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Surgery and Cosmetics

Cosmetic Dermatology: Who Should Be Doing This?

David Goldberg, James M. Spencer, MD, MS

Tuesday, February 07, 2006

In this two-part thought leader commentary, Dr. Goldberg and Dr. Spencer offer their views on cosmetic dermatology:

Dr. Goldberg's view

Dr. Spencer's view

Editor's Note:

Readers will note in the Commentary by Dr. Goldberg that the language and issues seem to be directed primarily toward dermatologists in the United States. He includes references to the American Society for Dermatologic Surgery and comments on Thomas L. Friedman's description of "outsourcing" of American labor. Moreover, Dr. Goldberg refers to important issues of liability risk, which, at least until now, have been distinctly American problems. By contrast, DermQuest is an information resource for all dermatologists, in all countries. You might ask: "What are we doing here?" And our answer is simple. We want to know about dermatology in the other 100+ countries. We want to stimulate discussion, so that we can learn from each other. To do this, go to the Contact Us page. Tell us how it is where you live. Tell us what you would like to see appear on this resource. Let's begin a dialogue, and prove that Thomas Friedman is correct, that the world is flat.

Dr. Goldberg:

Cosmetic dermatology may be the largest and fastest growing field in medicine today. The advent of a variety of lasers, fillers, peels, botulinum toxin injections, and other relatively simple procedures has made cosmetic dermatology appealing to a wide range of non-dermatologist physicians and non-physicians. Should they be doing these procedures? What is their liability? Should they be stopped from doing these procedures?

The answers to these questions can be and are difficult. Well meaning, ethical, and respected people can have and do have different views. In this piece, I will provide my thoughts, recognizing that others, whose views I greatly respect, may not agree with me.

First, it must be understood that the proliferation of cosmetic dermatology has resulted because of a variety of factors. The baby-boomer public has clamored for cosmetic and anti-aging approaches that do not involve surgery. They have come to recognize that although many cosmetic dermatologic approaches do not always produce the degree of improvement seen after surgery, they would rather have a more natural, less improved look that involves little to no down time. Another reason cosmetic dermatology has grown so much is because the dermasurgeon members of the American Society for Dermatologic Surgery (ASDS) have recognized this need and have created nearly all of the currently popular dermasurgery techniques that are now used throughout the world. Finally, the sheer reality of today's managed health care system has pushed both physicians of all kinds and non-physicians to want to perform such procedures.

Whether dermasurgeons like it or not, others will be doing these techniques. Most thought leaders of the ASDS have come to recognize this and see no point in fighting the issue. Since dermatologists have created most of the new techniques, they will generally be recognized as the leaders in the field. They will also be the ones who continue to develop new cosmetic dermatologic techniques. In his most recent book The World Is Flat (Farrar, Straus and Giroux, NY 2005), Thomas L. Friedman makes an important point about the "outsourcing" of American labor. Whether we like outsourcing or not, it is going to happen. Stop fighting it, he argues. Americans have always been leaders and have always created the newest techniques. The same analogy applies to cosmetic dermatology. We will always lead. If others choose to use our techniques, accept this as a compliment, move on, and develop new techniques.

The final and most important issue relates to the malpractice implications of non-dermatologists and non-physicians who choose to perform cosmetic dermatologic procedures. In particular, the use of physician extenders (including physician assistants and nurse practitioners) has increased significantly in medicine over the past few years and appears to have increased dramatically in the specialty of cosmetic dermatology. There are concerns, however, that the use of these non-physicians or non-dermatologists to perform cosmetic dermatologic procedures may decrease the overall quality of patient care. The liability risk for such individuals may increase because of their recognized expertise. It must be remembered that they will be held to the same standard of care as any dermatologist performing the identical procedures. It is clear, however, that the use of non-physician providers does not in any way release the supervising physician from malpractice liability. In the vast majority of lawsuits, the physician is sued along with the physician assistant or nurse practitioner based on the premise that it is the responsibility of the physician to adequately train and supervise the physician extender. The dermatologist in most cases can be held legally responsible for the acts of their physician assistant or nurse practitioner. Similarly, non-dermatologists performing cosmetic dermatologic procedures will not be able to shield any alleged negligence because they lack formal cosmetic dermatologic training.

All individuals practicing cosmetic dermatology must practice according to the standard of care. Unfortunately, in most cases, the standard of care is neither clearly definable nor consistently defined. It is a legal fiction to suggest that a generally accepted standard of care exists for any area of medical practice. At best, there are parameters within which experts will testify. Unfortunately, due to the increased reliance on cosmetic dermatologic technology by the medical profession, unrealistic expectations by the public, and a plethora of potential new regulations, physicians and non-physicians practicing cosmetic dermatology sometimes run the risk of being held to an unrealistic and unattainable standard of care. But in the end, it is the physician that establishes that standard of care. For non-dermatologists performing cosmetic dermatology, it should be expected that cosmetic dermasurgeons will be called in as experts.

Medical legal issues cannot be ignored. Appropriate legal advice from an attorney with such expertise may represent an unwanted legal situation. However, the value of such advice, in an increasingly hostile health care environment, cannot be underestimated. Such advice, an insurance policy against the vagaries of health care law, has become a necessity in our litigious society.

In the end, cosmetic dermatology will be performed by many non-dermatologists. The public will need to be educated about the risks of such treatments. Ultimately the public, and the potential for lawsuits, will decide if cosmetic dermatology should only be performed by dermasurgeons.


  1. American Medical Association. (1994). Physician Characteristics and Distribution in the United States. Chicago, IL: American Medical Association.
  2. Physician Insurers Association of America. (Annual). A Risk Management Review of Malpractice Claims: Dermatology. Rockville, MD: Physicians Insurers Association of America.
  3. Geronemus R, Bisaccia E, Brody HJ, et al. Current issues in dermatologic office-based surgery. J Am Acad Dermatol. 1999 Oct;41(4):624-34.

Dr. Spencer:

A conjunction of events has aligned to induce non-dermatologists to leave their traditional areas of expertise and move into providing cosmetic dermatologic care. First and foremost, the cause of this shift is declining insurance reimbursements to physicians for providing medical care. At the same time, dermatologists have developed easily learned, relatively safe noninvasive cosmetic therapies that make it possible for physicians of any background to switch their practice and become "cosmetic" doctors. A very real question arises for dermatologists: How should we respond to this trend, especially in the area of teaching cosmetic dermatology to non-dermatologists?

Not so long ago, there was an unspoken covenant between society and physicians. Physicians would give a lifetime of honest service and in return they would be financially comfortable. Maybe not rich, but comfortable. When I was a medical student in the late 1980s, it was unseemly for physicians to discuss money. It was demeaning to the profession. At that time, the American Medical Association (AMA) discussed expelling members who lowered themselves to the level of crass commerce by advertising. Medicine was a noble and special profession, not a business. Medical students chose a residency in the field they loved with little thought of income potential. Since that time, insurance companies have, in my opinion, broken the covenant. Several medical disciplines no longer offer a comfortable living. Fields such as family practice and internal medicine are vital to society, and yet many physicians in these fields are not able to make the sort of living they expected to in return for the level of service to the community they are providing. Put yourself in the shoes a 50-year-old family practitioner: income continues to go down every year while overhead costs of your practice continue to go up. At your age, what change could you make to increase your income? A second career in an entirely different field outside of the practice of medicine is hard to imagine. How could you use your medical license in a new way?

This is where cosmetic dermatology comes in. Dermatologists have pioneered a number of easily learned minimally invasive to noninvasive cosmetic therapies that other physicians can pick up. One could not imagine casually learning to perform a facelift or a blepharoplasty in a weekend course, so in the past, cosmetic surgery really was limited to those who had extensive training in it. Now, the trend is for cosmetic therapies to be nonsurgical and really rather easily learned. Laser and IPL companies and manufacturers of injectable cosmetic medications are more than happy to organize weekend courses for any and all physicians, nurses, physician assistants, chiropractors, whoever, to drive sales of their products. The best courses to take would be dermatology meetings: For example, the American Academy of Dermatology (AAD) and the American Society for Dermatologic Surgery (ASDS) annual meetings offer the latest from world leaders in cosmetic dermatology.

That brings up my original question: Should dermatologists participate in educating non-dermatologists in cosmetic therapies?

A growing number of physicians will enter cosmetic practice. There are about 10,000 dermatologists, 5,500 plastic surgeons, and 1,500 facial plastic surgeons in the United States. All share a common interest in cosmetic dermatology and cosmetic surgery. There are over 100,000 internists and about 100,000 family practitioners in the United States, and if only 10% of these groups go into cosmetic practice, there will be more of them than dermatologists, plastic surgeons, and facial plastic surgeons combined. Physicians trained in emergency medicine, anesthesiology, and many other fields may wish to change practices as well. They will change the name from "cosmetic dermatology" to "cosmetic medicine" or perhaps "aesthetic medicine." The trend is unstoppable, but a reasonable response on our part is not clear.

At the annual AAD meeting, cosmetic sessions are now "dermatologists only." Refusing to educate internists will not stop them. Legal action is doomed to failure. They are licensed physicians, and it hard to imagine state medical boards refusing to allow them to inject botulinum toxin. Nonetheless, facilitating the movement of non-dermatologists toward cosmetic dermatology is troubling for many.

I would guess that most physicians who chose to study internal medicine or family practice are interested in those fields. Dermatologists and plastic surgeons must have been interested in the skin and its appearance as medical students or they would not have gone into their respective fields. I cannot help but wonder how many non-dermatologists have any interest at all in the skin and its appearance. I would therefore argue that dermatologists will continue to be the innovators and leaders in cosmetic dermatology. Perhaps the best response to the changing nature of cosmetic practice is to vigorously inform the public of dermatologists' proven record of innovation and leadership in cosmetic therapies.