A Knife Fight in Capitol

SACRAMENTO —  Though he is not a plastic surgeon, Dr. Peter Scheer has repaired some of Palm Springs’ most grisly visages.

There was the jet skier whose face was sliced up when he roared into a water-ski towrope. There was the suicidal man whose jittery trigger finger skewed his aim, sparing his life but blowing off the front of his face. There were the two victims of a machete-wielding bar patron: the unintended recipient, whose skull was in the way of the blade’s backswing, and the actual target, who literally got scalped.

Scheer is an oral surgeon, a dentist with extensive operating room training. In the forced moments of emergencies, he and his fellow oral surgeons have frequently mended facial features beyond the mouth. Now they want permission to perform nose jobs, eyelifts and other types of elective plastic surgery that are among the most lucrative of operations. The effort is firmly opposed, however, by physicians with medical school degrees.

This clash over cosmetic surgery is anything but pretty. Following the course taken by eye doctors, medical assistants and holistic healers, the oral surgeons are making their case before the California Legislature, where the operating tools of choice are commonly the campaign donation and the lobbyist rather than the scalpel and the sponge.

Doctors, nurses, dentists and other practitioners together make up one of Sacramento’s best-endowed lobbies.

Their political action committees have already injected more than $2 million into campaign kitties for this fall’s races, state records show. They also have spent $14 million on lobbyists since 2003.

Their rhetoric can be as blunt as their deployment of cash; they often diagnose their adversaries as suffering from greed, sloth, hypocrisy, incompetence and inflamed egos.

“I’ve been doing rhinoplastics for thirty years and it’s one of the most delicate procedures you can do. There’s no way on God’s Earth these people can go in and do nose jobs,” said Dr. Harvey Zarem, a Santa Monica physician who is president of the California Society of Plastic Surgeons. “The exclusive reason [oral surgeons] want to do this is money. They want to make more money.”

Oral surgeons offer equally uncharitable assessments in return.

“The plastics people want you to believe these are difficult surgeries. They are not,” said Dr. Larry Moore, former chief of oral surgery at Long Beach Memorial Medical Center. “No one is standing up and saying, ‘We’ve got to get these dentists out of the emergency room,’ because if we left the emergency room they’d have to go back. In many hospitals, you can’t get a [plastic] surgeon for trauma cases, and the reason is, it doesn’t pay.”

The cosmetic surgery proposal is just one among many so-called “scope of practice” debates pending in Sacramento. Podiatrists are asking for authorization to amputate parts of feet and perform surgery as far up as the ankle.

Physical therapists want to be permitted to treat healthy as well as injured people, a move that would allow them to tap into the burgeoning fitness industry.

Social workers are seeking to be eligible for Medicare reimbursement for diagnosing patients with mental problems, an effort psychologists view as an incursion onto their turf. In the last four years, at least 48 of these kinds of measures have been proposed.

“Because healthcare funding is limited, we have more and more people scrambling for titles and legitimacy,” said Liz Figueroa (D-Fremont), the chairwoman of the Senate Business and Professions Committee, which referees these disputes. “People seem to get ownership over certain titles and certain words. The word ‘manipulations’ -- chiropractors think they own that word. So when the physical therapists mention it, they go crazy.”

Ophthalmologists spent more than a decade blocking optometrists from prescribing drugs to treat glaucoma and other diseases of the eye. The optometrists finally won in 2000. The following year, lawmakers made it easier for medical assistants -- unlicensed aides in physicians’ offices -- to perform basic procedures without a doctor’s supervision. The idea was unpopular among nurses, who feared that their tasks were being usurped by people with far less training.

Last year, a proposal to allow any appropriately trained holistic healer to identify him or herself as a “doctor of naturopathy” was opposed not only by physicians and acupuncturists but also by some herbal healers who lacked formal training. They feared they would be driven out of business. The measure was ultimately enacted.

A recent analysis by California Common Cause of gifts during the 2001-02 election cycle found that the California Dental Assn. contributed $1.5 million, more than any other single group, including state employees, Realtors, teachers and prison guards. The California Medical Assn., which represents physicians, ranked fifth. Both groups have placed in Common Cause’s top 10 list since the group began tracking contributions in 1983.

Group efforts are significantly augmented by individual donations: Since 2001, Scheer and his professional partner, for instance, have together given $14,200 to Figueroa and Sen. Sam Aanestad (R-Grass Valley), the Republican vice chairman of the business and professions panel. That is far more than the $1,500 that the two Rancho Mirage oral surgeons gave to the state senator from their district.

Indeed, a disproportionate amount of the donations go to the lawmakers who have the most authority over practitioners’ livelihoods. Aanestad, an oral surgeon himself -- and the Senate’s only healthcare practitioner -- received $502,381 from the dental and medical associations in the previous election cycle, more than any other legislator, according to the Common Cause analysis. During the current election cycle, individual practitioners, political action committees and the drug industry have given more than $105,000 to Figueroa, according to campaign finance records. That amounts to 40% of all of her donations.

It is only in the last few years that oral surgeons have started pressing for legislative help. Until the late 1990s, many routinely performed voluntary cosmetic surgery, thinking it was perfectly appropriate, given their four years’ training in hospital surgical residencies.

There, they learned how to repair damage to the jawbone and teeth, including reconstructing facial malformations such as cleft palates and severe overbites, as well as the devastation caused by gunshots, car crashes and dog attacks. Elective cosmetic surgery seemed to employ the same skills under less harrowing circumstances, the oral surgeons reasoned. Also, they noted, the state Dental Practice Act says dentists can perform work on teeth, gums, jaws “or associated structures,” the last of which oral surgeons interpreted to include lips, noses and chins.

Then California’s healthcare regulators began to crack down on outpatient plastic surgery after several patients died from wrongly applied anesthesia. Though oral surgeons were not implicated in those deaths, in 2000 the Dental Board of California issued a clarification that state law did not authorize dentists to perform cosmetic procedures unless they were part of the treatment of a dental condition.

Shut out from the most profitable portion of their profession, the oral surgeons first tried to cut a deal with the plastic surgeons, one that would allow them to come to the Legislature with unified backing.

When that failed, they were able to enlist the most powerful lawmaker in California as their bill’s sponsor: John Burton (D-San Francisco), the Senate president. Burton has sponsored so many scope of practice bills that he is known around Sacramento as “the pope of scope,” and the Democrats who control the Senate are more inclined to defer to him than to any other colleague.

Burton said he has been amazed at how fiercely practitioners try to fend off advances by other disciplines. “Whoever gets in first wants to pull the ladder up,” he said.

Burton’s bill, SB 1336, would authorize the state dental board to issue permits to perform cosmetic surgery on the neck and face to any dentist who had completed a residency program in oral and maxillofacial surgery, and paid $150 for a permit. There are about 600 oral surgeons in California.

The plastic surgeons, however, were not cowed. They enlisted the support of the California Medical Assn., the industry heavyweight, as well as the state’s association of emergency room doctors, who the oral surgeons had hoped would be in their corner. (The ER doctors and the plastic surgeons, however, are bound together in one important way: Both share the same lobbyist in Sacramento, according to state records.)

The physicians’ critique has not been subtle, as they argue that oral surgeons may be competent to do spot repairs to bone but cannot be trusted to dexterously mold flesh. In written testimony, Dr. Jack Bruner, president of the California Society of Plastic Surgeons, called the bill “one of the most menacing pieces of legislation threatening public safety under consideration by this year’s legislators.”

The debate has exposed the resentment between the various castes of healers. The oral surgeons regularly portray the plastic surgeons as prima donnas who fled the late-night world of the emergency room, where treating the injured supersedes performing a “wallet biopsy” to make sure they are adequately insured.

Cosmetic surgeons say the oral surgeons are trying to elevate themselves from the pedestrian realm of dentistry, which does not carry the same prestige that physicians hold.

“That’s been a problem for the dental profession over the years. They’ve suffered from an inferiority complex,” said Dr. Robert Roth, a Fremont dermatologist and dental school graduate who says dental courses “are watered down compared to what the medical schools teach.”

Despite such arguments, so far the oral surgeons are winning. Their bill passed in the Senate on May 19. An aggressive lobbying campaign to kill the measure in the Assembly has been underway for weeks, and people on both sides predict the fight will grow more intense there.

“With increasing regulation and decreasing reimbursements, the entire medical community is looking for a financial life raft,” said Scheer, the Rancho Mirage oral surgeon. “And of course the elective [surgery] market is that life raft.”

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Big donors

Medical professionals are among the top contributors to California legislators and legislative campaigns.

Donations in 2001-02:

*--* 1. California Dental Assn.$1,532,774 2. California State Council of Service Employees$1,451,806 3. California Real Estate Assn.$1,422,353 4. California Teachers Assn.$1,322,965 5. California Medical Assn.$1,148,633 6. California Correctional Peace Officers Assn.$1,145,809 7. California School Employees Assn.$962,205 8. 21st Century Insurance$853,750 9. Agua Caliente Band of Cahuilla Indians$744,050 10. California State Employees Assn.$690,434

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Source: California Common Cause