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Esthetics before essentials
Lucrative practice. Hospital ORs are tied up by MDs for unnecessary cosmetic surgery

AARON DERFEL
The Gazette

2/1/04

Dr. Clifford Albert injects an acrylic gel to treat wrinkles at the Montreal Institute for Laser Surgery. To have patients on waiting lists, when procedures that are not medically required are being done in hospital ORs, is "obscene," Albert says.

Plastic surgeons and other doctors are using up the scarce resources of Montreal hospitals to conduct hundreds of medically unnecessary procedures - facelifts, tummy tucks and breast implants.

This highly lucrative practice, as a Gazette investigation has found, is straining already lengthy waiting lists for essential procedures like cataract removal and even emergency cancer surgery.

Although the practice is technically not illegal, critics charge that it does raise ethical concerns about whether public hospitals should be exploited for private for-profit esthetic services.

Cosmetic surgery has grown into a colossal business in Quebec, raking in an estimated $600 million annually. Many Montreal plastic surgeons earn more than $500,000 a year - most of it from increasingly popular cosmetic procedures like liposuction.

Yet despite huge profits, many of these doctors would prefer to draw upon the resources of cash-starved hospitals rather than invest in setting up their own clinics.

Hospital administrators tolerate the practice because they want to keep their star physicians who also perform medically necessary procedures like reconstructive plastic surgery - for example, rebuilding a patient's jaw after a car crash. In addition, administrators believe the cosmetic services raise revenue.

But taxpayers might be indirectly subsidizing cosmetic surgery. Although patients usually pay a $300 fee for "renting" the operating room, experts say that does not truly cover the cost of sterilizing instruments, nursing and disposable materials.

"These procedures should not be done in a hospital milieu," said Dr. André Chollet, president of the Association des spécialistes en chirurgie plastique et esthétique du Québec.

Hospital administrators concede that esthetic surgery goes on, but say it rarely occurs, and therefore, is not a problem.

A Gazette survey, however, has found that 19 out of the 47 Montreal plastic surgeons who perform breast augmentation choose to do it routinely in hospital. That's 40 per cent.

That doesn't count the ear, nose and throat surgeons who sculpt noses; ophthalmologists who eliminate baggy eyelids; and dermatologists who smooth wrinkles with Botox injections as well as eradicate varicose veins. All of this in a hospital, during weekday hours.

Anesthetists - in short supply in Quebec - sedate patients during cosmetic surgery. This can cause delays for such surgery as hip and knee replacements.

Among the hospitals where cosmetic surgery is performed - to greater or lesser degrees - are the Lakeshore General, Jewish General, Montreal General, St. Luc, Maisonneuve-Rosemont, Fleury, Santa Cabrini, Sacré Coeur, Lachine, Verdun and LaSalle.

Perhaps the most glaring instance takes place at the Lakeshore General. Few doctors were willing to go on the record, but Sharon Dalrymple, a general surgeon, reluctantly described the difficulties at the Lakeshore.

She said plastic surgeons are monopolizing precious OR time for liposuction, breast augmentation, tummy tucks and facelifts. One plastic surgeon, she noted, often exceeds his allotted OR time, and this bumps her cases: gallbladder operations, hernia repairs and cancer surgery for abdominal, rectal and colonic tumours.

"Ten patients in the months of November and December were just cancelled," Dalrymple said.

"I have to rebook them, whereas the abdominoplasties (tummy tucks) and facelifts were coming in and were not cancelled.

"So why do they get preferential treatment over patients who actually have life-threatening diseases?"

Even emergency cases are postponed when cosmetic surgery takes too long.

"The emergency list is supposed to start at 3:30 p.m.," Dalrymple explained. "If it doesn't start until 6 and you have 10 patients on the list and my patient happens to be No. 5, I might have to wait till the next day."

The chief of surgery allocates doctors' OR time based on the speciality. Cardiac surgeons - given what they do - grab the lion's share. Each surgeon decides how to best use that time. But some doctors will squeeze cosmetic cases into their OR time. Consequently, their own patients might have to wait longer for crucial surgery.

Plastic surgeon Arie Benchetrit confirmed that all his facelifts and breast implants are done at the Lakeshore, up to 15 a month. But he said a lot are conducted on Saturdays, when four of the five ORs are idle.

He contends this generates much-needed revenue for the hospital, because patients pay a facility fee.

"It's very easy to make this look like I somehow support the delay of essential surgery, which of course, I'm not," he said. "My ethics dictate that essential services will never be postponed or cancelled by non-essential ones."

In contrast, Dr. Stephen Nicolaidis, a plastic surgeon at St. Luc, said he operates cosmetically in the hospital only "once in a blue moon." And he's planning to phase out these procedures from his hospital practice.

"In the operating rooms, when you've got people taking care of emergencies, at least on my end it's hard to justify doing a cosmetic case," he said.

"Hospitals tend to be overwhelmed with essential cases, and cosmetics are considered non-essential."

Nicolaidis is renowned for repairing damaged faces and hands. That comprises 80 per cent of his caseload. The balance is cosmetic, like breast implants, performed in private surgical suites that he rents.

Dr. Chaim Edelstein, an ophthalmologist who divides his time between his private practice and the Montreal General, specializes in surgery for cancer of the eye and cataract removal. He estimates that 35 per cent of his work is cosmetic.

Edelstein said he occasionally conducts in a hospital a blepharoplasty - eliminating baggy eyelids. Sometimes, he confessed, he has to juggle cosmetic and cataract cases.

"If someone comes in and they need to be booked for cataract surgery, and two hours later, someone else comes in and wants a cosmetic blepharoplasty and you have a spot in two weeks, the truth is I don't think it makes much of a difference in the grand scheme of things which patient you do in that time."

Several hospital administrators told The Gazette they discourage cosmetic procedures.

"Does none of it go on?" asked Dr. Hugh Scott, who last month retired as executive director of the McGill University Health Centre.

"Probably the answer is some does. If anything, we're trying to contain what does go on. It's certainly less than five per cent and I wouldn't be surprised if it would be in the one-per-cent zone."

Still, at only one per cent, that would represent 125 esthetic procedures performed each year in MUHC hospitals. That's about 300 hours of OR time.

Scott allowed as acceptable surgeons who "piggyback" a procedure like a blepharoplasty following cataract removal.

There are no reliable statistics, but Quebec probably leads all provinces in its volume of cosmetic procedures, according to experts. It's certainly No. 1 for breast augmentation.

That might explain, in part, why hospital esthetic surgery is not as prevalent in other major Canadian cities. Dr. Gary Lobay, president of the Canadian Society of Plastic Surgeons, noted in Vancouver almost all cosmetic surgery is done in private.

"In a hospital where there is limited time and resources, they should think very carefully about allowing a cosmetic procedure," said Lobay, who works in Edmonton. "In fact, in our community it hasn't been done in more than a decade."

Lobay's views were echoed by Dr. Denis Bisson, head of the Canadian Academy of Cosmetic Surgery, based in Montreal.

"If you're talking pure cosmetics - a facelift, implants and liposuction - it's not normal that in 2004 we still have those procedures done a couple of times per week in each hospital," he said.

"I don't think Dr. (Philippe) Couillard, our new minister of health in Quebec, would be happy to learn about this."

Government officials appear to accept the practice, denying it's widespread.

"These must be isolated cases," said Dominique Breton of the Quebec Health Department.

"It's not the reality."

Dr. Pierre Masson, of Montreal's Regional Health Board, suggested as long as hospitals reach their goals for the number of medicare operations performed yearly, plastic surgeons are free to do as they please.

"Noninsured surgery should be carried out in hospital outside of normal operating hours," Masson said. "But you have to understand that the board does not have the judicial power to force a hospital to respect this."

Each hospital fixes a flat rate for renting out an OR. A cosmetic patient pays the hospital $300 to $400 for nursing and other expenses. The patient also pays the anesthetist and the surgeon.

However, critics note the hospital fee doesn't cover the cost of the recovery room for those who have undergone something as complex as a tummy tuck.

By comparison, doctors fork out $600 to $700 to rent private ORs, which better reflects the true cost.

For doctors, the financial advantages are obvious. First, they don't have to spend millions on medical equipment. Second, they make more money from cosmetic surgery in a hospital.

The price of breast implants is about $5,000 - whether it's done in hospital or in private. But doctors renting a private OR don't pocket the full $5,000 as they do in hospital; they must absorb the $600 private facility fee. In hospital, doctors can justify asking patients to cover the facility fee.

There's an added bonus for those working in hospital, and it comes from the Régie de l'assurance maladie du Québec, the medicare board. RAMQ reimburses all plastic surgeons who work in hospital about $8,000 a year in malpractice insurance premiums. That applies even to those who carry out private for-profit procedures in hospital.

Some physicians defend esthetic procedures in hospital as medically justified. Dr. Tassos Dionisopoulos, a plastic surgeon at the Jewish General, said he performs breast enlargements in hospital on women who have underlying medical conditions.

Moreover, he trains medical residents in cosmetic techniques - an opportunity not always available in private. "It's a debate that one can have," he said. "But in terms of the big picture of resource allocation, I don't think it's such an issue."

Clifford Albert, an ER physician at Jean Talon Hospital, begs to differ. Albert is also a specialist in cosmetic laser surgery. It was precisely because of his concerns about the impact on the public system that he said he decided to do such procedures exclusively in private.

Albert and a partner invested more than $1 million in the Montreal Institute for Laser Surgery. He often invites medical residents to assist him and learn.

"I operate in the former Queen Elizabeth Hospital," Albert said. "My ORs are accredited.

"For me, to have patients sitting on waiting lists, when procedures that are not medically required are being done in hospital operating rooms, is obscene."

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Speaking Out

"In my hospital, the plastic surgeon has received beds for his (cosmetic) patients, whereas my patients have been cancelled, which can include those with cancer."

- Sharon Dalrymple, general surgeon at the Lakeshore."How can a doctor tell a patient that they're going to have to wait nine months for something that's essential, and yet they're going ahead with a cosmetic procedure?"

- Stephen Nicolaidis, a plastic surgeon at St. Luc.

"For reasons of safety, it's entirely acceptable ... that these (esthetic) interventions take place in hospital."

- Dr. Pierre Masson, of the Montreal Regional Health Board.

aderfel@thegazette.canwest.com

http://www.canada.com/national/story.asp?id=1F2C0F79-FA3D-46E1-A76F-02CCC91BF6D9