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Practice makes perfect?

The demand for cosmetic surgery in Hong Kong is on the rise as more and more patients pursue the “perfect” image. But for doctors, providing these services in an unregulated environment can be risky business. Rachel Seddon investigates

How many times do you need to perform a medical procedure before you feel comfortable doing it without any supervision or reference material to guide you? Some medical schools still use a model of “see one, do one, teach one” to train students in carrying out procedures.1 But if a patient comes to you asking for cosmetic treatment that you have no prior experience in, how would you respond?

For doctors, conducting plastic surgery is an area of practice fraught with difficulties. There are currently no regulations in Hong Kong to govern who can and cannot provide cosmetic treatments; as long as you hold a licence to practise, you are considered qualified.2,3 Clearly, this means inexperienced doctors may end up performing procedures outside their competence; many others may face ethical dilemmas if they fail to fully understand what is expected of them.

What’s more, without regulations to govern what doctors can and can’t do, doctors are unsurprisingly finding themselves at the receiving end of more complaints than ever when patients don’t get the end result they were hoping for.

This is not a new issue; the Hong Kong Medical Association has been campaigning for regulations to be developed for plastic surgeons for more than ten years. In 2006, it proposed to the Legislative Council that: “All material to be injected, or implanted into the body has to be registered... Such procedures, whether carried out by needle injection or by surgery, will be a medical procedure, and may only be performed by a registered medical practitioner with the necessary training.”4

Pertinent measures would need to target relevant practitioners, the procedures they perform, the medications and devices they use, involved institutions, and consumer education

A recent article featured in the Hong Kong Medical Journal went further, describing the nature of the regulations that are needed. It said: “The ultimate aim of any reform is patient safety... Pertinent measures would need to target relevant practitioners, the procedures they perform, the medications and devices they use, involved institutions, and consumer education.”5

One positive step came with the launch of the Hong Kong Association of Cosmetic Surgery (HKACS) in 2010, which lists promoting “the advancement and safe practice of cosmetic surgery and medicine [and maintaining] a high ethical professional standard in the practice of cosmetic surgery” among its objectives.6

Despite this, definitive government regulations are still needed to provide guidance for doctors and deliver peace of mind for patients.

The lure of advertising

Advertising has its role to play in the problems surrounding the delivery of cosmetic surgery in Hong Kong. Whilst doctors are not allowed to advertise their services, other clinics and beauty salons are – many of whom claim they can provide the same cosmetic treatments as a doctor, but all too often are under-qualified.7 This has meant that patients can find themselves tempted to go to a clinic, which leaves them open to the risk of something going wrong.

Inevitably, after experiencing an adverse outcome – instead of going back to the clinic and exposing themselves to more problems, patients go to their trusted doctor to get it fixed. Many surgeons report that fixing someone else’s mistake can be more difficult than doing the procedure themselves in the first placeand that it can be more difficult, at this late stage, to set realistic expectations for the patient.

The right person for the job

When you’re consulting with a patient who wants plastic surgery, it is important to think it through carefully before deciding whether you should proceed. Chris Howse, Partner at law firm Howse Williams Bowers, says: “There are three important questions you must ask yourself before administering any cosmetic treatment. Firstly, do you have good grounds, supported where necessary by trial results, to support the procedure? Secondly, do you have the necessary skills, facilities and equipment available to allow you to carry it out safely? And thirdly, do you have a full understanding of the risks involved? Don’t proceed with any treatment without carefully considering these issues.”

If you feel that you are lacking the skill, experience or equipment, you must be honest with the patient

If you feel that you are lacking the skill, experience or equipment, you must be honest with the patient. Offer to refer them to a colleague who you know does have all the right credentials, and make sure the patient understands why it is in their best interests that you have refused to treat them. They may think they are better off by having cosmetic surgery, but if you are not the right person to do it then it is always safer to refer.

If you are happy to provide the treatment, you must be confident that the procedure is within your competence and that it is included in the scope of your indemnity. Be prepared to disclose any details of the training you’ve had, as well as that of any assistants who will be involved to the patient if they ask.

Before scheduling any treatment, it is crucial that you ask yourself: 

  • Does the patient fully understand the procedure, along with its associated advantages, disadvantages and risks?
  • Does the patient have realistic expectations of their outcome?
  • Has the patient provided valid consent for the procedure, and has this discussion been captured in the patient’s notes?

If there is any doubt around whether the patient has provided valid consent, or if you think they haven’t fully understood the risks involved, consider rescheduling the appointment for another day to give them ample opportunity to think it through.

What to do when something goes wrong

Sometimes, even the simplest procedure can go wrong, despite planning for it and being fully trained. If you do receive a complaint, contact MPS who will work with legal advisers on your behalf to:

  • Respond to the complaint
  • Take a record of your recollection of the situation
  • Check all relevant documents and evidence, including the medical notes
  • Get the advice of a medical expert, if required
  • Communicate with the patient’s legal advisers.

It is important that you seek advice as soon as possible after a complaint is made; delays will only cause the problem to escalate. Despite the absence of regulations, keeping detailed medical records and always practising with the patient’s best interests in mind will stand you in good stead when faced with these potentially risky situations.

MPS advice

  • Manage patients’ expectations
  • Practise within your limitations
  • Don’t be afraid to refer patients, or refuse to carry out treatment if you don’t think it’s in the patient’s best interests
  • Only carry out procedures that you know are within the scope of your indemnity – check with MPS before proceeding if you are unsure
  • Make sure you always keep detailed notes about any consultations involving discussions around cosmetic surgery, particularly around consent.

References

  1. Yadla S and Rattigan E M, See One, Do One, Teach One: Competence versus Confidence in Performing ProceduresAmerican Medical Association Journal of Ethics Vol. 5 no. 12  
  2. Loh A, Cosmetic surgery: Cure or curse? Reader’s Digest Asia [Accessed 4 June 2013]
  3. Yau E, Korean plastic surgeon shares his views on industry regulationsSouth China Morning Post (18 February 2013) 
  4. HKMA, Call to regulate organizations that provide medical and beauty procedures (9 October 2012) 
  5. Wong D S J, Regulation of the beauty industryHong Kong Med J Vol. 18 No 6
  6. The Federation of Medical Societies of Hong KongThe Hong Kong Medical Diary Vol 15 no 6, June 2010
  7. Loh A, Cosmetic surgery: Cure or curse? Reader’s Digest Asia [Accessed 4 June 2013]
  8. Cox L, Cosmetic Surgery Desperation and Depression (14 November 2008) ABC News Medical Unit
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