It Is Time for Plastic Surgeons to Start Picking Up the Tab

“If you want to know who controls you, look at who you are not allowed to criticize.” – Voltaire¹

Kansas City has a local society of plastic surgeons that meets 4 times annually. An invited speaker makes a presentation at a well-known restaurant. The meetings are sponsored by companies, and the speaker is reimbursed. Plastic surgeons enjoy wine, hors d'ouevres, and an excellent steak dinner. The annual fee for membership is US $100. The presentations are repetitive and product-oriented (hence, the wine). No one objects. No one reaches for the bill. No one seems to remember when it was any different.

A similar scenario plays out Down Under. A plastic surgeon in Melbourne, Australia (not R.J.B.), hosts an annual dinner for plastic surgeons, always sponsored by the same company. The host makes the obligatory opening comments about conflict of interest and transparency, thanks the sponsor, and commends the altruism of the company for bringing along no promotional materials. The host's office staff is also invited.

Plastic surgeons may feel that they have worked hard and paid their dues, and what harm can come from being treated to an occasional free dinner? However, a feeling of entitlement is perpetuated.² Even small gestures build a feeling of reciprocity.³

At a recent symposium on Breast Implant–Associated Anaplastic Large-Cell Lymphoma in Rome, Italy, the hosts started by thanking the sponsors for making the conference possible and supplying “the roof, the walls, the chairs.” Attendees were reassured that the sponsors had “foregone any kind of control over our content today. They had no say with regard to our lectures or what they would say.”⁴ The chilling flip side to these comments is the recognition that companies do influence the content of our scientific meetings.⁵

“Quid pro quo” has become a popular political expression recently. Reciprocity is simply a business reality for health care manufacturers. There would be no reason to spend millions of dollars subsidizing plastic surgeons, plastic surgery societies, and our meetings, unless a compensatory benefit is derived. At the 2017 meetings of the American Society for Aesthetic Plastic Surgery and the American Society of Plastic Surgeons, 46% and 34% of the speakers respectively were reimbursed by Allergan plc (Dublin, Ireland), totaling US $6.57 million.⁵

The contributions to our societies and meetings are not generally known but likely on a similar scale. With this level of sponsorship, we need to be careful that our societies do not become the de facto “Allergan Society of Plastic Surgeons.” The fellowship pledge of the American College of Surgeons forbids “any arrangement or improper financial dealings that induce referral.”⁶ Should there not be a similar prohibition on financial enticements paid by industry to plastic surgeons?⁷

Conflict of interest is often discussed at our meetings but with little in the way of resolution or results. Greater transparency is a good start,³ but we need to do more. The recent textured implant crisis makes clear that this issue impacts real patients, their health, and their lives. There is precedence in our specialty. According to its president, members of the French Society of Plastic and Aesthetic Surgery “are not allowed to have a [financial] disclosure and to participate with a company.”⁸ The Agence Nationale de Sécurité du Médicament led the way in banning Allergan's Biocell textured breast implants in Europe in December 2018.⁹ Why did this happen in France, where textured implants have been preferred for decades? Why did it not happen in the United States, which trailed over 40 countries in making this important decision?⁴

The problem is clear, and so is the remedy.^3,7 We must realign our priorities. For members of the American Society of Plastic Surgeons, the cost to attend a meeting is about US $1200, the same as the fee for injecting 2 syringes of hyaluronic acid filler. Plastic surgeons earn, on average, US $389,000 annually.¹⁰ Both authors of this letter have (independently) relinquished all corporate handouts. When we attend a sponsored dinner, we pay the restaurant directly or reimburse the sponsor for the meal (typically US $80). When the breast implant company wants to bring lunch to the office, we pick up the tab. Sales representatives are not permitted to bring coffee for the staff.

Our meetings may still serve as an opportunity for plastic surgeons to learn about new products, medical instruments, and ancillary services. Companies can set up in the exhibit halls and pay their way but should not be permitted to fund the meeting or any “satellite” sessions. Attendees will not be instructed to visit the exhibitors “without whom the meeting would not be possible.” We are no more dependent on companies than they are on us. The truth is, we are all dependent on our patients, who ultimately foot the bill. We need to be better custodians of our patients' (largely women) finances.^2,3 Plastic surgeons can afford higher meeting fees, which may be offset by lower prices for products.^3,7 Does anyone know what a breast implant would cost if the built-in costs of subsidizing plastic surgeons were eliminated?

As trusted professionals, with patient care as our primary focus, plastic surgeons do well to heed the lessons of the recent past. Corporate support may be an oxymoron. Relinquishing industry subsidies for what are meant to be (and once were) independent educational meetings is a logical remedy. Companies will not object. Manufacturers will save money, and these savings should be passed on to plastic surgeons and to our patients. Financial conflicts created a moral blind spot in our reaction to the textured implant crisis.⁷ This experience serves as a wake-up call to plastic surgeons and our societies to change our ways and to start reaching for the check.