Vanity fair
Concerns are escalating over the increased promotion of aesthetic procedures in Singapore. Sara Williams explores the risks of using medicine as a marketing tool
Last year a doctor was fined S$5,000 for breaching patient confidentiality, after two photographs of a patient receiving laser treatment to her face appeared in a local magazine without her consent.
Dr K saw the patient between October 2006 and April 2007 at the Aesthetic Clinic and did not deliberately publish the images, so issued an apology.1
However, the Singapore Medical Council (SMC) Disciplinary Committee ruled that even though the breach was a result of an error, it was a serious enough breach to warrant sanction. But this wasn’t the end of it – on top of the fine, Dr K was criticised for associating himself with persons not qualified to provide medical support services.
His commercial interests were also scrutinised. The Committee said that although steps had been taken to disassociate him from the spa business of Ultimate Wellness Haven, Dr K should not have put himself in a difficult position by entering into a service agreement with the clinic, a commercial provider.
This case highlights the problems that doctors can encounter by associating themselves with commercial companies who offer aesthetic services. Medicine is not market-driven, nor are patients customers; they are patients first and foremost. Market forces are not bound by a duty of care, nor a duty of confidentiality to patients in the same way medics are; given this context, it is easy to see a real conflict of interest when medicine is used to make money.
This conflict of interest has given rise to much debate around the regulation of aesthetic practice around the world. Doctors who practise aesthetic medicine need to protect themselves by being familiar with the guidelines and the regulation that surrounds it.
The case for regulation
The need for firmer regulation of advertising and aesthetic practice is not unique to Singapore. Recently, Nigel Mercer, president of the British Association of Aesthetic Plastic Surgeons in the UK, made the case for tighter regulation, arguing that practitioners should sell their advice, not their procedures.
Writing in the Royal Society of Medicine’s journal Clinical Risk, he said: “There has been a massive increase in ‘marketing’, including discount vouchers, 2-for-1 offers and holidays with surgery… What is worse is that national governments would not allow it to happen in other areas of medicine. Imagine a '2-for-1' advert for general surgery? That way lies madness.”
He further argued that if doctors cannot self-regulate, then, like financial institutions, regulation will eventually be imposed.
Although the General Medical Council (GMC) in the UK regulates doctors and hospitals/premises where treatments are performed, there is no regulatory body for businesses involved in the aesthetic surgery industry.2 This is in contrast to countries like Denmark and France, who have laws in place to limit who can do what to whom.
In the UK, MPS has been involved in an intercollegiate committee set up to look into self-regulation of aesthetic practice in the UK. This has now borne fruit, with the formation of the British Academy of Cosmetic Practice.
In other countries such as Ireland, questions have been raised on the back of poor practice by some surgeons.
An Italian plastic surgeon was recently found guilty of misconduct in relation to his treatment of a 33-year-old Dublin woman who attended him for a breast augmentation operation. The inquiry has drawn attention to a range of questionable practices around promotion by private cosmetic surgery clinics, such as giving surgeons commission depending on how much business they can generate.
The doctor’s contract stated he would get 8% commission if he earned the ACS clinic more than €25,000 a day.3
Dr Sean Carroll, an experienced plastic surgeon based in Dublin, says the only way this can be controlled is by inspecting the units. “Sometimes patients get text messages saying they will be offered a discount if they hurry up and make up their mind. It’s akin to second-hand car dealerships.”
How to protect yourself
Avoid aggressive advertising techniques
Doctors need to be aware of current legislation on promoting cosmetic surgery services. Dr Ming Keng Teoh, MPS head of medical services in Asia, says: “Doctors are advised against aggressively promoting services that offer cosmetic treatments, in a manner that may be deemed as soliciting. The Private Hospitals and Medical Clinics Act advertising guidelines and the SMC Ethical Code and Guidelines warn against such robust advertising.”
According to Dr Teoh, this includes practices such as:
- promoting credit card discount schemes
- using advertorials (in particular, disguising them as journal review articles)
- pushing non-essential services and procedures at the elderly, vulnerable groups and the poor.
Comply with directives and guidelines
In 2008, guidelines for performing aesthetic surgery in Singapore came into force for the first time, requiring that certain criteria relating to past practice must be met before surgery can be carried out.
The guidelines on aesthetic practices for doctors were jointly produced by the SMC, the Academy of Medicine, Singapore, and the College of Family Physicians Singapore.4 They state that doctors who have been performing aesthetic procedures must have appropriate indemnity; non-compliance could result in disciplinary action by the SMC.
Have the correct indemnity
Following the guidelines, MPS made changes to the international GP/cosmetic categories of membership for Singapore. The categories are:
GP procedural (without obstetrics) – this includes aesthetic procedures such as chemical peels, botox injections and laser treatment for medical conditions and skin rejuvenation. This is provided that the gross income from aesthetic practice is less than 50% of total gross income.
Cosmetic practitioner – this includes the procedures mentioned above, but when their gross income from these procedures is more than 50% of total gross income. This concerns doctors who perform any additional invasive aesthetic procedures included in the categories hair transplant without flap surgery, laser therapy (ablative – eg, CO2/YAG for skin resurfacing), dermabrasion and free fat grafting.
High-risk cosmetic practitioner – any medical practitioner undertaking aesthetic procedures with little support from scientific evidence, or which have their acceptability questioned by expert consensus. These procedures include mesotherapy, skin-whitening injections and carboxytherapy, in addition to liposuction undertaken by non-specialist plastic surgeons.
Dr Teoh said: “Our stance is based on the principles that:
1) the procedure is in the patient’s best interests
2) the doctor performing the procedure is competent to do so
3) procedures should be sufficiently evidence-based, and
4) the doctor is complying with local directives and guidelines.
"MPS can assist in problems arising from doctors performing procedures in other clinics or appropriate premises but is unlikely to do so if the tasks are delegated to and performed by nurses or others.”
He added: “We base our assessment of the appropriate subscription rate for a member on the information they give us, which we take on trust at the time. However, in the event of a claim or when members seek assistance from us, MPS may conduct checks and ask members to provide evidence that they are paying the appropriate subscription rates. So make sure MPS is contacted when practice plans change or new ones are initiated.”
Avoid complaints and claims
- Avoid medical mishaps – keep good and contemporaneous records (no records no defence), communicate effectively (two-way process), maintain good medical practice (training, CME, etc), work within your competence.
- Avoid disputes – be professional, offer a professional service, use chaperones, safeguard records, charge appropriately, manage patient expectations.
- Manage medical mishaps - good communication (most litigation is a result of poor doctor–patient communication; it should be open, timely and sustained), full disclosure of mishap (failure to do so adds insult to injury), take responsibility, apologise and offer redress when appropriate.
Treatment should not be driven by profit
Self-regulation in this challenging branch of medicine must be vigorously and fairly pursued, for how else can medical professionals enjoy the trust of society? To protect this trust, the motive for performing any procedure must never be financial gain. “The safety and best interests of the patient must be doctors’ first and foremost consideration,” concludes Dr Teoh. “Safe practice must be followed, but the profit motive should not come into the patient safety equation.”
Case 1
Mrs C, a 56-year-old housewife, wanted her wrinkles removed. She went to her GP to ask for injections to get rid of them. Her GP gave her Dysport (Botulinum Type A). A consequence of the treatment was that her eyelids drooped. Mrs C was not very happy and alleged that her GP had given her Dysport when she wanted Botox. She stressed that she was not informed that Dysport had a supposedly higher complication rate.
Learning points
- Ensure informed consent - full explanation could have avoided the patient’s unwarranted suspicion about the higher complication with Dysport.
- Respect the patient’s wishes.
- Ensure the patient has realistic expectations.
Case 2
Surgeon Mr Q excised a 4cm lipoma from the chest wall of Mr M. He removed the sutures on day seven. As Mr M was arriving home the wound gaped open – he became very distressed as his shirt was soaked in blood. Mr Q was dogmatic and bullish in his reaction to Mr M’s situation, muttering that “he always removed sutures on day seven without any problems”. Mr M made a complaint against Mr Q, saying that he was ignoring his concerns and the risks of a haematoma/infection from the soaked shirt.
Learning points
- Acknowledge and address patient concerns before attempting to explain.
- Apologise for clear upset and disappointment.
- Try to see it from the patient’s perspective and avoid defensiveness.
- Good communication.
References
- Channel News Asia, Singapore Medical Council disciplines doctors (18 January 2010)
- BBC News, Dangers of ‘lax’ cosmetic surgery (3 March 2010)
- Donnellan, Eithne, When it all goes wrong, Irish Times (9 February 2010)
- SMC, Guidelines on Aesthetic Practices for Doctors (2008).