You know life is getting interesting around here when the new Permanent Secretary for Law doesn’t have a law degree but a MBBS (S’pore). Given the mindset on health regulation in recent times, maybe the next DMS should have a law degree and not a MBBS.
We have been grappling with the business of aesthetics for a long time. Much angst, vexation and even anger has come forth. But after years of mucking around, we are still no nearer a well thought-out solution to this problem than finding a cure for the common cold
But first, let’s remind ourselves of how we doctors got into the realm of aesthetics. Other old coot doctors like this hobbit will remember the days of yore when doctors do not practise aesthetics. This was when locums charged $45 per hour, the polyclinic only had beta-blockers and diuretics and medical officers were paid forty bucks a call. In other words, this was circa 3rd century BC when Hannibal and his barbarians wacked the daylights out of the Romans and middle-aged people had sex (if they had any at all) in a bedroom and not in a Big Splash car-park lot. Hannibal actually looks rather civilized in today’s context – I am told he had fun on a bed. Those were also the days when we had a drive-in cinema where people made out. We have of course progressed a lot since then, we now know the cinema bit is redundant and we only need a car park lot. Which brings us to the point as to why we don’t have enough babies on this island – we don’t have enough car-park lots.
Seriously, other than the odd skin peel that GPs performed on patients, aesthetic practice was rare beyond plastic surgeons and a few dermatologists back then – in the nineties. Generally speaking, the people who did this beauty stuff on homo sapiens were either morticians or beauticians, depending on the GCS score of the person concerned. What happened then? Some beauticians were performing procedures that were way over their heads. I remember there was a case reported in The Straits Times where a beautician injected silicone directly into a lady’s eyelids and nose and caused gross and permanent disfiguration. The beautician was charged under the Medical Registration Act (MRA) for illegal practice of medicine. The fines were rather low then and the MRA was amended sometime after that. This happened about 15 years ago and it was only in the last 10 to 12 years or so did aesthetic practice take off in a big way among doctors.
One can rationalize this trend to a few simple reasons
- Demand for aesthetic practice has always been there and is increasing. The question is who is performing the service? Most people feel that it’s a lot safer to get their fix from a medically trained person than a beautician.
- Other than safety, doctors can avail themselves to drugs that the beautician has no access to
- The high cost of practice, i.e. rent, salaries etc means GPs have to generate more revenue faster than before and it’s a lot easier to do with aesthetics than seeing common ailments
But then problems arise when we then try to fit aesthetic practice into our “normal” framework of medicine. Its like a bad donor-host rejection from a botched transplant job.
Let’s consider what the normal framework of medicine is: –
- There is a patient complaint and a consequent pathology or symptom to address and manage and in most cases, a therapeutic end-point.
- There is evidenced-based body of knowledge that the doctor should rely on whenever practically possible
- There is a social contract between the patient and doctors, such as that described by Parson’s sick role.
- There is the ethical framework for informed consent which is based on risk, benefits and alternatives to a certain treatment modality to manage a symptom or a disease.
Now in aesthetics, there is no real pathology or disease. Maybe at best, a “symptom” (if it can be called one at all) of a feeling of a lack of beauty. And since there is no real disease to treat, there is also no therapeutic end-point that can be objectively agreed upon. As such, how can there be good evidence to say that a modality works (maybe some evidence, but certainly not the good evidence you can get from say, a randomized control trial)? There is also no real sick role – nothing for the patient to be excused from and he doesn’t need to want to get better and hence, the social contract that exists in clinical medicine doesn’t quite fit here either, and neither does consent as we know in the usual sense of the word.
Let’s face it, other than in some instances involving reconstruction work, the majority of aesthetic work doesn’t quite fit into the realm of clinical medicine. In fact, one would argue that aesthetic practice is not clinical medicine. It is a service provided by a medically trained person for safety reasons. And maybe we will be better off by acknowledging as such. There will be much less angst for folks like us that do not offer any aesthetic services and for those that do so almost all the time, the full-time aesthetic practitioners.
So really, there should be another register of aesthetic practitioners who are medically trained. These guys can then be governed by a different set of professional registration laws and ethical codes while they retain the right to use drugs and perform invasive procedures so that consumer (not patient) safety is ensured. The PHMC Act can also have a different class of clinics called “aesthetic clinics” with its own set of requirements.
How about those doctors that want to retain their clinical work while still offering aesthetic services part-time? Well, we can learn from the example of a registered medical practitioner who is also a registered TCM practitioner. Here, the same person must practice in different premises. The TCM premise must have its own signboard and entrance which must be apparent to the patient or the aesthetic customer. Or if this not feasible, as a minimum, the clinic should state clearly and separate the operating hours for clinical medicine and that for aesthetic practice, so that the patient or consumer walking into this one clinic will know up-front if he or she is walking in as a patient or as a consumer of an aesthetic practice.
This hobbit is not trying to put down doctors who office aesthetic services, on the contrary, they try to fulfill a desire in many people to look better. But to continue to foist stuff like evidence based and clinical medicine and even clinical practice ethics on this group of people is not going to solve the problem. They will feel frustrated and over-regulated. The only aspect we should not compromise is consumer safety. But what is safe need not be evidence-based to be therapeutic. This is the principle of TCM regulation today as well. We don’t really have hard evidence that many TCM modalities work, but we still allow the practice of these modalities as long as they are reasonably safe.
What is the alternative? We crush the development of aesthetic services here through the weight of current laws and SMC ethical framework and people will still try to get their fix overseas or to the local beauticians who will try to fill up the gap. The current approach makes it easy to find doctors guilty but it will not address the consumer’s desire for beauty.
Many people will obviously not agree with the views expressed in this note. They are fully entitled to their opinions. But we could perhaps at least agree that the current approach is not working out well and a new mindset and a new approach is needed to deal with regulating doctors who offer aesthetic services.
In the meantime, we should also ensure that we have an environment that does not push more and more doctors into offering aesthetic practices so as to make ends meet. The joke going around these days is that with HDB heartland clinic rents exceeding $30,000 a month, the only way for these clinics to survive is to turn them into 24 hour aesthetic clinics.
But there may be a little light at the end of the tunnel – with all this obtaining sexual gratification stuff going around, it is rumoured that certain IT companies’ recruitment advertisements now come with the tagline “Beautiful people need not apply”.