Apr 1, 2008

The Elusive Nature of Medical & Other Truths - Part 1

Recently, the practice of "aesthetic medicine" in Singapore received a lot of media attention. Since I like my own face as it is, I did not really pay much attention to the specifics of the debate.

However, I did gather that some doctors in Singapore have been offering beauty treatments which are "scientifically unsubstantiated". The issue is whether these doctors should be stopped, and if so, how.

For more background, refer to these doctors' blogs - Angry Doctor; Alien Doc; and No Fear Singapore. (Notice how doctors tend to choose such unusual blogging names for themselves).

Health Minister Khaw Boon Wan has taken the position that the Ministry will step in only as far as invasive, high-risk procedures are concerned.

Thus the Ministry will not bother to intervene with non-risky beauty treatments, even if their benefits are not scientifically proven. Instead the Ministry will leave it to the medical profession to regulate itself on such matters, through organisations such as the Academy of Medicine.

In my opinion (although Angry Doctor would furiously disagree), Khaw's approach is very sensible.

I am quite confident that most, if not all, the aesthetic treatments offered by your neighbourhood HDB beautician are also "scientifically unsubstantiated". This does not mean that all these aesthetic treatments do not work.

It merely means that the treatment either does not work, or the treatment works, but has not been "scientifically" proven to work. And most of the time, the latter simply means that scientists have not bothered to do research on that particular treatment.

Which is quite alright, if the treatment does not harm or hurt you. It just means that you may have wasted some of your money on your neighbourhood HDB beautician. Your loss. Next time, try some other fruit or vegetable.

"Mr Wang is wrong. Chillis would hurt.
And durians could be downright dangerous."

Now the question then is whether we should regard doctors who provide aesthetic treatments in the same light as neighbourhood HDB beauticians.

Obviously there is some risk to the reputation of the medical profession, if many doctors go around offering beauty treatments which are non-risky but scientifically unsubstantiated to be beneficial.

The reputational risk to the medical profession would decrease, if these doctors offer beauty treatments which are non-risky and scientifically unsubstantiated, and actually work. (Happy patients don't file complaints).

But either way, the potential damage is only to (1) the medical profession's reputation, and (2) the patient's purse.

If you're not a doctor, well, frankly, who cares about Risk (1). And if you're the patient, well, Risk (2) is no different from the kind of risk you face, going to any beauty salon or parlour.

So I think Khaw is quite wise to leave it to the medical profession to regulate itself.


Anonymous said...

Bravo, Mr Wang!
As you should have read by now, Mr Khaw has been described as the "best health minister Singapore ever had" by none less than our Esteemed SM Goh.
This is yet another reason why Mr Khaw deserves all his accolades... he's right yet again!

Anonymous said...

This area of asthetic medicine is called "nice to have" things.
So it should not be an area gahmen should care too much and should be lowest priority. There are already too many areas of "should have" things which they didn't care enough.

geriatric_eunuch said...

A BAD move by Khaw, a-bloody-gain. 'Aesthetic medicine' is a particularly clever and insidious euphemism for 'Quack nostrum' which blurs the distinction between evidence-based procedure and voodoo-magic panacea. The claims of the former can always be investigated, ripped to shreds if needed, and discarded because data to agreed standards is available. You take the latter on blind faith.

Khaw is washing his hands of responsibility to regulate solely to allow the less scrupulous denizens of the medical profession to share in a $200 million bonanza. What's the harm if it's not high-risk and is non-invasive, he says, even if its efficacy is questionable. Well, by coincidence the BBC has just run an investigation on THE RISE OF THE LIFESTYLE NUTRITIONISTS by Dr Ben Goldacre which looks at just ONE aspect of these endless miraculous claims. Listen for yourself and reflect on whether S'pore's trained doctors really ought to be peddling these therapeutic treatments to the gullible.

No harm? A quote from the program about the Hadacol craze:

Promoted as “good for whatever ails you” Hadacol contained 12 percent alcohol and was so popular that poor families in the southern United States would buy a bottle when they didn’t have money to buy food.

The inventor, when asked why he named it 'Hadacol' replied, "Well, I hadda call it something". LOL. But its unfortunate victims probably didn't get the joke.

I think the damage to a medical practitioner's reputation would be akin to that which would be suffered by Mr. Wang if he, being in banking, were to be now caught running a profitable little sideline punting sub-prime mortgages - by no means illegal but highly risky to one's trustworthiness. It's rather disingenuous to claim that it's merely a case of parting a fool from his money.

Do I want my dentist to offer me MesoTherapy or inject me with a cocktail of unproven worth while she's putting in a filling? Er, thanks, but no thanks - and goodbye. I don't think Khaw is being 'wise' in the slightest, he's being irresponsible.

The first poster said:

Mr Khaw has been described as the "best health minister Singapore ever had" by none less than our Esteemed SM Goh.

Would this be the same ignorant Mr Khaw of National Kidney Foundation scandal notoriety? And would that be the same esteemed SM Goh of 'tacit OB-markers but kinder, gentler Singapore' ill-repute? Isn't that rather like Count Dracula congratulating Jack The Ripper on the excellence of his blood-letting service?

You'll want to nominate Wong Kan Seng for the Nobel Peace Prize for letting Mas Selamat Kastari 'escape' next, I suppose.

Anonymous said...

We need a fool-proof regulation of fools from being fools.

Gilbert Koh aka Mr Wang said...

Well, then, say "No" to your dentist.

Simple as that.

It is always up to you to accept or decline whatever beauty products or treatment you wish. This applies whether you're talking to a doctor; or a salesgirl at The Body
Shop; or the spa therapist recommending a particular body scrub.

No, I do not think that the Health Ministry should regulate
Body Shop salesgirls or spa therapists.

Xtrocious said...

I think I may be generalising here but a lot of Singaporeans like to be treated like sheep...

Everything has to be regulated by the government - if there is no law for something, they don't feel right...

What Mr Wang said is correct - the choice lies with us (the consumers) and it also better for the profession to self regulate because they know best (assuming they can separate the conflict of interest issues)...

Gilbert Koh aka Mr Wang said...

But how do you regulate the HDB aunties away from the stock market? Or the HDB uncles away from the oily char kway teow?

angry doc said...

I do disagree with you, Mr Wang, although not so much on Mr Khaw's wisdom as your take on "scientifically unsubstantiated" treatment, whcih I will elaborate on my blog.

As for regulation, I agree that the medical profession should regulate itself. However, I expect the ministry to set a higher standard than basically 'anything goes as long as no harm done'. I certainly expect the medical profession to have higher standards than that.

geriatric_eunuch said...

Well, then, say "No" to your dentist.

Simple as that.

Sure thing Mr Wang, for you and me - a no-brainer. But I can think of several acquaintances, some of my relations included, for whom it isn't as simple as that. Perhaps you can too.

The medical profession occupies a peculiar position of respect and trust by and large because of its association with caring and healing. For many (especially of my mother's generation) their advice is practically gospel. If recommended by a doctor, they would gladly buy into a procedure, or elixir, or device from which the more savvy of us would walk away.

In fact, trying to dissuade them from proceeding does invariably invite the retort, "How would you know, you're not a doctor"! Already, untrained use of Botox for cosmetic treatments is causing some concern.

Therein lies the problem and the need for close regulation to exclude the cowboys and their hypothetical remedies as far as feasible.

Body scrubs? Not a problem. A tattoo or two afterwards? Ah, then I would very much like to see compliance with hygiene regulations and some understanding of the dangers of disease transmission, wouldn't you?

Gilbert Koh aka Mr Wang said...

Firstly, we are discussing treatments which may or may not be effective; but are harmless. Therefore examples of "Botox gone wrong" or "disease-spreading tattooing" are irrelevant.

Secondly, G.E has made the point that doctors occupy a position of respect and trust in society, and therefore more-naive or less-educated members of the public may be apt to believe them and accept their recommendations.

The simple way to address this is that the doctor should brief the patient properly on the recommended procedure, so that the patient can make an informed decision as to whether she wants to undergo the recommended procedure or not.

As a matter of fact, this is routine for any procedure done by doctors, whether standard or not.

On scientifically unsubstantiated aesthetic treatments, the doctor may explain, for example, that a particular procedure is supposed to bring XYZ benefits by ABC methods, but that there are few, or no, or inconclusive published studies on the efficacy of this procedure. The doctor may go on to explain (if this is so) that even if the procedure does not work, it is harmless. The doctor may also discuss his success/failure rate with his previous patients etc.

It is then up to the patient to decide whether she wants to undergo the procedure or not.

A rich tai tai may well think, "Oh well, it only costs $500, if it works, that it would be great, if it doesn't, the $500 is no big deal to me. Anyway, the procedure is harmless, so why not give it a try".

And in fact, the tai tai's thinking would be quite logical.

As a matter of fact, doctors would be briefing their patients on the recommended procedures, whether these procedures are standard or non-standard.

geriatric_eunuch said...

Mr. Wang,

Given an ideal world I would be first to agree with your position on the obligation of medical professionals to volunteer, in a cool unbiased manner, the pros and cons of their advice to their clueless customers. Standard operating procedure, as you correctly point out. No regulation ought really to be necessary.

However, recent history shows all too clearly that the once-esteemed professions of law, accountancy, and medicine, have been tried, tested, and been found sorely wanting due to the rogues within their midst. Today, the priesthood stands accused for similar irregularities.

Self-regulation relies upon the willingness of members of the order to blow the whistle when they spot unethical or suspicious behavior in one of their own. Seriously, is this likely to happen in our cosy medical establishment, in our face-saving society?

Notice that in the recent first run on a UK bank in more than a century, no member of that business ratted on Northern Rock despite private misgivings about the wisdom of its business plan. Until the brown fecal matter hit the fan and news headlines, there was instead a shuffling of feet, a closing of ranks, and a denial of the facts.

Realistically, this is as likely as not to be the preferred scenario in the unscrupulous world of 'aesthetic medicine'. In other words, so long as the cup runneth over, you'd have to be as mad as a sackful of frogs to want to rock the boat and attract the attention of authority. The saying that When Profit walks in the door, Principle hurriedly leaves by the window springs to mind.

I think we must agree to disagree on the venality of parts of the medical industry, and the need for a firm regulatory hand.

This is why I feel no S'pore medical professional who values his reputation and integrity ought to drink from the poisoned chalice that is dodgy aesthetic medicine, ostensibly harmless or not, regulated or otherwise. Prevention is indeed highly preferable to a painful future judicial cure a la the infamous 'safe' slimming pills.

BTW Mr. Wang, rich tai-tais and tattooed eyebrows are as inseparable as Siamese twins so tattooing is not irrelevant to this discussion! * wink *

Anonymous said...

Well I think the government should actually focus its attention on more pressing matters than these nitty gritty stuff. If the government has actually voiced its concern over this issue, I think they have properly wasted their time. So for this rare occasion, I think that the government is actually right. But I still expect them to do a better job in other areas.

Anonymous said...

Khaw is in charge of MOH, not CASE. He wouldn't care if ignorant consumers are ripped off, because it's not his KPI.

Peddling unproven services is not medically harmful, but it sure causes financial damage.

This is about consumer protection, not an health issue.

How is this different from selling snake oil or magic stones? Hey the customer believed it and willingly paid up.

I think it's disingenuous of Wang to suggest that this is OK.

Anders Brink said...

Firstly, we are discussing treatments which may or may not be effective; but are harmless. Therefore examples of "Botox gone wrong" or "disease-spreading tattooing" are irrelevant.

But how would you know until after the fact? After the fact of harmless medicine, we can all say and do anything. The important thing is, before the fact of harmful medicine, what you do.

Anonymous said...

Turf wars!!!

The easiest way to make sense of things in Singapore is to look at the cents.

Anonymous said...

To be fair, it is not possible to research all beauty/alternative treatments. The cost is too high.

An example is, there are few "scientifically proven" or "researched" for traditional medication, alternative medication, bomohs, mediums, monks, priests, pastors, etc

But everyone has a choice to seek out the form of medication (physical or spiritual) they want. I stand with Mr Wang on this issue, but I want more information and education be made available for better consumer decisions.

Anonymous said...

i, for one, have serious reservations about whether such treatments are "harmless". until there is conclusive evidence to prove a particular treament is harmless, why would anyone risk their health with any of such treamtments? it's not unlike digging into a bag of snacks when you have absolutely no idea what the ingredients are, or mean. but what the hell, as long as that picture on the bag looks yummy, right?

Anonymous said...

Government Regulations? Are Medical Doctors not sworn to Hippocratic Oath?

After swearing to the Oath and if any becomes Hypocrite, then regulations may not stop their craze and crave for money.

And if Doctors become unscrupulous, there are likely to be complaints. When complaints are made with Authority, can the Authority answer 'You asked for it', therefore it is 'none of my business'?


Gilbert Koh aka Mr Wang said...

If protection of the public from the possible harm of aesthetic treatments not known to be harmful and not scientifically substantiated for efficacy is the main concern, then I think doctors; beauticians etc should be govt- regulated or unregulated to the same extent.

If the reputation of the medical profession is the main issue, then I think this should be a matter for self-regulation by the profession itself.

Anonymous said...

Look at how many doc own condos in Orchard rd?

geriatric_eunuch said...

Feh! Why the turgid intellectual excavating for the hidden interstices of meaning in Harry's perfectly unremarkable verbiage as if it were the ambiguous predictions of a Nostradamus or the deliberately equivocal mutterings of a Paul Volker?

His invisible offspring cannot be trusted to string two sentences together in public without committing a rib-tickling gaffe. His blundering Minister For Home Affairs has demonstrated an unenviable aptitude for fumbling the ball. That leaves just Mr. World Statesman to pronounce gravely from on high that, yes, it was actually your fault all the time, complacent Singaporeans. Got that? Good.

Harry's doing what all worried politicians do when they sense a major PR disaster in the making --- passing the buck. He has unsurprisingly forgotten the sign "The Buck Stops HERE" that was on President Truman's desk in his White House office.

Mr. Wang is right to call it for what it is - a painfully transparent attempt to muddy up the waters and distract focus from the people truly responsible for this fiasco.

A botched effort if my wet-market ter bak ah chek's scornful take is anything to go by:

"Wha, now Mas run road our fault ah? What for we give them 3 pau chiak Big Sweep 1st Prize tickets every year then? Plus performance bonus some more. Like that I oso can do man"!

geriatric_eunuch said...

Whoops, sorry Mr. W! I just posted into the wrong thread. Could you either delete my last post or move it to its intended place in your "Very Poor Service By The Straits Times" thread, please?