The War Over Facial Aesthetics: Who Truly Holds Expertise?

 

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:

1. 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.
2. 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.
3. 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.

1. 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.
2. 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.
3. 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.
4. 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.
5. 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.
6. 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.
7. 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.
8. 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