency candidates and programs rank each other to fill first and second-year post-graduate residency training positions in programs accredited by the Accreditation Council for Graduate Medical Education (ACGME).
According to statistics published by the National Resident Matching Program (NRMP), the not-for-profit organization in charge of the Match process, there were only 91 Integrated Plastic Surgery Programs offered in the United States in 2023. Of those programs, only 207 positions were offered, and all were filled. In 2022, there was a 55% match-rate of those who applied and successfully achieved plastic surgery positions. So, although there is a high demand for those interested in specializing in plastic surgery, an unnecessarily small portion of those qualified are able to secure these coveted positions. Over time, increasing the availability of positions for qualified plastic surgery candidates will increase the likelihood that candidates are able to obtain the proper training to perform cosmetic procedures (at least with those with a passion for performing them).
The Need for Disclosures to the Public
The general public has little knowledge of the distinction between cosmetic surgeons and plastic surgeons, as well as the discrepancy between the levels of education required of each. Given that any licensed physician can legally perform cosmetic surgery, it’s of the utmost importance that patients have all of the information necessary to make an informed decision regarding what kind of physician they engage to perform cosmetic surgery. As it stands, to find the most qualified physician, a patient interested in cosmetic surgery must compare the physician’s overall (residency and post-residency) training, experience, and competence in practice with respect to a given cosmetic procedure. I propose that those who are trained in cosmetic surgery alone—having not completed a surgical residency—should be required to disclaim this fact in some way, shape, or form on their businesses, or websites. The rules in place regarding representations of board certification are simply not enough—more should be done to inform the general public of their risk when selecting a specialist to perform cosmetic procedures.
Anne Schneider
Anne Schneider is an associate attorney with Fenton Law Group, LLP. Anne represents and advises healthcare providers on litigation and regulatory matters. She also represents healthcare professionals in administrative hearings and investigations conducted by the Medical Board, Board of Pharmacy, as well as internal investigations by hospitals, and other like organizations. She also represents providers in employment discrimination cases, and unlawful termination cases.
