A few weeks before 26-year-old Sarah Smith died after a breast operation in her physician's office, she had called at least one other doctor for information.
Dr. Peter M. Calamel says he believes Mrs. Smith of Depew was shopping for prices.
Calamel was more expensive than Dr. Anthony S. Pignataro, who could offer Mrs. Smith a discount because he worked in his West Seneca office, thereby avoiding anesthesiologist and hospital fees.
Surgery with Calamel would cost about $6,000. He said Pignataro, as well as other doctors who operate in offices, can do it for at least $1,000 less.
Patients who pay more attention to prices than a doctor's qualifications court trouble, experts say.
But the case of Mrs. Smith, who died a week after her heart stopped Aug. 25 during breast augmentation surgery, raises other troubling questions about the last field of medicine where patients pay completely out of their pockets and physicians compete with little regulation.
"Cosmetic surgery is the last bastion of capitalism in medicine, and it's a free for all out there," said Calamel, president of the Buffalo Plastic Surgery Society.
Pignataro has been accused of providing substandard care in at least eight cosmetic-surgery cases under review by the state Health Department, according to local plastic surgeons and medical malpractice attorneys.
The Health Department suspended his medical license, claiming he may have failed to follow up on Mrs. Smith's history of an irregular heartbeat, performed the procedure with inadequate anesthesia support and administered inappropriate drugs.
Many patients do not realize that once doctors complete medical school, they can practice any specialty, including surgery, even though they might lack advanced training.
Complex and dangerous procedures require the expertise and equipment found only in hospitals, where physicians review each other's work and systems have been established to monitor patients.
But an increasing number of procedures are being done in medical offices and clinics because of improved technology and pressure from health insurance companies to cut costs.
The quality of doctors' work in their offices
largely escapes oversight, especially for procedures like cosmetic surgery that are not subject even to standards an insurer might impose.
State investigators say Mrs. Smith received a general anesthetic, although Pignataro was not trained as an anesthesiologist. Nor is it clear yet if he was trained in how to diagnose and react to anesthetic emergencies.
Many physicians routinely perform procedures in their offices, but Pignataro may have had no choice. At the time the state took action, he no longer had privileges to work in any hospital.
"Every doctor has complications. It doesn't make you a bad doctor. But in an office, you might not have the safeguards to back you up," said Dr. Franklin Zeplowitz, president of the Erie County Medical Society.
Dozens of doctors in Western New York offer liposuction, face lifts, tummy tucks, breast enlargements and other cosmetic procedures.
The business is competitive. Each year, more than 400,000 healthy Americans unhappy with their appearance pay doctors to make improvements, according to the American Society of Plastic and Reconstructive Surgery.
Anyone who tries to choose a doctor to trim fat or tighten jowls is guaranteed to be confused.
Unlike some other states, New York also has no central source of information where patients can find out about a doctor's disciplinary actions, malpractice claims and educational background.
Plastic surgeons are trained to work on the entire body and are the doctors who do reconstructive work. They cite their certification by the American Board of Plastic Surgery and membership in the American Society of Plastic and Reconstructive Surgery.
Board certification indicates advanced training. The requirements of the American Board of Plastic Surgery, one of 25 boards recognized by the American Board of Medical Specialties, include at least five years of hospital training, two of them in plastic surgery, as well as written and oral exams.
But many other "board-certified" specialists perform cosmetic surgery, although their boards are not recognized by the American Board of Medical Specialties.
Dermatologists and ear-nose-and-throat surgeons do facial cosmetic procedures and belong to their own boards. Pignataro was certified by another self-organized group, the American Board of Cosmetic Surgery. Still other boards certify physicians after brief seminars.
Pignataro received his medical degree from University Central del Caribe Medical School in Puerto Rico. He tried a higher level of training for the ear-nose-and-throat specialty and facial plastic surgery but never completed it.
He received certification from the American Board of Cosmetic Surgery, which requires doctors to pass oral and written exams and to have completed a certain number of procedures. But board-certified plastic surgeons for years have insisted that the requirements are not rigorous enough.
Carmen P. Tarantino, Pignataro's attorney, says the plastic surgeons' attitudes represent their fear of competition from other qualified physicians.
"It's very misleading for doctors to say that my client's board is not legitimate. It's indicative of the deep and acrimonious tension between the two groups," he said.
Tarantino has asked the public not to prejudge the doctor, whose license suspension will be the subject of a hearing tentatively set for Oct. 8 by the state's Office of Professional Medical Conduct.
"Dr. Pignataro has been crucified. When the facts come out, they will provoke people to rethink their views of this case," he said.
Doctors have denounced Pignataro in a rare display of the medical community publicly ganging up on one of its members.
"We knew he wasn't qualified to do the things he was doing," Calamel said.
He said he cared for a patient who had received a face-lift from Pignataro about three years ago and was unhappy with the result, quietly hoping the woman would sue Pignataro for malpractice.
"I was hoping it would be brought to public attention in a lawsuit. I would have been willing to help," he said.
But he didn't file a complaint with the state officials who investigate doctors, fearful that he would risk a libel lawsuit.
Is there a code of silence?
Zeplowitz said that may have been the case years ago but not in today's highly regulated era of medicine. Other doctors say they did file complaints before Mrs. Smith died, although this is difficult to verify because the state releases information about an investigation of a physician only when a disciplinary action is taken.
The disciplinary process became more secretive in 1993, when the State Court of Appeals ruled in favor of a doctor who had sued to keep his identity confidential while his case was under investigation. Since then, the public does not learn about medical misconduct charges against a bad doctor until a final decision is reached.
"We have to open up the misconduct hearings again," said Blair Horner, a representative of the New York Public Interest Research Group.
Earlier this year, NYPIRG and the Center for Medical Consumers issued a report that called on the state to improve its efforts to get rid of incompetent doctors and provide consumers with more information about their physicians.
Horner said the state now disciplines more doctors than in past years. But 51 percent of the cases are based on sanctions against doctors in other states who also have a license to practice in New York.
"Before the Pataki administration, New York was one of the worst states in physician discipline," Horner said. "It's now a higher priority, but all the out-of-state actions show they're padding the score."