MOH says 'stern action' for doctors who perform liposuction without accreditation, doctor urges tighter guidelines
SINGAPORE: Healthcare professionals who perform liposuction without accreditation face “stern action”, said the Ministry of Health (MOH), but one doctor said that accreditation guidelines could be tightened.
This comes after the High Court ruled in November last year that general surgeon Dr Edward Foo Chee Boon was liable for negligence in the death of his patient. He was ordered to pay about S$5.6 million in damages.
READ: Doctor ordered to pay about S$5.6m in damages after patient died from botched liposuction procedure
“Liposuction and related procedures are generally considered the specialty of plastic and reconstructive surgeons, and Dr Foo is a general surgeon who only attended several overseas liposuction courses and internships before practising liposuction,” said Justice Choo Han Teck.
Dr Foo delayed calling an ambulance even after his patient’s blood oxygen dipped to emergency level, the court heard.
“The fact that it took him 45 to 50 minutes to realise that he could not figure out what was going on compels me to infer that Dr Foo was not adequately trained for such surgeries,” said Justice Choo.
The judge said it was ultimately for the health authorities and medical authorities to sort out the boundaries as to whether a general surgeon should be allowed to carry out liposuction surgeries.
In response to CNA’s queries, MOH said Dr Foo was “negligent” in performing the liposuction procedure on his patient as well as his management of her postoperative condition.
“To protect the interest and safety of consumers, MOH will take stern action against any licensees or healthcare professionals who perform liposuction without the proper accreditation or compliance to the licensing conditions,” the ministry said.
MOH added that it has not received “any such feedback” on the conduct of such invasive procedures in the past year. The Singapore Medical Council (SMC) is currently looking into Dr Foo’s case, and said that its deliberations at this stage are confidential.
GUIDELINES FOR AESTHETIC SURGERIES
After news of the court case, questions were asked about the guidelines around general surgeons performing aesthetic surgeries.
Demand for aesthetic procedures has been growing for the past 10 years, with the rate slowing slightly in the last few years, said Dr Ivan Puah of Amaris B Clinic. Growth is stronger for minimally invasive or non-invasive procedures compared to invasive ones, he added.
The rise in demand is also partly related to the COVID-19 pandemic, as work-from-home arrangements allow patients to work and recuperate at the same time, said plastic surgeon Dr Andrew Khoo of the Aesthetic and Reconstructive Centre at Mount Elizabeth Medical Centre.
MOH told CNA that invasive procedures, like filler injections and cosmetic surgeries, should be performed only by trained medical practitioners who must be registered with the SMC.
These doctors must also comply with the SMC’s guidelines on the conduct of aesthetic procedures, which were first issued in July 2008, and updated in October 2008. They were last revised in 2016.
Under the guidelines, doctors who are not plastic surgeons or do not practise under other recognised specialities can still perform three types of invasive procedures: Free fat grafting, hair transplantation and mechanical dermabrasion.
They can do so as long as they have performed the specific type of procedure 10 times “with good outcomes” between Oct 1, 2006 and Sep 30, 2008, said the guidelines.
Doctors who do not meet that requirement can still perform the surgery if they receive a certificate of competence. As part of their application, they must include a certificate either from overseas or local training courses, details of the course, the amount of hands-on experience and the duration of the course, among other details.
All doctors who wish to perform liposuction in medical clinics, except those employed by hospitals, need to be accredited by the Accreditation Committee on Liposuction (ACL), an independent committee appointed by MOH.
They must follow the specific licensing conditions for liposuction that were rolled out by MOH and the ACL in 2015, which state that they must have received “proper and accredited surgical training”.
This means doctors must have undergone one year of surgical training in a hospital after housemanship. Relevant postings are not limited to plastic and reconstructive surgery, but also include general surgery and orthopaedic surgery, among other specialties.
Doctors must also have observed at least 10 liposuction procedures under preceptorship by a qualified surgeon, and have performed at least one liposuction procedure per month under close supervision by a qualified surgeon over the past two years.
Should a medical practitioner decide to perform more than one type of liposuction, they must satisfy the same training criteria for every type of liposuction.
ROOM FOR IMPROVEMENT
Doctors whom CNA spoke to were divided on whether the guidelines are sufficiently robust. There should be a minimum training period for doctors before they start doing aesthetic procedures, said Dr Khoo.
“In plastic and reconstructive surgery, for example, the training programme is four years long. The initial years are spent doing reconstructive surgery which is the foundation of good aesthetic surgery. We are supervised, trained and audited by our superiors,” Dr Khoo said.
“At the other end of the spectrum, there are three- and six-month fellowships given out by ‘certification bodies and institutions’ that will certify you in all manner of procedures. You pay the money, attend and get a certificate and put it on the wall. This can be improved.”
He suggested that specialist accreditation boards look at the number of cases a surgeon has done before allowing them to do aesthetic procedures.
“This can be calibrated – less documented experience for less risky procedures and more documented experience for more risky and invasive procedures,” he said.
Dr Khoo also acknowledged the difficulty of regulating medical practice in individual clinics as compared to hospitals, which have their own accreditation committees.
“Prohibition of procedures would affect the practice of many doctors who do responsible and safe aesthetic practice. A too laissez faire approach will lead to more mismanagement,” he said.
Dr Puah said Singapore’s guidelines on aesthetic procedures are “very comprehensive”.
“To ensure the safety of the patients, Singapore (has) erred on the safe side and rightly imposed very stringent guidelines on all aesthetic treatment, in relative comparison with most other countries,” he said.
The guidelines for liposuction, for example, are “one of the most stringent in the world, to ensure patient safety and maintain highest standard of care for patients”, he said.
Going forward, regulators of aesthetic treatments will face a two-fold challenge, said Dr Puah.
“One is to keep up with the change and development in the field with flexible and progressive guidelines, to allow Singapore to keep up with the best and be a centre of excellence for aesthetic procedures, as the patient demand is big and still growing,” he added.
“The other is to ensure treatment safety and high standard of care, to weed out the black sheep in the industry. It is not easy to find a balance between the two, but I hope (the authorities) will be able to achieve that.”
Dr Khoo said that in general, doctors and specialists in Singapore are well-trained and regulated.
“Maintaining a good standard of care depends on accredited training, the recognition of each practitioner of his or her own level of training and ability and for all practitioners, general and specialists alike, to practise at an appropriate level to their training," he added.
“As in all professions, there will be outliers, and this where regulatory bodies and the legal system may come into play.”
Aesthetic surgery is a “completely optional” procedure, Dr Khoo noted.
“Patient protection also comes from seeing the right surgeon, understanding the risks and benefits of the procedure you are embarking on and being comfortable with the experience and the results that that surgeon offers,” he said.
“Even with this, one only minimises the risk – properly trained doctors also have complications. The difference may be recognition of the complication and the ability to rectify it.”