Responses (edited for length)
College of Physicians and Surgeons of Ontario
The College’s Consent to Treatment Policy is clear that patient autonomy and respect for personal dignity are central to the provision of ethically sound care. In order to exercise their autonomy, patients have the moral and legal right to make decisions regarding their treatment when they are capable of doing so. This principle is fundamental to the physician-patient relationship and applies broadly.
The College also developed social media guidelines to help physicians apply existing policy and legislative requirements to the use of social media. That policy advises physicians to exercise caution when posting information online that relates to an actual patient and to avoid posting content that could be viewed as unprofessional. In addition to the College’s policies and guidelines, specific rules governing advertising by Ontario physicians are laid out in the Medicine Act, the legislation that governs physician conduct.
Consent forms are not a substitute for the full discussion required to ensure that a patient understands the risks involved in a given procedure and can provide informed consent. That discussion would be unique to each patient. Physicians are expected to comply with College policies to ensure that they are putting their patients first, treat each patient individually and work to ensure that they have the appropriate time and information to make informed choices about their health.
As discussed, there are rules that guide physicians in charging patients – including prohibiting charging for insured services or charging for services that aren’t rendered, and requiring that fees charged are reasonable. We would need more information about the specifics involved (i.e., is this an insured service, is it a refundable deposit, etc.), though we would have concerns about requiring any payment before a full consent discussion and treatment decision occurs.
Physicians are expected to comply with legislative requirements and College policies. Any time the College receives information that laws or policies are not being complied with, we would assess the concerns, and when appropriate, initiate a formal investigation. Where we have been alerted to the use of before and after photos in the past, we have held that they constitute testimonials in contravention of the regulation. At the same time, we recognize that despite effort to address this issue, changing technology has lead in part to increasing adoption of online and social media tools by physicians, dentists and other health professionals. We are determined to continue working with our partners – including specialty associations – to ensure that the public interest is being protected.
Ontario doctors are required to charge fees that are considered reasonable. The College and specialty associations provide guidance to physicians when setting fees for uninsured services. Physicians are also expected to consider patients’ ability to pay, when determining what is reasonable to charge. We always expect that physicians will respect legislation and policies, put the needs of their patients first and act in a way that upholds the reputation of their profession.
Dr. Martin Jugenburg
Thank you for giving me the opportunity to reply to the questions that arose from your researchers' visit to our clinic.
We go to great lengths to ensure that our patients provide informed consent. I honestly believe our patients are more informed than any other plastic surgery patients because of the teaching and education I provide on social media and the lengthy detailed discussions (our nurse) has with our patients. We encourage our patients to follow us so that they can see for themselves what they are getting into, understand the procedure, the risks, and the limitations of what I can offer them. Prior to social media and television, prospective patients only had access to surgical before and after pictures, which are inadequate in providing an understanding of the surgical process or the recovery period. Many of our patients have in fact given us feedback stating that they felt very comfortable and well informed going into their surgery because of the education and teaching we provide. Additionally, our written consent forms are comprehensive and are based on the American Society of Plastic Surgeons consent form template. Our information package lists pre- and post-operative instructions, a comprehensive list of possible complications, as well as procedure-specific risks. In addition to this, patients receive a consultation of approximately one hour, during which time they are given comprehensive information which enables them to provide informed consent.
Should the patient have any question, they are always welcome to email us, call us and come back to speak to us in person to further answer their questions and/or address their concerns.
Whenever my nurse is asked about the long-term risks of breast implants, she always provides a detailed answer. We also provided your researcher with a written list of surgical risks, including risks specifically associated with breast augmentation. In addition, (our nurse) recommends the patient go to the FDA website which has extremely detailed information, as she did during your researcher’s visit. The FDA provides the most comprehensive list of possible long term risks and is the authoritative site on this topic.
Finally, if our patients are ever concerned or have additional questions about any risks, they are always welcome to email or call (our nurse) directly. If they wish to come back to clarify and re-discuss any risks, they are always welcome to come for another visit with us.
Breast implants come with a lifetime warranty. Please refer to Allergan and Mentor for their warranty information.
We do not require patients to pay to see or receive the (consent) forms. That information is freely available online, and we freely email it to our patients upon request.
Our protocol is that patients must pay a $2000 booking fee prior to being scheduled for surgery. This deposit is required in order to reserve a surgical time slot and is designed to ensure that only serious patients are scheduled.
This was not clear during your researcher’s visit, and as a result of your feedback I made sure in the future there will be no confusion.
Our website and social media is a good informational source for our patients. Your ethicist did not review my website fully otherwise he/she would have seen that we show images of complications and other adverse events to educate our patients. We also have links out to other sources of information. Additionally, I spend a lot of time on my social media educating our followers about potential risks and adverse events.
I invite your researchers and ethicists to follow our Snapchat and Instagram stories to get a better grasp of the extent of education we provide.
I am very proud of the education and teaching that we provide to our patients, how we show ‘real’ plastic surgery and not only the ideal outcomes.
Again, thank you for giving me the opportunity to reply to your questions. Having reviewed the entire consultation, I am very proud of how my staff acted and performed the consultation. They took sufficient amount of time, did not rush through the process, discussed options, potential risks, and treated your researchers with kindness, empathy, and respect. Despite attempts to uncover unethical behavior, and trying to get my staff to agree to unethical practices, they performed in an exemplary fashion.
I agree with the College that changing technology has led to the increasing adoption of online and social media tools by doctors and as such, the College is aware that the use of before and after photos is widespread not only by Plastic Surgeons, but by ENTs, Dermatologists, Family Doctors, and basically every practitioner involved in the cosmetic field.
Before and after photographs provide pertinent information to the public, as patients increasingly perform their own research on the Internet, demand more transparency, more information, and more self-directed decision-making ability. Patient privacy is a very important part of this, and appropriate consent must be secured at all times.
With respect to your reference to allegations at the College, those allegations are denied and being defended. It would be inappropriate to make any further comments on the ongoing matter.
Dr. Sean Rice
Appreciating the CBC and Toronto Star’s commitment to report factual, accurate information; I wanted to identify several inaccurate statements related to a false examination your Marketplace researcher orchestrated while posing as a fake patient and scheduling a surgical procedure.
I question how ethical it is for a reporter to pose as a fake patient, spend over 2 hours in our office... Your reporter could have gotten all the information she wanted without paying a surgical fee and booking surgery . Paying a surgical fee and booking a date clearly indicated to my office that she wanted to proceed with surgery and was satisfied with the information she received. This subsequently lead to ordering supplies, nurses and an anaesthesiologist etc.
While participating in a full breast examination without identifying her media credentials, your Marketplace researcher requested breast implant surgery the next day. I did not proactively offer surgery the next day. When she contacted us on October 1 2018 she requested a surgical date of October the 18TH 2018. The office explored surgical options for the following day at her request. (Marketplace disputes this)
My nurse instructs all patients to review the consent form in detail outside of the clinic. I want to ensure all patients fully understand risks associated with their surgical procedure. I offer an opportunity to discuss the consent form after review to allow any follow-up questions before surgery. Patients deserve time to evaluate and question a consent from before endorsing. The patient was not asked to sign her consent form while in the office on her original consultation. The patient was asked to take the form home, review it carefully, make any notes of the points that she would like clarified then bring back that consent on the day of surgery, the following week, with her questions and have any questions answered.
In your pursuit to share accurate – factual – information with the Canadian public, I hope you will consider each of these points.
Dr. Mahmood Kara
Thank you for your request for an interview. We have reviewed all the materials. At this time, Dr. Kara would like to respectfully decline any comment on this matter.