Classification of plastic surgery malpractice complaints brought before the São Paulo Medical Board that were treated as professional-misconduct cases: a cross-sectional study

ABSTRACT BACKGROUND: Nowadays, there is an ethical and moral necessity to establish rules that govern professional attitudes and conduct. In the medical field, these rules are multifaceted, given the health consequences inherent to medical procedures. Ethics is an even more delicate subject when it comes to plastic surgery, since one of the aims of this particular medical specialty is esthetic improvement of the body. OBJECTIVE: To survey and classify São Paulo State Medical Board investigations of plastic-surgery complaints that were treated as professional-misconduct cases between 2007 and 2016. DESIGN AND SETTING: Cross-sectional study conducted in a medical council. METHODS: A total of 360 cases were reviewed. Among these, 8 (2.23%) were dismissed, 1 (0.27%) became an administrative lawsuit and 351 (97.50%) were treated as professional-misconduct cases. RESULTS: A breakdown of the complaints filed over the nine-year period showed that complaints concerning malpractice were the most common (28.43%), followed by those regarding medical advertising (24.19%) and poor doctor-patient relationships (10.39%). CONCLUSION: Overall, the number of complaints lodged decreased over the last two years reviewed, although complaints regarding malpractice and poor doctor-patient relationships increased by 10% over the same period. In order to further reduce the number of medical board investigations, the medical establishment needs to carefully review the medical training of students and doctors at every stage of their careers.


INTRODUCTION
They issue medical documentation and assess working conditions. Furthermore, they review, investigate and decide on the licensing status of doctors who breach professional rules and standards. Board oversight extends from individual activity to both public and private institutional operations, including the entire medical hierarchy of institutions that directly or indirectly provides healthcare services. This means that the CRMs have the power to authorize, order partial suspense of or prohibit the exercising of any activities, along with inspection of services and activities pursued by individuals or institutions in accordance with the law. 2 Since the CFM is a federally mandated autonomous agency, the CRMs are authorized to discipline medical activity via resolutions that determine medical permissions and prohibitions, and to investigate complaints and determine applicable disciplinary sanctions when the Code of Medical Ethics has been violated. Therefore, the CRMs have the legal prerogative to accept complaints, investigate the facts, judge the doctors involved and weigh up which sanctions are to be applied to each type of violation.
The numbers of formal complaints against doctors' attitudes that have resulted in investigations have been growing both domestically and internationally. 3 This has been seen especially within the civil courts, which are concerned with damages, and within the administrative courts, which are concerned with medical board investigations and reviews.
In 2017, the Courts of Justice of the State of Pará (Tribunal de   Justiça do Pará, TJPA) reviewed criminal cases under the search term "medical malpractice. " Cases were assigned to medical specialties as follows: eight cases in obstetrics/gynecology; four in emergency care; two in general surgery; one in anesthesiology/ plastic surgery; one in ophthalmology; one in orthopedics; and one in radiology. The courts concluded that surgery and emergency medicine, primarily obstetrics/gynecology, were the medical specialties against which most complaints and lawsuits had been filed. 4 Once a complaint has been lodged, the full regional medical board or the board's investigation committee opens an investigation to assess the facts of the case.
In the state of São Paulo, by law, the Regional Medical Council of the State of São Paulo (Conselho Regional de Medicina do Estado de São Paulo, CREMESP) must initially accept any complaint lodged by any citizen against doctors who practice within its jurisdiction.
Complaints are registered before a notary and are obligatorily subject to review. Upon initial review, the board may solicit clarifications in writing, following which the board will determine either that the case and said explanations and justifications are grounded or that there are insufficient grounds to proceed with an investigation. 5 Should the board determine that there are sufficient grounds to proceed, the complaint is referred to the disciplinary committee, which then names an investigator. Investigations proceed in accordance with the rules set forth in the Code of Medical Ethics.
Once investigations have been instituted and completed, they are debated in plenary sessions and assigned to investigative fora, which may then find for or against the complainant, may order reconciliation between the parties or may order that a behavioral change contract for a given duration be signed.
Investigations judged to have insufficient grounds are dismissed; investigations judged to have sufficient grounds are automatically referred to the Case Disciplinary Committee, which names an evidence-gathering board for hearings involving the parties (complainant, defendant and witnesses) and then one board member as a rapporteur and reviewer for subsequent remittance of the professional-misconduct case to judgment. sanctions that ran the gamut from confidential warning, to confidential censure, public censure, 30-day suspension and license revocation. 8 Silva et al. 9 also showed that the Regional Medical Council of the The majority (95.2%) were men; 35% had graduated from medical school 11-20 years earlier; 80.9% had been accused of more than one wrongdoing; and 71.4% were practicing as surgeons in the private healthcare system. General practitioners were the group most convicted (33.2%). The medical specialties with the greatest absolute numbers of convictions were obstetrics/gynecology (14.2%), anesthesiology (9.5%) and general surgery (9.5%).
The social impact of these medical malpractice complaints, which nearly always cause pain and suffering to patients and may involve poor doctor-patient relationships, is of great importance. 12,13 The fact that a doctor is accused does not mean that she or he will be convicted, but medical professionals who are ordered to appear before a medical board for regional board investigations do worry, because they know that there may be irreversible consequences to their actions or errors. 14

OBJECTIVE
The objective of this paper was to classify CREMESP investigations among plastic surgeons that were reviewed between 2007 and 2016 and were treated as professional-misconduct cases. al-misconduct cases that were dismissed or that were converted into administrative lawsuits (cases that were suspended because the defendant developed a disabling disease that prohibited him/ her from practicing medicine) were discarded from the sample.

METHODS
The study reviewed medical cases pursuant to the protocol established by the present authors. The protocol consisted of questions concerning the nature of the complaints and the year in which the complaints were lodged. Excel 2007 was used to provide a quantitative analysis of the data based on types of variable. A descriptive statistical analysis was used to generate percentages from the data analyzed.

A breakdown of the complaints over the period from 2007 to 2016
showed that complaints concerning malpractice (professional malpractice, recklessness or negligence) were the most common (28.43%), followed by complaints regarding medical advertising (24.19%) and poor doctor-patient relationships (10.39%).   Complications are also a concern during surgery, considering that surgical procedures are more likely to result in adverse events and severe consequences that are more visible and more easily demonstrable. Medical advertising was the second most common complaint over the nine years reviewed, although there were no complaints in this regard over the final two years studied. The CRMs state that there is no medical specialty officially recognized by the CFM in which the objective is esthetics. This means that the term "esthetic medicine" may not be used in a doctor's or clinic's advertising or marketing materials, since this creates a false sense that there is a discrete medical specialty known as "esthetic medicine. " This finding, that medical advertising was a common complaint, is backed by a 2017 study published by Shah et al. 16 Esthetic procedures are practiced in a number of medical fields.
The fact that there is a high demand for such procedures, given the current cultural and social standards of beauty and, consequently, that these procedures are financially lucrative, supports the findings of the present study.
However, doctors must not be influenced by perceived advantage, The promise of specific results puts doctors in a delicate spot since all procedures are subject to emergencies or unforeseen circumstances.
Advertising should disclose information that is scientifically accurate and accepted as good medical practice. Doctors must always act in accordance with the law and ethical standards.
Complaints regarding poor doctor-patient relationships also increased by 10% over the final two years of the study period.

CONCLUSION
Among the professional-misconduct cases reviewed between 2007 and 2016 that were included in this study, those classified as malpractice (negligence, recklessness and professional malpractice) occurred most often (28.43%).
It was clear from the data that CREMESP has dealt with the issue