Medical MattersHaving weight problems? Sick of diets? We can now offer you keyhole surgery at our purpose-built clinic in leafy Dublin 2. Fifty per cent weight loss in two years guaranteed or your money back! Houston Cosmetic Surgery Ltd is pleased to announce a minimally invasive weight-loss operation with no overnight stay needed. First consultation free. Phone 9876543.
Okay, so this is a spoof advertisement. But it is sobering to realise that such a notice could appear in tomorrow's newspaper and be perfectly legal. Never mind that I am not a qualified surgeon, cosmetic or otherwise. All I need is an idea, a brass plate, and a determination to make a quick buck.
By framing the business with a certain cachet of respectability, issues such as my (in)competence and the qualifications of the anaesthetist in whose hands unsuspecting members of the public will place their lives, can be glossed over.
The smart new building that will be home to this new business will help mask the fact that it will operate from a cramped basement. Nor do our prospective patients need to know that we have not made any specific arrangements with a major hospital to access intensive care facilities should a patient develop life-threatening complications.
Does it matter that laparoscopic weight-loss surgery is categorised throughout the western world as a sub-specialty of gastric surgery and is not recognised as a procedure that comes within the competence of plastic and reconstructive surgeons? And is there any regulatory authority that can step in and examine our claim that gastric banding can be safely and routinely carried out on a day case basis?
Unfortunately, the answer to these and other patient safety issues is no. Despite setting up a specialist register, the Medical Council still cannot prevent a doctor without specialist qualifications from offering specific treatments to patients. In theory, once a doctor has finished his intern year, he can establish an independent practice in any "ism" he likes.
Although we now have a statutory regulatory authority for healthcare - the Health Information and Quality Authority (HIQA) - it has no jurisdiction over private clinics, cosmetic or otherwise. For some inexplicable reason, Mary Harney, the Minister for Health, set up HIQA without giving it responsibility for private hospitals or private clinics.
This means that the 50 per cent of the Irish population who have private health insurance and others who pay from their own pockets for services such as cosmetic surgery are treated in a regulatory vacuum.
And so it is perfectly legal for a cosmetic surgery company to decide to operate on people with morbid obesity.
To put concerns about recent events in perspective, potentially dangerous surgery such as implanting a gastric band in a patient with morbid obesity requires the following: a full pre-operative assessment including assessment of cardiac and respiratory status; a detailed assessment of anaesthetic risk; transfer to a high dependency unit bed for immediate post- operative care; and the 24-hour back-up of anaesthetists, surgeons and intensivists should the person's condition deteriorate to the point where they require admission to a fully equipped intensive care unit.
This is the standard of care given to the relatively few patients who have obesity surgery in public hospitals in the Republic. It is a recognition that people who need gastric banding and related procedures are, by definition, at risk of major complications.
Responsible doctors here, in Britain and in the US restrict obesity surgery to the morbidly obese - people whose body mass index (BMI) is greater that 40kgs/m2. Patients with a BMI greater than 35 and who have other medical conditions made worse by obesity are also eligible. In addition, candidates for surgery must undergo full psychological assessment.
Research in the current issue of the US medical journal, Archives of Surgery, shows that some 6 per cent of patients who had undergone bariatric (obesity) surgery died within five years of the operation. The authors say the high mortality rate is probably due to the co-morbidities suffered by obese patients. Heart disease was the leading cause of death while death from suicide was also higher in these patients.
Despite the well-established risks and internationally accepted best practice in the area of obesity surgery, the Department of Health and the Minister seem unwilling to intervene. In the absence of a clear-cut role for the HIQA, passing the buck from the Department of Health to the Health Service Executive to the Medical Council is a poor substitute for proper regulation.
Finally, with the parting words of the valiant Susie Long still ringing in our ears, consider this: the brave cancer victim's case illustrated the inequity of our public health system and the apparent advantage of "going private".
Those choosing this option need to be aware that availing of unregulated private facilities may also result in substandard care and a potentially fatal outcome.
Dr Muiris Houston is pleased to hear from readers at mhouston@irish-times.ie but regrets he is unable to respond to individual medical queries.
