Angry Doctor

Sunday, April 06, 2008

Whose "Medicine" is it anyway?

A letter from Dr Tan Cheng Bock was published in Today yesterday:


(emphasis mine)

WHAT's HAPPENING TO MEDICINE?
More stringency needed in managing aesthetics
Dr Tan Cheng Bock

THE recent debate on aesthetics and medicine has prompted me to write this article.

I write out of concern for the future of medical practice, and how changing medical practices can affect our National Health Programmes and the management of infectious diseases in future.

I do not perform aesthetic procedures, I only practise medicine.

Aesthetics is a lifestyle industry, it is not medical practice. It does not heal but only enhances appearances. The practitioner of aesthetics is not treating sick patients but healthy individuals who want to change and improve their looks. Hence, we have procedures, for example, to remove fat and pimples and whiten the skin.

An aesthetics practitioner need not be a doctor or go through medical school. He relies on machines and creams to do the job.

However, there is a big demand for aesthetics because of the growing wealth and expectations to look slim and flawless. This big lifestyle industry, which has developed and spread rapidly in the region, is worth about $200 million.

Aesthetic practitioners used to be beauticians who conducted minor procedures. But with newer and more advanced equipment, the more complicated and difficult procedures were beyond them. Doctors were then roped in to assist in the complications.

However, doctors — both general practitioners (GPs) and specialists — were soon caught up in this wave and started providing such services to meet the demands. In doing so, they shifted their emphasis from healing the sick to undertaking this more lucrative practice where returns were very good.

GPs face hard times with their high rentals and overheads and so some opt for aesthetics practice to supplement their medical practice.

This is a worrying trend. If six out of 10 doctors, according to a Straits Times report, choose aesthetics rather than their usual medical practice, it begs the question: Why train such doctors who end up doing so little medical practice?

This will have an impact on the national healthcare programmes, such as the current chronic disease management of diabetes and high blood pressure.

Which doctor would want to be involved in such healthcare programmes which give him $300 per Medisave account per year, compared to an aesthetics procedure that pays between $150 and $500 per visit?

Moreover, since the Chronic Disease Management Programme requires doctors to follow a strict protocol of management before payment, my concern is that, in time, many GPs will opt out of the programme. The polyclinics will then be even more overloaded if GPs' participation rate is low.

Of greater concern is in the event of an acute infectious disease — such as bird flu or Sars — how are we going to get support from GPs involved in aesthetics care? They are likely to close their clinics to avoid the risks as they are not prepared to manage such a situation.

GPs giving up their medical practice is another likely scenario if the Government comes down too hard on these doctors, especially if they find that offering aesthetics procedures provides them with more than enough income to maintain their lifestyle without struggling with the daily medical practice which pays relatively very little.

I can see why some GPs give up their medical practice. But a doctor is trained to treat patients. What happened to the Hippocratic Oath they took?

All students enter medical school with a noble calling to serve their patients. But as the realities of life hit home when they start practising and have to cope with financial needs to meet the rising cost of living, many doctors will find their calling slowly eroded.

Life was much simpler for my generation of doctors who practise medicine. People were content to lead a lifestyle without a need to change the shape of their nose, have double eyelids or an implant to augment their physical assets.

But with affluence, patients no longer see doctors just as healers but also as practitioners who can improve their physical assets.

Doctors' attitudes also start to change; they now advertise their services, which was not allowed when I became a doctor. Worse, the Government started calling medicine an industry.

I remember protesting against this term "medical industry" because if medicine is an industry, then like any industry, a doctor is just a worker and has to conform to industry norm, working the stipulated hours.

That impinges on the Hippocratic Oath doctors take. The Oath becomes less binding because the "medical industry" shifts the emphasis from practising medicine to being just a worker in an industry. Moreover, the bottom line in an industry is making money while medicine's bottom line is caring for patients.

The Government calls medicine an industry because it wants to promote Singapore as a medical hub. But this drive is so over-emphasised that the cost of medical care has increased as every medical institution, private and public, has to meet the bottom line — an industrial norm especially for those listed on the Singapore Stock Exchange.

How do we manage the situation? We have two pressing issues to be on the lookout for.

One is the management of chronic diseases such as diabetes and hypertension. It is very important to involve the medical community, both private and public, because the debilitating end stage side-effects like stroke, blindness, kidney failure and amputations will deplete the patients' savings as institutional care in hospitals will be very expensive.

Two, if we are not sufficiently prepared, epidemics such as Sars will have serious consequences for the country.

In managing the current trend of aesthetics care, we need to consider:

1) The role of doctors in the aesthetics industry. Identify the procedures that GPs and specialists can or cannot do. Under the Medical Clinics & Hospital Act, which regulates what constitutes a medical clinic, can doctors conduct aesthetics in their clinics? Are doctors who do so complying with the regulations?

2) The role of operators of beauty spas and salons. What are the limits to their work procedures?

3) The role of doctors in our National Health Programmes as the emphasis of medical practice shifts. How can the Ministry of Health encourage GPs to stay on these programmes in the light of the aesthetics factor? One possible consideration is to let the patient carry his subsidy from the public to the private sector for the chronic disease programme.

The writer is a GP and former Member of Parliament.


Dr Tan's letter reminds angry doc of another letter by another 'old-timer' published in the ST Forum a week ago:


(emphasis mine)

Over-medicalised, under-analysed industry

THE public is being bombarded daily with so-called health news and tips which have no scientific basis. This includes the use of pseudo-scientific terms which cannot be found in medical dictionaries, promotion of numerous products which have never been subjected to any laboratory toxic tests, or products whereby test results have not been published in any peer-reviewed journal. And yet, we are told these products are completely safe.

Many human conditions are being 'medicalised' so that companies can sell their products or make customers part with their money. These include everyday conditions like ageing, baldness, small breasts, small penis, shyness and acne.

Celebrity endorsements and participants who are paid various sums of money or given free products are commonplace. One example is the issue of weight. Obesity is a serious medical problem and studies in the United States show that obesity will be the No. 1 public health problem and cause of death in five years' time. It is not a cosmetic problem and weight management should be for life and not just for two to four weeks or just to fit into a Versace dress.

Whether someone will take the right actions to stay healthy depends on his health literacy and whether he listens to the right advice and not by reading fancy advertisements. As a prominent health correspondent in a British newspaper, The Independent, said: 'Advice from untrained people is the most dangerous drug on offer today. My advice for you is to take less advice.'

Prof Feng Pao Hsii
Emeritus Consultant
Department of Rheumatology
Tan Tock Seng Hospital Singapore

Adjunct Professor of Medicine
Yong Loo Lin School of Medicine
National University of Singapore


What strikes angry doc is the fact that both writers do not consider acne a real disease nor treatment for acne real medicine.

Acne is so common in adolescents that some people considered it a normal physiological state rather than a pathological one, and aside from the unsightly appearance it doesn't really do those who are afflicted by it any physical harm. In other words, it is an 'aesthetic' condition.

So should we treat acne?

It seems that question was one that the medical profession had to ask itself at one point in time.

angry doc was brought up thinking that acne is a disease - one that we have effective, evidence-based treatment for - and one which he treats because of all the psychological sequelae (as described in the editorial linked to above) that may result from acne and its resultant scarring.

(So does angry doc practise "aesthetic medicine"?)

Admittedly the psychological trauma result not from the acne itself, but the social difficulties faced by the sufferers; yet as society's expectations change, will not those who have "baldness, small breasts, small penis" and other socially-embarrassing conditions encounter the same kind of distress, and suffer from the same psychological trauma? Will these conditions not become diseases, and accordingly require treatment?

angry doc is not sure, but he that believes as long as people suffer, or perceive themselves to be suffering, they will turn to doctors for relief.

Perhaps whether a particular condition should be considered a disease or not should be judged depending on its own set of circumstances, but angry doc feels our guiding principle for whatever treatment we offer to those who come to us, be it "aesthetic procedures" or for silent diseases which patients do not complain of, should be based on good evidence.

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9 Comments:

  • Good article by Dr. Tan Cheng Bock. It accurately reflects the situation on the ground for most GPs.

    GDoc thinks that there will always be some doctors who want to enter the Aesthetics market for reasons of their own.

    However, if GPs were compensated in a fair manner for their work, perhaps less would be tempted to leave medicine for aesthetics. That said, GPs should also give their patients "value for money" by keeping abreast of new modalities of treatment, medications, and guidelines.

    Given the current GP compensation, it would not surprise GDoc that we would be seeing an increasing number of doctors (GPs or Specialists) working as over-qualified beauticians in the field of Aesthetics.

    The trend of doctors migrating to Aesthetics is not unique to Singapore. This situation is also being repeated in America, where they are losing GPs and Specialists to Aesthetics.

    By Blogger GuinnessDoc, At April 06, 2008 11:54 am  

  • agree with you, angrydoc.

    Dr Tan's view, with all due respect, is not realistic in today's context, noble it may be.

    As for Prof Feng's letter, perhaps the term "medicalised" may not have been the best word to use. The more appropriate word may be "commercialised". What he said in his letter makes a lot of sense though, don't you think? I dodn't think he meant to say that acne is NOT a medical condition...just that treatment of many such conditions have been commercialised to the point where non-medical products are being promoted to "treat" these conditions.

    By Blogger aliendoc, At April 06, 2008 8:20 pm  

  • Qn: General Medicine by right should be a "specialization" in its own right, as the dr needs to know the entire spectrum in order to accurately/adequately decide if the patient needs further investigation/treatment by the relevant specialist, ya? And they are the ones who specialize in education & management of chronic cases... So, why the drastic difference in attitude towards this group by the medical fraternity?

    By Blogger pretzel, At April 06, 2008 8:55 pm  

  • Well, Prof Feng wrote that he considers "ageing, baldness, small breasts, small penis, shyness and acne" to be "everyday conditions", by which I interprete he considers them non-pathological conditions and therefore not diseases or 'medical conditions'.

    I agree that much of what he wrote is true, even if they are not very "sensitive" things to say in the modern doctor-patient-relationship climate.

    I think what both writers do need to consider though is that our definitions for diseases are not always static, and they will change both with what medical professionals learn about the human body, as well as what changing expectations amongst patients. One problem we are facing now is a mismatch in this perception, so that you have doctors trying to persuade patients to have treatment for asymptomatic silent diseases which patients cannot see the point of, and patients wanting doctors to provide treatment for conditions which we may think nothing of. Nevertheless, as long as patients are willing to pay for treatment for these conditions, we can expect that people will research and provide them.

    Right now you and I probably agree that acne is worth treating. Baldness is stretching it a little for both of us, and small penises probably way out there. But what if changing social norms mean that those who are bald or have small penises face so much social embarrassment that it impacts their daily functions significantly? And what if we have efficacious and relatively safe treatment for those conditions that nonetheless need to be administered by trained professionals who can monitor and manage any adverse reactions?

    I guess my point is whether or not we should treat something can at times be a value-judgement, and our profession may need to adapt to changing norms. However, whether a form of treatment is truly effective is an objective judgement, and here our profession should not compromise on.

    (Incidentally, I just realised that Prof Feng managed to have the word 'penis' published on the ST Forum.)

    By Blogger angry doc, At April 06, 2008 9:27 pm  

  • "So, why the drastic difference in attitude towards this group by the medical fraternity?"

    I think the reasons are largely historical.

    "General practice" (not "general medicine") started out as what everyone who graduated from medical school is qualified to do, so you didn't need further specialisation to be a GP. Things have changed with recognition that general practice requires more knowledge than what medical school equips you with, and locally we are beginning to implement further training for GPs as a requisite.

    Nevertheless I don't think that perception will change for a long time to come. For one thing, fees for general practice must remain affordable, and what people pay little for they value little too.

    Also, if you were a surgeon or cardiologist, why wouldn't you want to think that your specialty is more prestigous than and superior to general practice?

    By Blogger angry doc, At April 06, 2008 9:36 pm  

  • Dr Tan Cheng Bock wrote :

    "One is the management of chronic diseases such as diabetes and hypertension. It is very important to involve the medical community, both private and public, because the debilitating end stage side-effects like stroke, blindness, kidney failure and amputations will deplete the patients' savings as institutional care in hospitals will be very expensive."

    I thought this paragraph was inconsistent and even contradictory to the tone of his letter which was talking about how "medicine is not about MONEY".

    Why did Dr Tan choose to describe the plight of patients with poorly managed diseases as a monetary drain rather than to their suffering as human beings in pain?

    It's almost as if we should only bother about these patients who have such chronic ailments because it will drain their bank accounts and/or cost the government money.

    Well then maybe that is a subconscious slip and indeed medicine IS ABOUT MONEY.

    Personally I think this is something we cannot run away from. The reason why the government watches and manages health care is because of the potential dangers of draining resources, and hurting the economy. So it's about NOT losing $$$.

    For the doctors we live in a world where success is measured according to how much you are remunerated. So the $$$ is a form of reward and acknowledgment of your efforts and achievements.

    Unfortunately for doctors and the government their two objectives are counter to one another. Govt would rather doctors be paid as little as possible (less drain of $$$). The doctors want to be recognized fairly and appropriately for their good work (as compared to say other fields like finance) and ask for top dollar.

    The reality is that the majority of patients are not rich and the govt will have to pay part of the bill. Payment of costs also goes in the form of a hierachy. Pharmaceuticals and listed companies will be paid according to inflationary determined market rates (raise prices) while doctors and health care professionals will be left last or never in the considerations to pay them more.

    Hence overall the medical profession will have to accept that in the coming years ahead their earnings will be stagnant or simply will not keep up with the inflation we have seen in the past 2 years.

    For all young students aspiring to be doctors, at no other point in history except today does the phrase "if you want to do medicine, don't think about the money" hold so much truth.

    Think carefully.

    Meanwhile I'm getting ready to change professions. My objective is to leave medicine and go into finance.

    Cheers
    ex-doctor blogger

    By Anonymous Anonymous, At April 08, 2008 1:24 pm  

  • "Hence overall the medical profession will have to accept that in the coming years ahead their earnings will be stagnant or simply will not keep up with the inflation we have seen in the past 2 years.

    For all young students aspiring to be doctors, at no other point in history except today does the phrase "if you want to do medicine, don't think about the money" hold so much truth.

    Think carefully."


    Sad, but so true.......


    "Meanwhile I'm getting ready to change professions. My objective is to leave medicine and go into finance."


    Sounds like a plan. GDoc supports your new endevour. It's always worth exploring new avenues if one's position is no longer tenable.

    Dunno about the timing though. Finance industry isn't looking all too healthy with the credit crunch and all.

    GDoc knows of a few doctors who have crossed into different sectors of the financial industry with varying degrees of success. To cut a long story short: The grass may look greener on the other side, but more often than not, it's really brown almost everywhere you look.

    It may be prudent to remain registered with the Medical Council. Medicine could always serve as a fall back option.

    All the best for the new career. Do keep us posted on how things work out. Who knows, GDoc may be inspired to join you too!

    By Blogger GuinnessDoc, At April 08, 2008 10:07 pm  

  • "Also, if you were a surgeon or cardiologist, why wouldn't you want to think that your specialty is more prestigous than and superior to general practice?"
    GOOD Question! Anybody dares to answer?

    By Anonymous Fairfax Doctor, At April 14, 2008 7:51 am  

  • "for reasons of their own." or more exact money. But in America, especial in rich areas the market is hard to penetrate.

    By Anonymous Physician, At December 09, 2009 9:53 am  

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