House Calls

Medical and other musings of a plastic surgeon

Board-certification in plastic surgery and why it matters

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I have been told that U.S. Treasury agents who investigate counterfeiting are trained by studying real currency. By really knowing the real deal, they will recognize counterfeit money when they see it. An analogous situation applies to medicine. To recognize “counterfeit” plastic surgeons, you must know what the real thing is.

I tend to make a big deal about board-certification in my writing and yet I wonder if the general public really understands why this matters. Doctors are intelligent people. Why can’t they be trusted to train themselves in any way they choose? Why should there be only one pathway to legitimacy in medical practice? This question takes on major importance in my own specialty of plastic surgery because it seems that doctors from practically every other specialty want to become cosmetic plastic surgeons these days.


It is instructive to recall that modern medical practice really dates back to the late 1800’s. Until then medical education and training of doctors was a somewhat haphazard and informal affair. There were few medical schools and no residency training programs. Young doctors who wanted to focus their practice on a particular area would find an experienced practitioner and apprentice under them for a variable period of time. Understandably, the quality of the training varied widely.


In 1889, Sir William Osler, a giant in the history of American medicine, established the first residency program to train young doctors in various medical specialties at Johns Hopkins University. He was joined by three other famous doctors: William Stuart Halsted, William Henry Welch, and Howard Kelly. They recognized the need for a more formal, standardized system of training physicians to improve the quality and consistency of medical care from one program to another. They adopted standards of excellence for training young doctors through a process that came to be called a residency, because the doctors often resided on the grounds of the hospital during their training . The residency system they devised remains to this day and produces the best educated physicians in every specialty. It is copied worldwide.


In 1933, the doctors in the specialties of dermatology, obstetrics and gynecology, otolaryngology, and ophthalmology got together and founded the American Board of Medical Specialties. Their goal was to have experts in these disciplines establish an examination process to certify that doctors in these specialties were properly trained and qualified to practice the specialty safely and competently. The goal was to promote excellence as well as protect the general public, i.e. their patients, from unqualified practitioners. Soon, other specialties joined the ABMS, first orthopedics, then pediatrics, and so forth, until all 24 of the acknowledged medical specialties were on board. The American Board of Plastic Surgery joined the ABMS in 1941.

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From left to right: William Henry Welch, William Stewart Halsted, William Osler, Howard Kelly

To be board-certified, a physician must have completed their training in a residency program that is accredited by the ABMS, then passed the certifying examination by the particular specialty board. Some physicians are certified by more than one board. It is not uncommon for plastic surgeons, for example to certified by the American Board of Surgery or the American Board of Otolaryngology as well as the American Board of Plastic Surgery.


Within these main specialty boards there are additional certificates for some subspecialties. In plastic surgery, there are only two subspecialty certifications: plastic surgery of the head and neck and hand surgery. To obtain either of these, you must first be properly board-certified as a plastic surgeon. There is no ABMS  approved sub-specialty certification for cosmetic surgery despite the claims of many “cosmetic” surgeons.

Board-certification in plastic surgery means that the surgeon has completed a minimum of 6 years of training in a residency program accredited by the ABMS and the American Board of Plastic Surgery. Then, they must present a record of cases they have performed over the course of a year for review and pass a rigorous written examination followed by an oral examination where they are questioned, grilled is more like it, by experienced plastic surgeons. There is no shortcut to board-certification.


There are a number of non-ABMS organizations that offer a “certification” in cosmetic surgery to physicians seeking a way to legitimize practicing outside their primary specialty. While a few have strict standards for membership, many offer a certificate to any physician who pays the fee. Physicians in practically every medical specialty have marketed themselves as “certified” in plastic or cosmetic surgery by some non-ABMS organization. In Central Florida, there are pediatricians, internists, family doctors, obstetrician/gynecologists, general surgeons, dermatologists, and even ophthalmologists passing themselves off as plastic surgeons and claiming “certification” of some sort.


So, again the question: what’s wrong with any physician taking some courses and performing cosmetic surgery if they wish? I would allow that many such physicians do excellent quality work, perhaps even better than some board-certified surgeons. The problem is that when you throw out agreed upon standards, you open up a Pandora’s box wherein you just don’t know what your surgeon’s credentials are. How do you choose a surgeon then?


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Word of mouth testimonials are notoriously unreliable. Even mediocre and bad surgeons get good results at times. Online reviews are no better. Advertisements? Every physician is “acclaimed”, “reknown”, “exceptional”, or some other superlative in their own ads and websites. Without accepted standards and accountability, it is the Wild Wild West out there and many patients have discovered, too late, that their “plastic surgeon” or “cosmetic surgeon” was not what they claimed to be.


Is board-certification proof that a surgeon is good at what they do? No. Although board-certification assures patients that surgeons have met minimum standards of competence, some are better than others. Once you verify board-certification status, you should check further. Seek out former patients, view the surgeon’s results, often posted online, check with the local medical society, verify they have hospital privileges, check the National Physician’s Data Bank for their practice history. Ask questions, lots of questions. Good surgeons typically have stable practices. Beware of surgeons that move around a lot.

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