On October 12, 2009, the “Donda West Law” was signed by Arnold Schwarzenegger in California. The law states that “medical clearance” is required prior to undergoing elective cosmetic surgery. As a Board Certified plastic surgeon who performs primarily elective cosmetic surgery procedures, I have some concerns about the meaning behind the need for this legislation. But first, let’s review what we know about the Donda West incident that occured in 2007.
Mrs. West underwent a combination of cosmetic procedures by plastic surgeon, Dr. Jan Adams, including breast and abdominal surgery. Dr. Adams was the host of Discovery Health Channel’s Plastic Surgery: Before and After and frequently featured cosmetic surgery expert on the Oprah Winfrey show. Dr. Jan Adams is not certified by the American Board of Plastic Surgery. Prior to seeing Dr. Adams, she was reportedly denied surgery by another plastic surgeon due to health concerns. The day following her surgery, Mrs. West was found unresponsive, taken to Centinela Freeman Regional Medical Center in Marina del rey, California, and died. We do not know the truth about her medical condition and risk factors prior to surgery nor do we know the precise cause of her death. According to the autopsy report, “the manner of death could not be determined”. The Medical Examiner ultimately attributed her death to “pre-existing coronary artery disease and multiple postoperative factors” including aspiration, pneumonia, pain medication, and tight compression garments.
Many have heard about this tragedy and assume someone is to blame. Is the surgeon at fault? Should Mrs. West have been “medically cleared” prior to her operation? Her risk factors for surgical complications certainly should have been assessed, but by whom? And were they? Although Dr. Adams is not Board Certified, we can’t determine that he acted improperly. But this incident highlights several issues about cosmetic plastic surgery in our society that I believe need to be addressed.
The key to minimizing the risk of elective cosmetic surgery is based upon three recommendations made by the American Society of Plastic Surgeons: a) the surgery is performed by a properly trained and Board Certified plastic surgeon, b) the surgery is performed in a safe, appropriately accredited surgical facility, and c) the patient is healthy. We know that Dr. Adams is not Board Certified by the American Board of Plastic Surgery. I do not know if the procedures were performed in an accredited operating room. And I do not know if Mrs. West had preoperative health problems, despite rumoured suspicion that she did. Would the new Donda West Law’s requirement for “medical clearance” have helped? To answer this requires some understanding of “medical clearance”.
In the surgery world, “medical clearance” refers to the evaluation from a non-surgical doctor as to the safety of a patient undergoing a proposed operation. That doctor will take a history, evaluate known medical conditions, perform a physical exam, and obtain any testing to follow up on health concerns. This sounds reasonable. But to mandate that all patients seek “medical clearance” from an internist or family practice doctor ignores the fact that plastic surgeons are medical doctors as well and ultimately responsible for engaging in a surgical relationship with a patient. The truth is that all surgeons should be able to identify risk factors for surgical complications and implement the appropriate preoperative screening such as an EKG and basic blood tests. And all surgeons should know when a medical consultation is necessary to further evaluate concerns that are beyond their expertise. Absolutely, there is a place for medical specialty consultation and I frequently request them, whether it’s from an internist, a cardiologist, a rheumatologist, a neurologist, a nephrologist, or whichever specialty makes sense. However, even with proper preoperative evaluation from the plastic surgeon, other doctors, or both, complications from surgery will still happen. We don’t know if Mrs. West had any health problems that were identifiable in a thorough medical evaluation. She may have had the appropriate evaluation and still suffered a tragic result. Asymptomatic coronary artery disease would often not be identified in a history, physical, and EKG. Although “medical clearance” may identify those at risk or who should not have surgery at all, patients that are “cleared” are not guaranteed a safe outcome. Nonetheless, it is reasonable to assume that mandatory “medical clearance” would serve as another layer of protection for patients, especially for those choosing surgeons that don’t take the safe course of action on their own. I would argue that a Board Certified Plastic Surgeon is more likely to take the appropriate safety precautions including a consultation with a medical specialist when necessary. So, why did Donda West choose a Plastic Surgeon lacking these basic credentials?
Although not Board Certified, Dr. Adams has been celebrated on the Oprah Winfrey show and the Discovery Channel as a famous expert on plastic surgery. Similarly, perhaps the most well-known plastic surgeon in America, Dr. 90210, Robert Rey is not Board Certified. Yet, he appears in the media on TV channels such as CNN to field questions as the plastic surgery expert. We live in a country where media fame counts more than credentials; where privileges associated with popular culture trump ability. We live in a country where those in the inner circle of former NASDAQ Chairman, Bernie Madoff, chose to invest with him depsite never having received a true investment transaction statement. And we live in a country where a doctor on TV is presumed more capable than a doctor with basic credentials verifiable on the internet. I can’t say that this was the impetus for Mrs. West’s chose in surgeon, nor can I say that Dr. Adams acted unsafely just because he never obtained his Board Certification. But before a law mandating preoperative “medical clearance” is instituted, perhaps there should have been a law requiring that only appropriately credentialed surgeons perform specialty surgery? Maybe this would obviate the need to bypass plastic surgeons as responsible physicians in search of another specialty to compensate for the country’s preoccupation with fame and lack of personal responsibility to make safer choices?
Despite these questions, I feel that an additional “medical clearance” requirement for patients prior to any surgery may help save lives. This “Donda West Law”, although not addressing the core issues of proper, safe surgical practice and individual patient responsibility, may ultimately help save some people from bad outcomes. We don’t know if it would have helped Donda West.