In this era of declining insurance reimbursement, physicians are scampering to find ways to supplement their income.Some otolaryngologists, dermatologists, and ophthalmologists are performing plastic surgery. Even primary care physicians such as family doctors and obstetricians are getting into the act.Usually these non-plastic surgeons call themselves cosmetic surgeons. Shockingly, nurses now want to inject fillers and Botox, and laser wrinkles independent of surgeons! They are taking one- or two-day courses hoping to learn to perform chemical peels, Botox injections, laser hair removal, collagen and Restylane injections, and other procedures.In New Jersey one obstetrician advertised a three-day course for obstetricians in breast augmentation, liposuction, and abdominoplasties! With minimal or no formal aesthetic training in a residency program or understanding of the skin and beauty, these doctors are taking advantage of their medical licenses and opening cosmetic practices.The ad for the three-day course pointed out that ‘‘the investment in time and resources to learn aesthetic procedures is minimal.’’ Just what the public wants to hear! And, according to the ad, ‘‘Upon completion of these seminars, the physician will have sufficient knowledge and hands-on training to safely and effectively perform cosmetic procedures in the office setting.’’I spent over two years in plastic surgery residency following four years of general surgery learning how to do these procedures. I guess I wasted a lot of time. I should have just taken the three-day course!Inadequately trained surgeons have been around for a long time. In the 1950s surgeons returning from World War II started new practices after taking two-week courses in rhinoplasty.Certainly, non–plastic surgeons may be capable of performing some cosmetic surgery within the anatomic boundaries of their specialties. Some ophthalmologists legitimately perform cosmetic eyelid surgery, but how do they justify performing breast augmentations, as one near my office does? Ear, nose, and throat doctors may be capable of performing rhinoplasty, and even other facial cosmetic surgery, but how is it that they are trained to do liposuction of the thighs, as another in New Jersey does?And dermatologists are not surgeons: their area is not recognized by the American College of Surgeons as a surgical specialty. They may do minor procedures, but their field is medicine of the skin. Even with a one-year ‘‘dermatologic surgery’’ fellowship, their training is vastly different from that of a real surgeon. Yet again, all over the world dermatologists are performing liposuction, face-lifts, and breast augmentations. Family doctors? They treat colds, sprained ankles, diabetes, and hypertension—and now they inject Botox. Where does this come from? Think money. Plain and simple.It gets worse. Dentists are now claiming they have the right to do cosmetic surgery. California has already granted them this privilege. Laser and drug companies are egging them on, offering them lasers for wrinkle, acne, and hair removal and cellulite reduction systems with ultrasound. Where will it end? Ask your legislator.Beware of Lots of Letters after the Doctor’s NameDuring my ten years as a governor’s appointee to the New Jersey State Board of Medical Examiners, I noticed that many fraudulent doctors have quite a few letters after their names. In fact, multiple letters may be the telltale sign of an inadequately trained doctor trying to impress the public.Certainly your doctor should have the letters M.D. (Medical Doctor) or D.O. (Doctor of Osteopathy) after his name. He might even have one or more master’s degrees (M.S., M.P.H., M.B.A. or M.A.), but these degrees are irrelevant to plastic surgery. He might also have a Ph.D., impressive but again irrelevant medically. Patients are well advised to select a plastic surgeon with the letters F.A.C.S. (Fellow, American College of Surgeons) after his name.These letters are awarded only to surgeons who are certified by one of the surgical boards of the American Board of Medical Specialties. Any other letters must be carefully scrutinized. I have seen people use letters from medical societies and virtually self-made societies. Some of the letters are awarded after completion of weekend courses! Most of the time, the multilettered doctors are not real plastic surgeons. I have even seen doctors who joined the International College of Surgeons just so they could add F.I.C.S. (Fellow, International College of Surgeons) to their names.