Though he is not a plastic surgeon, Dr. Peter Scheer has repaired some of the most grisly visages in Palm Springs, Calif.
There was the Jet Skier whose face was sliced up when he roared into a water-ski towrope. There was the suicidal man whose jittery trigger finger skewed his aim, sparing his life but blowing off the front of his face. There were the two victims of a machete-wielding bar patron: the unintended recipient, whose skull was in the way of the blade's backswing, and the actual target, who got scalped.
Scheer is an oral surgeon, a dentist with extensive operating-room training. In emergencies, he and his fellow oral surgeons often have mended facial features beyond the mouth. Now they want permission in California to perform nose jobs, eyelifts and other elective plastic surgeries that are among the most lucrative of operations. Physicians with medical school degrees oppose the effort.
This clash over cosmetic surgery is anything but pretty. Following the course taken by eye doctors, medical assistants and holistic healers, the oral surgeons are making their case before the California Legislature, where the operating tools of choice are the campaign donation and the lobbyist rather than the scalpel and the sponge.
Doctors, nurses, dentists and other practitioners make up one of the state's best-endowed lobbies. Their political action committees have injected more than $2 million into campaign kitties for this fall, state records indicate. They also have spent $14 million on lobbyists this year.
Their rhetoric can be as blunt as their deployment of cash; they often diagnose their adversaries as suffering from greed, sloth, hypocrisy, incompetence and inflated egos.
"I've been doing rhinoplastics for 30 years and it's one of the most delicate procedures you can do. There's no way on God's earth these people can go in and do nose jobs," said Dr. Harvey Zarem, a Santa Monica physician who is president of the California Society of Plastic Surgeons. "The exclusive reason [oral surgeons] want to do this is money. They want to make more money."
"The plastics people want you to believe these are difficult surgeries. They are not," said Dr. Larry Moore, former chief of oral surgery at Long Beach Memorial Medical Center. "No one is standing up and saying, `We've got to get these dentists out of the emergency room,' because if we left the emergency room they'd have to go back. In many hospitals, you can't get a [plastic] surgeon for trauma cases, and the reason is, it doesn't pay."
The cosmetic-surgery proposal is one among many "scope of practice" debates pending in Sacramento.
Podiatrists want authorization to amputate parts of feet and perform surgery up to the ankle. Physical therapists want to be permitted to treat healthy as well as injured people, allowing them to tap into the fitness industry. In the last four years, at least 48 such measures have been proposed.
"Because health-care funding is limited, we have more and more people scrambling for titles and legitimacy," said state Sen. Liz Figueroa, a Democrat and chairwoman of the Senate Business and Professions Committee, which referees these disputes.
It is only in the last few years that oral surgeons have started pressing for legislative help. Until the late 1990s, many routinely performed voluntary cosmetic surgery, thinking it was appropriate, given their four years' training in hospital surgical residencies.
There, they learned how to repair damage to the jawbone and teeth resulting from facial malformations as well as gunshots, car crashes and dog attacks. Elective cosmetic surgery seemed to employ the same skills under less harrowing circumstances, the oral surgeons reasoned.
Also, they noted, the state Dental Practice Act says dentists can perform work on teeth, gums, jaws "or associated structures," the last of which oral surgeons interpreted to include lips, noses and chins.
State officials crack down.
California's health-care regulators began to crack down on outpatient plastic surgery after several patients died from wrongly applied anesthesia. Though oral surgeons were not implicated in those deaths, in 2000 the Dental Board of California issued a clarification that state law did not authorize dentists to do cosmetic procedures unless they were part of the treatment of a dental condition.
The oral surgeons enlisted the support of Senate President John Burton, who has sponsored so many scope-of-practice bills that he is known as "the pope of scope."
Burton's bill would authorize the state dental board to issue permits to perform cosmetic surgery on the neck and face to any dentist who had completed a residency program in oral and maxillofacial surgery, and paid $150 for a permit. California has about 600 oral surgeons.
The plastic surgeons gained the support of the California Medical Association as well as the state's association of emergency room doctors.
The physicians argue that oral surgeons may be competent to do spot repairs to bone but cannot be trusted to dexterously mold flesh.
Despite such arguments, so far the oral surgeons are winning. The Senate passed their bill May 19 and now there is a lobbying campaign to kill the measure in the Assembly.