Medico-legal risk: What physicians performing cosmetic procedures need to know

Physicians in different medical specialties perform cosmetic procedures.¹ These include plastic surgery, family physicians, dermatology, and ophthalmology. This report describes findings from 644 medico-legal cases closed in CMPA between 2019 and 2023 where physicians performed cosmetic procedures.

What medical specialties were involved in medico-legal cases related to cosmetic procedures? (n=644)

Other specialties include surgical assistance or consultation, obstetrics and gynecology, pediatrics, anesthesiology, and others. In a very small number of cases, non-physicians such as registered nurses or technicians also performed cosmetic procedures on patients.

What are the most common procedures and peer expert² criticism?

The most common peer expert criticism on these procedures are:

• Inadequate informed consent process
• Inadequate documentation
• Deficient patient assessment
• Inadequate office procedures
• Insufficient knowledge or skills

In 74 cases, patient suffered injuries associated with the procedure. For example:

• Physician failed to perform patch test for patient undergoing Intense Pulsed Light (IPL) treatment. The treatment should not have been used for the patient’s skin type even though the manufacture’s manual indicated otherwise. The patient suffered second-degree burns as a result of IPL treatment.
• Staff mislabeled injection syringes. The physician mistakenly injected Botox instead of local anesthetic for nerve block, leaving the patient with some paralysis of the muscles.
• Physician used a toxic cleaning solution skin preparation for a face and brow lift. Some of the solution spilled into the patient’s eye which resulted in keratitis and vision loss.

What are the most common patient complaints and peer expert criticism? (n=644)

Complaints are a reflection of the patient’s perception that a problem occurred during care. These complaints are not always supported by peer expert opinion. Peer experts may not be critical of care provided or may have criticisms that are not part of the patients’ allegation.

Inadequate consent process is an area with frequent patient complaint and peer expert criticism. For example:

• The patient alleged results of breast implant removal and breast lift were of poor quality and not as agreed upon. The College was satisfied that the plastic surgeon’s overall documentation was thorough and consent forms were detailed. However, the College stated it would have been optimal for plastic surgeon’s consent discussion documentation to address patient expectations explicitly to avoid misunderstanding.
• The patient alleged that the dermatologist failed to inform of potential risk and side effects prior to starting the skin regimen. The College was supportive of the dermatologist’s care and documentation. However, the College stated it is their expectation that consent discussions be documented and that documentation include a description of common side effects as well as rare but serious complications.
• The patient complained to the College that the family physician failed to inform of the number of syringes of filler that would be necessary in order to obtain the expected result, the time required to obtain this result, and possible complications. Peer expert stated the family physician’s documentation was thorough and detailed as to the consent discussion, cost, and total number of Botox units to be injected.

What are the top factors associated with severe patient harm³ in medico-legal cases? (n=644)

Risk reduction reminders

An in-depth review of medico-legal cases related to cosmetic procedures highlights the following risk reduction considerations.

• Gather an appropriate history, including co-morbidities and current medications, and conduct an appropriate systematic physical examination with vital signs.
• In obtaining informed consent, physicians should discuss the following:
  • the nature of the proposed treatment
  • risks (including rare but important risks of major consequence)
  • chances of success or anticipated results
  • breakdown of charges and additional fees that may apply
  • alternative treatments (including non-treatment and its potential consequences)
  • the material risks and special risks associated with the proposed and alternative treatments
  • pre- and post-operative precautions
• During the informed consent discussion, ensure the patient’s questions and concerns are acknowledged and addressed. Document the discussion details in medical records.
• Be mindful of patient’s health literacy while observing their reaction for apparent confusion. Provide an opportunity for questions. Have the patient reflect back what their expectation is of the procedure to decrease the potential for misunderstanding of outcome. Ensure all consent discussions are properly documented in the medical record and avoid solely relying on generic consent forms.
• When a patient is ready for discharge, ensure your documentation reflects treatment, proposed follow-up care, and clear instructions on when and where to seek immediate medical attention.

Now that you know your risk…

Mitigate your medico-legal risk with CMPA Learning resources.

• CMPA Research:
  • Medico-legal closed case trends in Canadian plastic surgery
  • Exploring the dynamics of physician-patient relationships
• CMPA eLearning:
  • CMPA Good practices: Patient-centered communication
  • CMPA Good practices: Informed discharge
  • Informed consent

Looking for more?

For any data request, please contact [email protected]

This report received input from Dr. Jugpal Arneja; we appreciate his contribution.

Notes

1. 1. 
   Cosmetic procedures refer to medical and surgical treatments performed for cosmetic reasons, not covered under a provincial health insurance plan or not for health reasons.
2. 2. 
   Peer experts refer to physicians who interpret and provide their opinion on clinical, scientific, or technical issues surrounding the care provided. They are typically of similar training and experience as the physicians whose care they are reviewing.
3. 3. 
   Includes moderate, severe patient harm, and death. In the CMPA Research glossary, moderate harm is defined as symptomatic, requiring intervention or an increased length of stay, or causing permanent or temporary harm, or permanent or temporary loss of function. Severe patient harm is defined as symptomatic, requiring life-saving intervention or major medical/surgical intervention, or resulting in a shortened life expectancy, or causing major permanent or temporary harm, or major permanent or temporary loss of function.
4. 4. 
   Patient factors include any characteristics or medical conditions that apply to the patient at the time of the medical encounter, or any events that occur during the medical encounter.
5. 5. 
   Based on peer expert opinions. These include factors at provider, team, and system levels. For cosmetic procedures, there is no evidence for team or system level factors in the data.