Carlos Chaves, Mall Surgeon

Sure, an unlicensed doctor was performing liposuction at a hair salon. Stranger still: Clients kept showing up.

Chaves may not be licensed in the U.S., says his Houston criminal-defense lawyer, Kent Schaffer, but he is a trained surgeon. He attended medical school in Bolivia, at the Universidad Mayor de San Andreas, and has practiced for 12 years, including stints in both Bolivia and his native Colombia. Another of Chaves's lawyers, Victor Gutierrez of Miami, notes that Chaves has performed cosmetic surgeries, legally, all over South America, some of them under the supervision of noted plastic surgeons in Brazil. Gutierrez says he has talked to people who had work done by Chaves in other countries, and those people, he says, are highly satisfied customers.

In 1995 Chaves moved to Miami, where he has friends and family, but he remains a Colombian national. According to Gutierrez, Chaves applied for a physician's assistant license, and the State of Florida accepted his educational credentials; it's only the English-language tests that gave him trouble. According to Florida records, Chaves is instead licensed in two less demanding areas: to perform massage therapy, and to give facials.

Immigration lawyers say they've heard hundreds of similar stories, of immigrant doctors forced into other employment. It's extremely hard for a doctor, trained and licensed in a foreign country, to continue practicing his profession in the U.S. To be licensed in Texas, a doctor must pass a demanding battery of medical tests, be competent in English and undergo three years of residency training in the U.S. -- at low pay and long hours, even if a similar residency was previously served in another country. Furthermore, the U.S. requires that immigrant doctors practice at least two years in underserved parts of the country, undesirable places such as Appalachia; the penalty for working in a more desirable place is a whopping $250,000.

More Low Rider than W: Nellie Eleftherton, Chaves's assistant.
Houston Police Department
More Low Rider than W: Nellie Eleftherton, Chaves's assistant.
A full-service salon: In its ad, Switch offered cuts, color and lipo.
A full-service salon: In its ad, Switch offered cuts, color and lipo.

Immigration lawyer Clarissa Guajardo Shaw says that most foreign doctors don't even attempt to practice medicine in the U.S. The last time she talked to one of her clients, formerly a doctor, he was making piñatas.

Wellington Smith also deals with immigration issues; as part of the Texas Doctors Group, in Austin, he recruits physicians. He says that when practicing doctors immigrate to the U.S., they end up "driving taxicabs or working in used-car lots." But becoming certified to practice here? "I've never seen it."

The powerful American Medical Association lobbied for those tough standards in the mid-'90s, in part to preserve members' earning power. More doctors means more competition; why allow immigrants to undercut prices when HMOs are already slashing American doctors' incomes?

Competition is particularly fierce in cosmetic surgery, the profits of which have been relatively safe from penny-pinching HMOs. Few health plans cover cosmetic surgery, but consumers are willing to pay its hefty costs out of their own pockets. According to the American Society of Plastic Surgeons, in 1998 the average breast-augmentation surgery in Texas cost $2,850; the average face-lift, $4,000 to $5,300, depending on whether the surgeon used an endoscope.

Not only are the procedures cash cows, but the market is booming. The ASPS reports that more than a million people had cosmetic surgery in 1998, more than twice as many as in 1992, and that number is considered highly conservative. The future looks more profitable still, as baby boomers continue to age, bulge and sag, and as people grow ever more likely to believe that cosmetic surgery is safe and socially acceptable.

Naturally, lots of doctors want to get in on a good thing -- and not only those who trained long and hard in the field. The most demanding certification body, the American Board of Plastic Surgery, requires at least three years of training in general surgery and two in plastic surgery, but legally, any licensed doctor can perform cosmetic surgery, and its practitioners include dermatologists, gynecologists, ear, nose and throat specialists, family practitioners and even dentists. Many doctors tout their certification by groups such as the American Board of Cosmetic Surgery, the American Society of Liposuction Surgery or the American Board of Facial Plastic and Reconstructive Surgery; but despite their impressive-sounding names, those groups require little in the way of specialized training. In some cases their only membership requirements are that doctors pay a fee and attend a weekend course.

Such distinctions are lost on the surgery-seeking public. Do prospective patients ever ask about credentials? "Never," says John K. Long, a Houston M.D. certified by the American Board of Plastic Surgery. "Never, never, never."

Instead, patients appear to pay attention to ads, on billboards or in print. You see those ads everywhere: here in the Houston Press, in the Houston Chronicle, Semana, Texas Monthly and, in their highest local concentration, Houston Health & Fitness. Sometimes the ads depict a serious-looking doctor in scrubs or talking to a patient, but more often, and more memorably, they show the surgeon's former patients, usually women and usually striking ones -- models, dancers and beauty-pageant winners. They beam bleached smiles or pout, the better to show off their plump lips. They wear diamonds and expensive evening dresses (short ones, to show off their slender thighs). Their perky noses, smooth foreheads and tiny waists read as carefully chosen accessories, signs of good taste. The message is that of the mall: Buy this, and you can be transformed.

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