Botox injections

Medicolegal Adviser Dr Pallavi Bradshaw warns new doctors about the administration of Botox

It is a momentous occasion when finally, after years of blood, sweat and tears, a new doctor can finally ring their credit card company and change their title to “doctor”. In the months following graduation, the novelty of that title and the respect and privileges that accompany it, can sometimes lead new doctors to become impatient and push the boundaries of their expertise, embarking on new and exciting areas of medicine outside the remit of the Oxford Clinical Handbook.

Perhaps it is the pressure of student loans and poor pay banding, or the wish to emulate Dr Troy, that leads some new doctors into the realm of cosmetic practice. MPS has had a number of queries from foundation year doctors who want to carry out minor cosmetic procedures, such as the administration of Botox and other anti-wrinkle treatments.

Thankfully some of these doctors realise that they need adequate indemnity, but there are others who aren’t aware of this professional obligation or the risks of going without it.

Patients are often searching for perfection and anything below it is, in their eyes, unacceptable

Medicolegal pitfalls

Forewarned is forearmed and all doctors must be aware of the medicolegal pitfalls of any practice that they undertake. Cosmetic medicine by its very nature invites a higher risk of a claim. Patients are often searching for perfection and anything below it is, in their eyes, unacceptable. This means that managing patient expectation and undertaking a robust consent process are hugely important.

Are you competent?

The purpose of the foundation years is to gain experience in a supervised environment in specialties that will underpin your future career

So, you are a fully qualified doctor, you have been on a training course and got the certificate, your indemnity is sorted, you give injections every day and nurses and beauticians can give Botox injections; so what could go wrong? The purpose of the foundation years is to gain experience in a supervised environment in specialties that will underpin your future career in medicine. The programme is a training schedule and trainees must be aware of the limitations placed upon them and the reasons that underpin them.

F1s can only prescribe in a clinical setting under supervision, and therefore some consultants may be prescribing on behalf of F1s and F2s. It is envisaged that F2 doctors will be supervised when they are prescribing in the community. So it will be the more senior colleague who may be liable should a claim be brought against a junior doctor.

It would therefore seem counter-intuitive to condone this cohort of doctors to prescribe and handle drugs, which they would not use in their everyday practice. In fact, an F1 would have to rely on the prescription of another suitably-qualified practitioner. Even so, this would not exonerate the F1 from the responsibility of assessing the patient and their suitability for the treatment.

In turn, the prescriber should also have satisfied themselves that the medication was suitable and that the F1 was appropriately trained and competent to undertake the procedure and consent the patient. As this is a prescribed drug the individual’s regular GP should also be informed.

In the eyes of the law

Junior doctors contemplating administering anti-wrinkle injections should familiarise themselves with the General Medical Council’s guidance Good Practice in Prescribing Medicines (2008), particularly paragraph 5b. The guidance states that patients who have Botox, Vistabel or Dysport treatments to paralyse muscles, which cause wrinkles, require an assessment of individual suitability.

It also states that when prescribing medicines you must ensure that your prescribing is appropriate and responsible, and in the patient’s best interests. It also states that you must be in possession of, or take, an adequate history from the patient, including: any previous adverse reactions to medicines; current medical conditions; and concurrent or recent use of medicines, including non-prescription medicines.

The GMC warns against group prescriptions, or Patient Group Directions, which allow bulk prescriptions to be administered by a number of people without seeing a doctor; and instead, it advocates patient-specific prescriptions. In addition the British Association of Cosmetic Doctors (BACD) states that cosmetic dermatology must be delivered in a safe medical environment by a competent, well-trained healthcare professional, preferably registered with the BACD, which has more than 300 qualified members and awards a Diploma of Cosmetic Medicine.

Given this guidance and the common-sense approach applied when prescribing or administering any drug, as a doctor you must be satisfied that you have assessed the patient, counselled them of the risks and benefits and have prescribed the medication in the best interests of that individual.

Concerns

There are practical concerns, such as ensuring that there is suitable expertise in the drawing up, dilutions, injection technique and disposal of the drugs.

Junior doctors in private clinics may work in isolation and the lack of supervision is a major concern. As a doctor working in an “alien” environment you should ensure that there is suitable equipment, such as resuscitation equipment, at hand and that you are able to deal with the side effects and complications that could occur. It is easy to become blasé about the use of Botox, but you should always be mindful of all adverse risks, however minor.

Duty of care

It is also tempting to be lured into a false sense of security when these procedures can be carried out by non-healthcare professionals, and to see the recipients as “clients”. As a doctor, you will have an established duty of care to these individuals and it is likely that they will have greater expectation of your skills and behaviour than those who are not.

It is difficult to detract from the fact that you are a qualified doctor and that in turn will alter the public’s perception of you, even in a “non-clinical” environment. With this in mind, “clients” may expect better results, better communication and will seek recourse if things have gone wrong. They may wish to make a claim or a complaint, and there are more avenues that could be pursued against a registered doctor than others who undertake the same work.

Is it worth it?

Any doctor contemplating earning the extra cash should ensure that it does not conflict with their trust employment contract

Without doubt the GMC will see you as a medical practitioner first and foremost and will look upon any complaint received within that context. As your regulator, the GMC has the jurisdiction to investigate matters that could call into question your fitness to practise and these can arise from non-clinical matters also.

A clear vulnerability in a case involving a junior doctor working in a private clinic, would be the concern about the appropriateness of the decision by the doctor to work within that environment – bearing in mind the requirements of the training programme and restrictions on practice in the NHS.

Any complaint to the GMC, whether with merit or not, is distressing and may compromise career progression. The trust and your consultants would be notified on receipt of any complaint and it is unlikely to be helpful for a fledgling career. Further, any doctor contemplating earning the extra cash should ensure that it does not conflict with their trust employment contract.

Is it really worth jeopardising your career to earn extra money when undoubtedly there are other skills that could be pursued in those early years? The old adage “don’t run before you can walk” comes to mind.

BOX 1: Extra income

Trainees need to be aware that earning extra money through assisting consultants in private practice should be appropriately indemnified, as should “helping out” with initiative lists, to cover potential claims or complaints. For years doctors have supplemented their incomes by undertaking locum work and this can be a lucrative business.

If such locums are being carried out in the NHS, trust indemnity should cover those shifts, but it would be wise to clarify that with the locum agency or HR department prior to the appointment. The same principles apply when considering locum posts as with any other job; do you have the suitable skills, training and competence to undertake the work? It could be tempting to “act up” in situations either in your current post, if there are staff shortages, or whilst doing locum shifts as they may pay better.

You have a responsibility to be honest about your competence and to stay within your area of expertise and be mindful of “over-egging” your CV, as you will only find difficulties in the long run. Finally, make sure you do not take on too many commitments over and above those of the “day job”. Over-tired doctors are at risk of making errors and this may not only impact on your training, but also leads to patient safety concerns.