Dr Steven Land argues why the responsibility of complication management resides with the treating practitioner
All aesthetic practitioners will experience some kind of complication during their career and, in spite of a lack of empirical data, anecdotally the number of complications is increasing.1,2 This would be in keeping with the growth of the sector as a whole – even if the complication rate remained steady, we would expect a greater number if more procedures were being done.
As we see more and more inexperienced, unregulated, non-medical injectors enter the market it would seem only logical that this rate is actually on the increase,3 and that certainly appears to be the case to those of us who regularly pick up the pieces. So, who is responsible for these problems? Who should be accountable and who is it that actually ends up shouldering the responsibility? Here I discuss these questions and propose what we can do about it.
The medical practitioner’s responsibility
It’s commonly argued that complications should ultimately come down to the person that does the treatment – if you caused the problem, you should fix it. But we know it’s not actually that simple as fixing the adverse event may require resources outside of what you have available personally. Alongside this, many training providers do not go into much depth when it comes to complication recognition and management in a short foundation course.
No one expects every practitioner to be able to fix every single potential complication and side effect from aesthetic treatments. However, I would expect every medical practitioner to make an appropriate differential diagnosis of the problem based on their history and examination and refer the patient on appropriately. Ultimately, the responsibility still resides with the original treating practitioner to ensure they have access to the resources needed and seek additional training to correctly diagnose, and manage, the complications that their treatment may cause. The individual practitioner’s role in complication management has many facets. Primary amongst these is education – knowing how to avoid complications and how to manage them requires constant updating of knowledge and skills as new research and new modalities become available – such as ultrasound.3
This leads onto self-awareness: good practitioners know what they know, but also know what they don’t know and the gaps in their knowledge and skills. Known as the Dunning-Kruger effect (a hypothetical cognitive bias stating that people with low ability at a task overestimate their ability)4 practitioners need to be able to recognise gaps in their own knowledge or skills and what can help them plug these gaps.
Support networks can be vital in avoiding and dealing with complications. They can be a way of learning from others ‘mistakes’ (thus avoiding or lessening certain stages of the Dunning-Kruger effect) and they can be a source of help in the event of a complication. All practitioners should strive to develop a support network of some sort – this may be local practitioners they can call on for help and advice, a regional online support group, industry associations such as the BACN or BCAM, or one of the well-established complications groups such as ACE Group World or the CMAC.
I feel all practitioners should strive to make contacts within secondary care organisations too, for example, those in plastic surgery, maxilla-facial surgery and/or ophthalmology. These colleagues can provide vital input in the event of serious complications – dermal filler-related necrosis or blindness, significant abscess or infection. Armed with all of these weapons – education, complications management skills, self-awareness and a support network – most practitioners should be able to deal with almost anything the field of aesthetic medicine can throw at them.
Regulatory considerations and the NHS
As we know, there is no regulation of who can carry out aesthetic procedures, no benchmark for the standards they should be achieving, or even a legal framework for the level of education they should have attained before putting needle to skin. How do you know your training and complications course actually equip you to avoid or deal with a problem when it occurs? Furthermore, aesthetic complications are medical conditions requiring medical intervention, which makes it difficult for non-medical injectors to take proper ownership of their complications.
What we should all be certain about is that these problems should not default to the NHS. Time and again across internet forums we see the default option ‘send them to see their GP/A&E’ and I see this from both medics as well as non-medics. There is a very minimal role for the NHS in dealing with the majority of aesthetic medicine complications as they do not usually have the skills, knowledge and training in specific aesthetic complications. Certainly, there is the odd, incredibly rare complication that will require NHS input – blindness, abscesses requiring formal surgical drainage – but this pathway should be the absolute exception, not the norm.
Complications are a priority
We move this forward by getting our own house in order. Every practitioner should come to terms with the fact that they are responsible for the outcome of their treatment. They should have up-to-date knowledge of aesthetic complications – how to avoid and deal with them – from a reputable training provider. Every practitioner should endeavour to cultivate a support network to help out should the worst happen; and every practitioner needs to be pushing for regulation to remove the cowboys (both training and practicing) and create a safer specialty.
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