Introduction
The question of whose domain facial aesthetics falls under
is both a million-dollar question and a matter of professional identity. As an
Oral and Maxillofacial Surgeon (OMFS) with a legal background, I bring a unique
perspective to this debate.
Background in Oral and Maxillofacial Surgery
My training path has been through dentistry. To clarify,
maxillofacial surgery is a specialty within dentistry, with varying
international mandates regarding its scope and privileges. Contrary to popular
belief, only about 10-15% of global OMFS practitioners require dual
qualifications, mainly in Europe and Australia. In many countries, including
India, a single qualification in dentistry is sufficient to practice this
specialty. This is also true for many regions in China, Japan, South Asia,
South America, Africa, and Russia. Any shortfall in the dental curricula is
typically addressed through additional training in maxillofacial surgery.
It’s important to note that I do not perform aesthetic
surgery and have no vested interest in this debate. However, I wish to
emphasize the unique standards and requirements of Oral and Maxillofacial
Surgery and its scope.
Evolution of the Specialty
At the time of my qualification, the core focus of my
specialty included the surgical removal of stubborn teeth, jaw cysts, treatment
of facial bone fractures, and surgery of the temporomandibular joint (TMJ).
Over the decades, the field has evolved into a sophisticated specialty. Many
practitioners, like myself, have exclusively practiced oral and maxillofacial
surgery while remaining rooted in our foundational training in dentistry.
Dentistry itself is a demanding field, with a curriculum
that includes essential medical sciences, enabling practitioners to treat
patients safely and effectively. The culmination of this training results in a
degree called Bachelor of Dental Surgery (BDS).
Interdisciplinary Perspectives
I have many talented physician colleagues, including dermatologists
and plastic surgeons, who have also evolved their skill sets over the years.
For instance, dermatologists have expanded from diagnosing skin conditions to
performing cosmetic procedures. Although dermatology is a medical specialty
that typically follows an MBBS degree, it now includes surgical interventions.
Defining Key Terms
A contentious issue is whether facial aesthetics falls
exclusively under any one specialty. Before sharing my opinion, I would like to
define some commonly used terms in our discourse:
- Aesthetic
Procedures: This term has sparked debate among specialties due to
varying interpretations. Aesthetics, which emerged in English medical
terminology in the 19th century, refers to the appreciation of beauty. In
medical terms, it often relates to cosmetic beauty, including structural
features such as the mouth, nose, eyes, and ears. It is much more than the
just the skin.
- Cosmetic
Procedures: This broader term includes any intervention designed to
alter or enhance appearance. It encompasses a wide range of practices,
from eyebrow threading and makeup to surgical options like facelifts and
orthodontics.
- Plastic:
The term "plastic" means "to mold" and is often
misinterpreted as solely relating to plastic surgery. While plastic
surgery has historical ties to specific specialists, many procedures—such
as cranioplasty and urethroplasty—are performed by various medical
professionals, including neurosurgeons and urologists. Pure dentistry
itself has very challenging plastic procedures like gungivoplasty, mucosal
grafts and use of botox and fillers.
Shared Responsibilities in Aesthetic Procedures
The National Medical Commission (NMC) and the Dental Council
of India (DCI) have not defined exclusivity regarding individual procedures.
Therefore, any assumptions about who performs what procedures are largely
arbitrary and speculative, driven by a narrow view of ownership.
The ongoing "turf war" highlights the complexities
of medical regulation in a country with diverse systems of medicine and multiple
regulatory bodies.
- Understanding
Competence: The distinction in training and statutory competence
between dermatologists and oral and maxillofacial surgeons is crucial.
While both specialties have overlapping areas concerning facial
aesthetics, the differences in their training pathways and regulatory
frameworks must be acknowledged. This brings to light the need for a more
nuanced understanding of the specific competencies each specialty brings
to aesthetic procedures.
- Regulatory
Framework: The fact that the NMC and the DCI (soon to be NDC) operate
under different legislative frameworks presents challenges for
practitioners and patients alike. It raises questions about the clarity
and consistency of regulations across different medical disciplines. There
may be a need for inter-regulatory dialogue to establish clearer
guidelines on who can perform aesthetic procedures, which could help
mitigate conflicts.
- Legal
Interpretations: It is necessary to understand the absence of
specialty registers in India. This is indeed significant. This gap in the
regulatory framework allows for a broader interpretation of who can
perform aesthetic procedures. However, it also raises the issue of patient
safety and the quality of care, as not all practitioners may have the same
level of training or expertise in aesthetic procedures. The deficiencies
are addressed in the curricula whether it be knowledge of surgery or
dentistry. The Role of Circulars and Notifications: The distinction
between regulations and circulars is an important legal point. Circulars,
notifications and guidelines, are often interpretative and do not carry
the same weight as formal regulations. This creates an environment where
practitioners may feel uncertain about their legal standing and scope of
practice, which can lead to professional discord. Some state councils have
placed too much importance to them and have exceeded their mandate in
imposing restrictions without considering the possibility of competence by
training.
- Public
Safety and Standards: The ultimate goal should indeed be the provision
of safe and effective healthcare. Establishing minimum training
requirements and standards for aesthetic procedures could help ensure that
all practitioners, regardless of their specialty, possess the necessary
knowledge and skills to perform these procedures safely. The health
ministry and regulatory bodies should prioritize public safety over
professional rivalry.
- Future
Directions: There is an opportunity for stakeholders from both
dermatology and oral and maxillofacial surgery to collaborate rather than
compete. Developing interdisciplinary training programs or joint
guidelines for aesthetic procedures could promote a healthier environment
for practitioners and enhance patient care.
- Legal Action and
Challenges: It is important
to understand that India does not have specialty registers like in many
other countries. The post graduate courses are ‘add on’ degrees used as
essential qualification for teaching at graduate and post graduate levels
in recognized medical and dental colleges. The essential and sole
registration for practicing medicine or dentistry comes from being in the
books of the MBBS/BDS register in the respective States or with the NMC.
In the absence of a specialty register one cannot technically be
restrained from practicing the full scope of medicine or dentistry. In
other words, any registered graduate can practice the full scope of their basic
qualification. The MCI / DCI has in the past issued notifications and
circulars restricting procedures to specialists. These are arbitrary and
has gone unchallenged. This aspect needs a judicial review.
- Restricting practice privileges: I wish to reiterate that notifications, memos
and guidelines by regulatory bodies are not actionable laws. These are
mere administrative opinions. So the notices issued by state councils
threatening to debar practitioners based on these memos or notifications can
be challenged in a court of law. Qualifications and competence are two
different things and need to be evaluated differently. The regulatory
bodies have no right in law to prohibit teaching or upskilling courses
because it is always in the best interest of the public that medical
professionals, irrespective of their qualification, acquire greater
competence through continuing education.
- Patient-Centric
Approach: Ultimately, the focus should be on patient welfare and
informed choice. Patients should be educated about the qualifications of
practitioners and the procedures they are considering, allowing them to
make informed decisions about their care.
We need a collective effort to enhance healthcare delivery
rather than restrict it. This collaborative approach could lead to improved
outcomes for patients and a more harmonious professional environment for all
practitioners involved in aesthetic medicine.
George Paul MDS DNB LLB Dip. Med. Law
