A more serious issue is practitioners with inadequate training but who call themselves dermatologists. "Because you can go to Bangkok and have a one-month training and then come back here and say you're a dermatologist," Castillo says.

    He grants that hospitals may have stricter licensing criteria than mall-based clinics. For a mall clinic, a permit from the Department of Health is also needed but it is the owner who decides if he wants to admit only those practitioners who have fully complied with all their residency requirements.

    "But definitely you cannot practice in a mall if you are not a diplomate. Some clinic owners would give leeway to those with training certificates already but hasn't taken the diplomate exams yet. Personally, I only accept those practitioners who are full diplomates," Castillo says.

Similar issues

    The scenario is similar in aesthetic surgery, now offered in many skin-care clinics alongside the derma services. Veteran plastic and reconstructive surgeon Archie La Madrid notes it only takes a basic degree in medicine to get a license to operate an aesthetic-surgery clinic in the country.

    "Most doctors doing surgery in these mall-based clinics are not adequately trained. You can go and observe in Japan for one week to two months, put up a shingle and call yourself an aesthetic surgeon. PRC (Professional Regulation Commission) cannot stop you from doing it, but if you get sued, then you're liable," he notes.

    There is only one professional association in the country, the Philippine Association of Plastic, Reconstructive, and Aesthetic Surgeons (PAPRAS), which has a residency requirement for incoming fellows. It counts a very select number-probably less than 10 percent of plastic and reconstructive surgeons in the country-as its members. On top of a three-year training as a general surgeon, a PAPRAS applicant must have two years of plastic-surgery residency and then pass a qualifying exam.

    With the boom in aesthetic surgery practice, many local professional associations with less stringent requirements have cropped up. "It doesn't mean that those in the other associations are not good. It's just that they are not selective. They believe there's security in numbers so the more members they have, the better they think it is for them," La Madrid says.

    On the other hand, there are practitioners who did not go through the rigors of a PPRS residency but have built a good reputation based on talent alone, their past work speaking for them. La Madrid himself is not a PPRS fellow but has managed to build his practice on word of mouth alone. But all things considered, he says, the attending surgeon's PPRS credential would still be the better safeguard for a patient.

    Castillo warns that there are some procedures, like the highly popular liposuction, that counts as a subspecialty, so learning by doing without expert guidance may not be enough. "A doctor should have another one to three years in perceptorial training with a well-known cosmetic surgeon who does a lot of this procedure," he says.

    But the best guarantee of all, says La Madrid, is if a doctor plans to do the surgery in a hospital, especially the bigger ones. "The big hospitals will not allow surgeons to operate unless they show proper credentials. And since these hospitals have highly specialized practices, they are very, very strict. You are subject to peer review by the other medical staff. This can form a basis for extending or cutting off your privilege to practice there."

    On this note, hospital-based doctors drawn to the malls are a welcome development. Pineda observes that many dermatologists now divide their time between their hospital- and mall-based clinics.

    But he scores the practice of hiring part-time dermatologists for the full-time requirement of many skin-care clinics in commercial and other nonhospital settings. "All true skin clinics are defined as ethical clinics manned full time by qualified dermatologists, although you may have nurses and other nondoctor medical personnel assisting with other functions."

Bigger peril

    For Pineda, the bigger peril of charlatanism in the multi-billion-peso aesthetic-clinic industry lies among nondoctors who handle procedures properly undertaken only by a qualified dermatologist.

    "Some mall-based clinics are manned by aestheticians and cosmetologists who finish one or two-year courses and then pose as beauty skin-care consultants. And the public put themselves under the care of these glorified beauticians under the perception that they are being treated by dermatologists," Pineda says.

    These lay personnel, Pineda adds, handle not only purely aesthetic treatments but also pathological cases such as acne and warts. He believes that among the wide and growing range of services in a typical skin-care clinic, only facials and other services not reaching the cellular level (i.e. hair treatment, make-up, massage) can be safely entrusted to nondoctors.

    As it is, even trained dermatologists are not infallible in diagnosing skin diseases. "Skin diseases tend to look alike, especially when the patient comes to you partially treated through self-medication. You really have to make sure by doing laboratory tests," says Castillo.

    With so many subspecialties, properly trained dermatologists also refer patients among themselves. "A PDS member will refer you to his or her colleagues 100-percent of the time if a patient's case is not within his specialty," he adds.

    Whether pathological or cosmetic, it always pays to ask the advice of two or three doctors if a patient is planning to undergo some procedures. "If you need to be operated on, syempre kailangang magtanong ka na kung ano ba ang training of the one doing the operation. The problem with some patients is they go for the lowest bidder," Castillo observes.

    La Madrid notes that most Filipino patients who plan to undergo procedures hardly bother to ask about the qualifications of the surgeon.

Technology misconceptions

    Technological advances also have a hand in the entry of nondoctors into the turf of duly qualified practitioners.

    Castillo, who specializes in laser-assisted procedures, said equipment used for this purpose could be deceptively easy to use, so that some clinics allow lay technicians to operate them, regardless of their knowledge about skin-interaction issues. "That's why we have been bombarded by news about people getting burned by laser treatments, even the nonablative kind like IPL (intense pulse light) for hair removal," he laments.

    Fanned by aggressive marketing of skin-care clinics that aim for a big client base, many patients also have the impression that newfangled technologies like laser is a one-size-fits-all treatment for all skin concerns, says Pineda.

    Castillo stresses the importance of getting as extensive a training as possible when dealing with new technology. "There are machines, like those for botox, where you can attend half-day or one-day seminars. Those who attend these seminars are better off than those who didn't train at all. At least you'd have an idea of what to do and what not to do."

    But compared with someone who underwent a one-month training with an expert doctor and saw difficult scenarios, Castillo says those with more superficial training will still be at a disadvantage.

    As a quality assurance, equipment manufacturers also provide certification. Castillo cites thermage, one of the newest technologies on the dermatology block. "Thermage is very easy to do. You can teach it in one hour. But you must be certified to do it, which means you know the ins and outs of the machine. Patients should seek doctors who are certified to do it and there are only very few of them as of now."

Hospital v. mall facilities

    As more machines find their way into aesthetic clinics, the flexibility of space allotment in a mall is viewed as a tremendous advantage over the limited space available in most hospitals. "Makati Med, for example, only has 20 to 30 square meters for a clinic. In the mall, you can have 100 to 300 square meters to build your clinic so long as you can afford it," says Pineda.

    For pathologic cases, Castillo says that the provision of laboratory services in a mall clinic or the lack of them is key to whether a patient in need of lab exams is better off going to a hospital or to a nearby mall clinic. "Like if a mall-based doctor needs to do a biopsy, does the clinic have the capability of doing it outpatient? Even if yes, the doctor still has to bring the biopsy specimen to the hospital."

    In aesthetic surgery, asepsis is a basic concern. La Madrid gets a lot of referrals to do corrective work on aesthetic procedures gone wrong, usually of patients who had work done in mall-based and other nonhospital-based clinics. From his experience, he maintains that for any kind of surgery, asepsis is better guaranteed in a hospital operating room than in a mall-based operation.

    "Although a nonhospital clinic might have a good setup and is clean, it's still more sterile in a hospital. For one thing, hospitals are very strict with infection control. In the corrective cases I've handled from nonhospital clinics, the common denominator is always infection," he says.

    He notes that the professional fees of attending surgeons in hospitals and mall clinics don't really vary greatly, unless you're comparing the highly established practitioners with relative novices. "Nagkakatalo mainly sa operating room and related fees which you usually don't have in nonhospital clinics. For a nose job, the main difference between the PhP40,000 you'll spend in the hospital and PhP25,000 in a mall-based clinic is the guarantee of sterility in the hospital," he explains.

    Pineda contends that almost 90 percent of aesthetic-surgery procedures are now possible outside the hospital and that more and more of these operations are being done in the malls. "But if there would be a need to hospitalize, upon the discretion of the doctor, as a result of morbid requirement, then you go to the hospitals," he adds.

    He observes that some procedures are also being done nowadays in even more nontraditional settings like offices, although the proximity to a hospital should always be a factor in considering these locations.

Regulation, education, attention

    There is, however, no hidden population out there of disgruntled patients with potential malpractice suits. According to La Madrid and Pineda, the news media have most of the adverse cases covered and the issues are the same whether you go to US and Europe or other developing countries.

    Pineda bats for institutional intervention to address the prevailing practice of nondoctors taking on the job of duly qualified professionals. He also hints at a need to control the marketing practices of skin-care clinics, especially the bigger ones, through stronger laws.

    "DOH, PMA (Philippine Medical Association) and the societies should do something to regulate. Sadly, we're not seeing any such initiative. At least, there should be some form of information dissemination to educate the public who do not know if they're dealing with a qualified dermatology clinic," he suggests.

    For Castillo, mall-based practitioners should always remember their basic commitment to each individual patient despite the pressures of a very busy practice. "Mall-based dermatologists should spend more time with their patients. If you're in a hurry, kung minsan nalilimutan mo na rin ang dapat gawin. Just like in any other services, there are always cases when you have to give more of your time." M

 

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