Key issue is patient safety, not partisan interests
Andy Ho
Wed, Mar 26, 2008
The Straits Times
LAST week, the Ministry of Health (MOH) came down on 11 aesthetic therapies offered by some local doctors. Ranging from skin whitening and colonic cleansing to endermologie - rollers to roll away rolls of fat - this is a market estimated to be worth $200 million annually.

Calling those involved 'doctors who sell snake oil', a Health Ministry spokesman said random checks might be used and 'recalcitrant doctors' thus identified could be hauled before the Medical Council. Yet the ministry is still investigating the 'appropriateness and standards' for such procedures. Perhaps it would have been better to have withheld judgment as to which therapies were kosher and which weren't while that investigation was going on.

In fact, the focus should have been more on patient safety rather than physician behaviour, ethical or otherwise. Public safety should also outweigh the private economic interests of various physicians. And if safety were the paramount concern, then aestheticians, cosmetologists or plain old beauticians should have been reined in too, perhaps in concert with the Trade and Industry Ministry.

This group can and does carry out many of these procedures - including chemical peels to whiten the skin, colonic cleansings for 'detoxifying' the system and even using lasers to remove skin blemishes and unwanted hair. As MP Halimah Yacob, who heads the parliamentary committee for health, observed, beauticians have not been reined in.

So long as the skin is not breached, beauticians do not infringe the Medical Act. Take mesotherapy - 'meso' means middle - where the objective is to get a cocktail of natural chemicals, including anti-oxidants and amino acids, into the fat below the skin in order to dissolve that fat. Doctors inject these concoctions under the skin. Law-abiding beauticians offer needle-free mesotherapy by applying these chemicals to the skin, for they can purportedly seep through to melt the fat below.

Plastic surgeons have generally welcomed the MOH's action. Did their opposition to GPs and other physicians doing aesthetic medicine arise primarily out of fear for patient safety? They have not raised a big stink about beauty salons offering similar treatments. Perhaps that is because they are not fellow medical practitioners and would thus not bring the profession into disrepute.

Or perhaps it is about turf. That is, this is an intramural tug-of-war within organised medicine - general practice in aesthetic medicine versus plastic surgeons. Is this about which sub-group will set the agenda in this for-profit market?

About 60 per cent of GPs here do some form of aesthetic medicine, as do some anaesthetists, gynaecologists and kidney specialists. They are arrayed against the plastic surgeons who, ever since aesthetic medicine caught on a few years ago, have been bemoaning the encroachment on what they deem to be their territory. The Health Ministry's clampdown would shield them from competition.

On Sunday, however, Health Minister Khaw Boon Wan took the focus off physician behaviour and rightly refocused the issue on patient safety instead. To delve too deeply into the minutiae of medical practice, absent incontrovertible evidence of harm, may not be wise. For one thing, technological advances can make the bright-lines around areas of practice meaningless.

Thus from the later 1990s, cardiologists began implanting pacemakers and defibrillators, something previously only cardiac surgeons could do. Miniaturisation technology rendered the procedures much less invasive, so cardiologists could now perform them safely.

Where aesthetic medicine is concerned, the non-plastic surgeon can come up with innovations too. For example, liposuction was invented in 1974 by an Italian gynaecologist named Giorgio Fischer. Had Rome banned his speciality from fiddling with aesthetic medicine, there would be no liposuction today.

Another example: When most of the plastic surgeons in private practice who are cheering the Health Ministry's action the loudest were themselves still in training, there was no commercial IPL (Intense Pulsed Light) machine around. Used to clear skin blemishes and remove unsightly hair, these machines were first introduced in 1995, when they had very likely already completed their speciality training.

Thus their own (short) training in the use of such machines must have occurred fairly recently. In these circumstances, it does seem rather churlish that some of them have criticised their GP colleagues for having undergone training in aesthetic medicine during a long weekend in Bali, as one plastic surgeon so colourfully put it.

Mr Khaw also said he would leave it to the profession - specifically, the Academy of Medicine and the College of Family Physicians - to decide if there were benefits to be derived from some of the 'low-risk' therapies in question.

This move is to be applauded because the authorities should restrict certain practices to those best trained to perform them only when not doing so would lead to serious public harm. This is a precaution that applies usually to prescribing drugs (as the Thalidomide disaster reminds us to this very day). Most aesthetic treatments have to do with one's looks, not some bodily function critical to life.

Where there is no risk of serious public harm, the Government should leave alone the individual who seeks some form of care - be it from a GP or a specialist. Consider mesotherapy, for example. It was invented by a French doctor, Michel Pistor, in 1948, and has been recognised by the French Academy of Medicine as a legitimate mode of treatment since 1987.

Liposuction, though, can be a procedure involving considerable risk. As Mr Khaw indicated, this particularly risky treatment will be regulated closely. In this case, I hope tough new standards will be imposed - and imposed equally on all concerned.

That is, those parties that are clamouring the loudest for such standards must not presume that they will be 'grandfathered' in. Instead, the best specialists in academic practice with no financial axe to grind should set licensing exams, which all, including plastic surgeons, should be required to pass.

That way we can ensure that patient safety, not partisan interests, will be really and fully served.



The focus should have been more on patient safety rather than physician behaviour, ethical or otherwise. Public safety should also outweigh the private economic interests of various physicians.

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