Our NSS journey started at the Envogue skin event with Dr Nimrod Friedman from Tel Aviv, Israel. Ian and Linzi did a great job filling the room with practitioners and nurses. Great food, great people and lots of technical questions. The information and live anatomical drawings were well received and a great start furthering our knowledge. Towards the end we chatted to a couple of experienced nurse injectors that we had worked with previously. When I asked, will we see you tomorrow? One of the nurses responded “no, we have boycotted the NSS” I was so gobsmacked, and I did not respond immediately. Eventually I said that it was a shame that they were not attending but they had their reasons. For hours afterwards I reflected and was so confused. How can you boycott education?
After a decent sleep, we woke up refreshed and ready to learn, we love NSS. We love the different people coming together, the quality of organisation, the exhibitors and of course the fantastic international speakers. NSS always attracts incredible speakers from Australia and around the world. We have a few favourites; Dr Naomi from Sydney spoke this year and Dr Sarah Hart is always a passionate presenter. It is impossible not to stayed glued to these charismatic female leaders.
This year saw some serious issues being addressed.
How best to create protocols and systems to address complications in an efficient and effective manner. Keeping in mind, injectors are not always trained in emergency treatment of ischemic events which can escalate to permanent blindness. Should there be a hotline for professionals? Could a team of specialist’s ophthalmologists, plastic surgeons and emergency physicians create protocols and a pathway for medical professionals and specifically the frontline paramedics and emergency departments? This was an interesting discussion, especially with Dr Patrick Trevidic from France. He reported that they have implemented a hotline. He discussed the various issues they have had with the hotline and this open forum facilitated questions from the audience. This is a topic to be watched and I have no doubt the leaders in non-surgical aesthetics will continue striving towards excellent preventative measures and emergency pathways.
Another important point raised was, informed consent. This is another complex and important topic across all medical professions. In an industry which is commercialised and when a patient’s physical health does not depend on having an injectable treatment, one must reflect and question, are injectors informing patients of the risks or do injectors have a sales target to strive towards? In a clinic which is purely medically driven there is no underlying KPI’s or targets to meet. You have Medicare item numbers and rebates. However, in an aesthetic business, profit margins matter. Wages, devices, rent and marketing are all ongoing expenses. We must also note the wholesale price of product decrease with the increase of volume. For instance, a franchise has the benefit of buying in bulk and then distributing across the various locations. This guarantees the franchise a lower cost, allowing them to offer a more competitive consumer price. This model only works on volume. The idea is to push patients through as quickly and efficiently as possible, whilst upselling along the way. This begs the question, based on this model, does the injector have the time to allow for informed consent? To clearly articulate the potential risks. If blindness and necrosis are discussed, does this put clients off and potentially lose the sale? Does this then place the injectors job at risk if sales are down? It does not seem like rocket science that if someone attends your business for a service and you point out the service can potentially leave you blind, deformed or looking worse, your business is not going to thrive. In saying that, simply asking clients to read and sign a complex consent form is NOT informed consent.
As a client we rely on the dermal therapist or health practitioner to inform us of the do’s and don’ts. We forget we are a commodity or part of someone’s monthly targets. Clinic owners and employees are in a very difficult position, one which I am sure will require further debate and evolve. I would hope more clinics and independent practitioners do explain the risks in a simple context and then explain their action plan. I am happier to accept the risk if I know the practitioner is prepared for the complication. If by chance I am the unlucky person who has an adverse event, I would like assurance that the injector will have a plan in place. They will have a pathway, will have an experienced physician on call if not themselves. I know of Dr Benjamin Burt in Melbourne and Dr Anthony Maloof in Sydney have partnered with clinics to help in the event of an adverse reaction. Maybe the best solution is to be honest, transparent and to simply assure the patient you have the experience and network to manage such complications.
The last hot topic which is new to NSS was, who should be involved in meetings such as NSS and in what capacity? Nurses were down in numbers this year and as nurses, we wanted to attend the open nurse’s forum to learn why firsthand. Sadly, we were politely asked to leave. It was not stated anywhere this was a closed forum only for nurses in attendance. In any event were sorry we caused any inconvenience or disruption, that was not our intention and we are in fact both registered nurses and we both work for surgeons in the industry.
This is an interesting debate and we believe not one to be behind closed doors, rather the opposite. Dentists, Dermatologists, GP’s, Gynaecologists, and Surgeons from General to Plastics are all injecting. I dare say over time more practitioners from other fields will be too. No one owns this space, there is no recognised benchmark qualification or protected AHPRA title for a cosmetic injector. There is no FRACS accredited training program and experience is acquired over time on real people, very few injectors have the luxury of practicing on cadavers. Feeling the needle hit the bone, working with multiple products to appreciate their viscosity and learning ethnical differences in facial anatomy is knowledge and skill acquired over time. Understanding features, movements and facial harmony is where the injector becomes an artist. The relationship between the muscles, skin type and product are practical critical thinking skills learnt over time. So, what constitutes an expert injector? Is it a qualification not actually related to injecting? A dermatologist is a skin expert, does that make the derms the best speakers and experts? A surgeon or better still a specialist plastic surgeon is an expert in microsurgery, trauma and aesthetic surgery, does that make them the expert? An ENT is an expert in noses, does that make him/her the safest non-surgical rhinoplasty injector? And a nurse is well, the nurse who in all traditional medical fields assists the above listed professionals, therefore would one assume the nurse is not the expert injector? Noting there is no nurse practitioner degree specifically for cosmetic nurses. The answer to all these hypothetical questions is a simple NO. There is no black and white in the non-surgical field. It is grey, and whilst all the above specialities can not only inject, they all can be leading injectors. We all know of these excellent presenters, all renowned for their work: Dr Steven Liew (Specialist Plastic Surgeon), Dr Greg Goodman (Dermatologist), Dr Sean Arendse (Cosmetic General Practitioner) Mike Clague (Registered Nurse), Dr Andrei Tutoveanu (Cosmetic Dentist). Dr Sonya Jessup is a pioneer cosmetic gynaecologist who offers vaginal Botox, labia fillers, labial tightening and body sculpting. The point being experience and collaboration matters when it comes to aesthetics, working with different ethnicity’s, age groups and genetic limitations is what builds an injectors repertoire. So, when we have nurses with 10 and 20 plus years’ experience in injecting, why are we not seeing them on the podium speaking? Keeping in mind NSS does not chase the KOL’s. The device companies facilitate their presence with an expectation their product will be endorsed throughout their presentation.
The Cosmetic Physicians College Australia (CPCA) does not have a membership for nurses, The Australasian Society of Aesthetic Plastic Surgeons (ASAPS) does not having a membership for nurses, the Australasian College of Aesthetic Medicine (ACAM) do have a membership for nurses however as per their website, no nurses have been awarded a fellowship and it would appear from the previous few conferences no keynote speakers were nurses. The Australian College of Cosmetic Surgeons (ACCS) has 15 affiliate nurses. The Australasian society of dermatologists (ACD) is specifically dermatology and accredited by the Australian medical council. Lastly the Australian society of dermal clinicians (ASDC). I believe nurses need to band together, form their own cosmetic nursing association with recognition from the Australian nurses & midwifery board, write publications, submit abstracts and be relentless, resilient and use real evidence to do so. Alternatively, the above groups would need to accept a nurse onto their board and open memberships to aesthetic nurses. An opinion-based discussion lead by the conference convenor and a Specialist Plastic Surgeon representing ASAPS is a great effort to mend burnt bridges. But it is not going to create the real action needed, especially not in an open and transparent forum with key objectives and outcomes. Having no media present or transparent minutes also leaves all the nurses not in attendance relying on hearsay. Nurses need to become influential in their own right to create change. Not by boycotting or a NSS peace treaty. Boycotting only harms nurses by leaving them out of educational opportunity, networking opportunities and comradery. Aesthetic nurses who are self employed are often isolated and this is potentially damaging to ones ongoing professional development.
A group of nurses who sought us out (they truly had no idea who we were until we were kicked out) said, “We need CPCA to expand and include nurses”. We asked the CPCA if they will expand to include a membership for nurses, to which the vice president informed us they have been approached and asked and it will be something they mention and review after the conference. The non-surgical symposium is by far the biggest conference, which attracts the most sponsors and the most prestigious speakers. Any nurse who choses not to attend due to politics is frankly missing out. We got kicked out of a session on the Friday and still attended early on the Saturday. If we had not attended the remainder of the conference, jaded at being asked to leave, we would not have built rapport with delegates, made new friends, learnt about the latest devices and been able to listen to the recognised experts. We have attended the laser & cosmetic medicine conference, Cosmetex, Cosmedicon, ASCD, ASAPS surgical, the Plastic Surgery Congress and many more smaller supplier events. No other event within Australia attracts 16 KOL’s from around the world in addition to the KOL’s within Australia. By far NSS is giving attendees the broadest possible range of experts. Nurses can have a stronger presence, will have a stronger presence and need to not wait to be asked.
There is clearly a shortage of cosmetic nurse presenters globally, we need to create abstracts and start applying to present. If you get knocked back, apply again, year after year. Alfie is an exceptional copywriter and editor; I offer him to any nurses wanting to create a presentation or abstract and get up there. Dr Naomi informed me she can’t eat before presenting, she feels so stressed the morning of a presentation. Her husband said to her “what if I am the only one in the audience” she laughed stating well that would be a good thing. Yet, every person we spoke to absolutely raved about her presentation and how relaxed she appeared. Putting yourself in an uncomfortable position is not easy, but nurses do this day after day. I have never heard a nurse say, “oh that surgeon never has a bad day, whilst all my patient’s are predictable and perfect”. LOL, we as nurses thrive for the challenge and getting on centre stage, I believe this is a challenge many nurses are ready to accept.
These are all exceptionally important questions that quickly become political and somewhat confusing. Alfie and I are registered practitioners, we do have a significant interest in patient safety and do believe these topics need to be discussed more and in an open forum. We must acknowledge we do have a bias being nurses, of course we want to see more nurses receive the accolades and recognition they deserve. Let’s hope more doctors post on social media “my nurse giving me injectables”, more nurses on the NSS social media pages, nurses presenting, more surgeons paying for their new to the industry nurse to attend. The nurses who are opinionated, who have been coming to these conferences for years and who are experts, we implore you to pave the way and be the innovators inspiring the next generation of nurses. Aesthetic nurses are not assistants, they are artists, anatomy experts and pioneers. We have nurses who perform thousands of treatments every year, lets tap into their knowledge, their concerns and their experience. Nurses do not need permission to use their voice or a closed forum, we all have a passion for patient outcomes and the power to facilitate a powerful positive presence.