Adunchai Thammasangsert felt proud when he attended a three-day cosmetic surgery course in South Korea in 2010. Four years after achieving board certification in plastic surgery in Thailand, he managed to save enough money to pay for the 150,000 baht course, hosted by the Korean College of Cosmetic Surgery at the University of Seoul. Out of roughly 30 participants, he was not only the sole Thai physician attending the workshop, but also the only plastic surgeon.
"A doctor asked me why I was even there since I was already a plastic surgeon," said Dr Adunchai, 43. "I told him Korean cosmetic surgery is very popular in Thailand, and getting a certificate from Korea would be considered pretty cool."
He came back with a certificate and pictures of himself smiling, standing next to his Asian peers -- both objects considered "wallpaper material" for the clinics of Thai physicians. Except when he did open his own clinic last year, Dr Adunchai opted for a picture of himself with a Thai actor instead of the certificate.
"It turned out that the instructors were not plastic surgeons, but in fact general medical doctors," he said.
Back at home in 2014, Dr Adunchai listened to a presentation at the Medical Council of Thailand on the growing trend of non-plastic surgeons practising cosmetic and aesthetic surgery.
The presentation was given by the Thai Association and Academy of Cosmetic Surgery and Medicine, a group representing more than 600 physicians, over half of whom are general practitioners.
"They claimed they are able to produce over 1,000 cosmetic surgeons a year, and they want plastic surgeons to focus only on reconstructive surgery," said Dr Adunchai.
Thailand, he thought, would soon follow in the footsteps of Korea. Six years after Dr Adunchai earned his certificate there, the workshops offered by the Korean College of Cosmetic Surgery are now more popular than ever, with a three-day course held in Bangkok earlier this year costing US$11,600 (around 400,000 baht).
For some, studying these short-term courses is the only way to gain hands-on training.
LONG AND SHORT OF IT
With more physicians entering the field, the difference between a plastic and cosmetic (also called aesthetic) surgeon is becoming more confusing. In reality, there is a big difference.
Woman with ruler against front of face plastic surgery photos: 123RF
After completing their six-year education, medical students are required to spend one to three years of internship and practice in rural areas before they can apply for a hospital residency in a specialty field.
To achieve board certification in plastic surgery in Thailand, a doctor is required to complete five to seven years of specialised residency -- with training in both general and plastic surgery -- and pass the board exams.
Plastic surgery covers both reconstructive and cosmetic surgery.
The number of medical students studying plastic surgery is determined by the Royal College of Surgeons but amounts to about 20 graduates each year.
Ear, nose and throat specialists and general surgeons can also be certified as facial, plastic and reconstructive surgeons after undertaking an additional two years of training under the Royal College of Otolaryngologists -- Head and Neck Surgeons of Thailand.
But the attempt to produce more cosmetic physicians over the past decade led to abuse. The royal college received complaints that members who had completed training were conducting short-term facial surgery courses for general practitioners.
In November last year, the royal college issued a statement condemning the practice, saying such courses are not approved by the medical council and are not up to standard, resulting in a risk of complications during medical procedures.
The Society of Aesthetic Plastic Surgeons of Thailand, and the Society of Plastic and Reconstructive Surgeons of Thailand, which represent 353 board-certified plastic surgeons in the country, claim none of its members have been involved in the courses.
FAST TRACKING
The Medical Profession Act does not prohibit physicians from practising outside their specialist area. This means many doctors who want to practise cosmetic surgery are forced to use unconventional methods to gain enough skills.
Rubbing shoulders: Adunchai Thammasangsert has pictures of celebrities in his clinic. PHOTO: SUPPLIED
The methods range from learning from fellow doctors and foreign lecturers to self-study through textbooks and even YouTube, experts familiar with the issue say, with training conducted at clinics and hotels.
Internet forums on medical websites are swamped with advertisements offering hands-on aesthetic and cosmetic surgery courses, ranging from one-day facial aesthetic training -- which includes Botox, fillers and threading workshops -- to more complicated surgical procedures. Upon completion of the training, participants are provided with certificates and patient referrals.
A course advertised by YB Clinic in January on the message board of www.thaiclinic.com offered training in a wide range of cosmetic surgery procedures including chin augmentation, nose augmentation and cheek reduction, with a seven-day full rhinoplasty course priced at 750,000 baht. Training is conducted at the clinic's branches in the Northeast, with housing, food and a personal driver provided, while qualified physicians are offered positions at the clinic.
Another post offering training in nose augmentation, lip reduction, double eyelid surgery and liposuction guaranteed that a participant would be able to perform the procedures in one day, while promising "professionalism" within a month.
When Spectrum called the agency, posing as a general practitioner, we were told that training in nose augmentation would cost 250,000 baht, with 20 hands-on cases. The agency said the instructor was a board certified plastic surgeon from Ramathibodi Hospital who has had additional training in Korea. However, his name was not listed as a member of Thailand's plastic surgeon associations.
Although they claim to be taught by specialists in the field, experts say the instructors are usually general practitioners who themselves have undergone short-term training.
Such courses are disapproved of by plastic surgeons, who consider short-term training inadequate compared to board certified training.
Society of Plastic and Reconstructive Surgeons president Sirachai Kindarak said specialists are more likely to know when complications will occur and how to deal with them. As a result, plastic surgeons avoid performing procedures that are too risky.
"Complications can be caused by plastic surgeons, but I believe the problems are much less severe [than surgery performed by non-plastic surgeons]," he said.
VICTIM OF COMPLICATIONS
The Health Service Support Department's Sanatorium and Art of Healing Bureau, which regulates private clinics and hospitals, reported 380 complaints last year against private clinics and hospitals. It is not possible to determine how many of those complaints arise from non-specialist practitioners, since the bureau does not provide these statistics.
THE SHORT CUT: An ad offering short-term cosmetic surgery courses, which have spread due to rising demand for aesthetic services. PHOTOS: www.facebook.com/ The Goal & Partners
Chamnong Chirawichada, a board certified plastic surgeon, said most complications arise from unqualified physicians who take short-term courses in aesthetic surgery.
"I get sick of having to treat patients who come to me with complications caused by non-plastic surgeons every single day," he said, adding that basic knowledge in reconstructive surgery gives certified plastic surgeons an upper hand in solving complications.
The most common complications include silicone implants protruding through the nose within one to two months of an operation and eyelid surgery resulting in patients being unable to open their eyes. Some inexperienced doctors also remove too much fat from the eyelid during surgery, causing a "hollow, bony and old look", said Dr Chamnong.
During his 15 years of practice, Dr Chamnong, who also teaches at Vajira Hospital's Faculty of Medicine, has received quite a few requests to teach short-term aesthetic surgery training courses. But he declined, not only because he believes plastic surgeons should go through the formal education system, but also because the industry's "false demand" is spurred by aggressive marketing and advertising.
Dr Chamnong injects facial fillers every now and then, but he always explains the risks to his patients. "Nine out of 10 people back away when they hear me talk about the risks, and that fillers can cause permanent blindness. But non-plastic surgeons never talk about these risks."
With the rise in cosmetic surgery mishaps, the Society of Aesthetic Plastic Surgeons published a cautionary note on its website in English for medical travellers. It warns them not to become a "victim of miserable complications reported by foreigners who had cosmetic surgery done by non-plastic surgeons".
The website also lists the names of non-plastic surgeons the society frequently receives inquiries about to "clarify" their qualifications.
"Currently there are some groups of physicians who do not have proper training but form organisations with names that sound similar to us," said the post. "Many of them have been practising for a long period of time and are so well known that people forget they are not board certified plastic surgeons."
KOREAN STYLE
It is common practice for medical associations to invite foreign physicians to conduct seminars and live demonstrations in Thailand, with the latter performed at hospitals.
PLASTIC PRACTICE: Dr Sirachai Kindarak. PHOTO: Nanchanok Wongsamuth
The Thai Association and Academy of Cosmetic Surgery and Medicine has sought the partnership of the Korean College of Cosmetic Surgery under a memorandum of understanding aimed at promoting knowledge sharing. In April, the Korean college held a three-day cadaver dissection course in Bangkok, which included breast augmentation, chin reduction, filler and Botox injections and face lifting. The two plan to co-host an Asean meeting of aesthetic surgery and medicine in November.
Private agencies, however, are now bringing in Korean cosmetic surgeons not only for training but also for treating Thai patients without a licence to practise, which is against Thai law.
The Korean College of Cosmetic Surgery didn't respond to Spectrum's email request for an interview.
A course advertised online offered a one-day training in liposculpture and fat grafting, with a registration fee of 20,000 baht. The session was scheduled for yesterday, with a morning lecture by Korean physician Kisu Sung and an afternoon live demonstration at Amed Clinic at Silom Road.
The Sanatorium and Art of Healing Bureau says conducting the lessons in clinics is illegal and violates the Sanatorium Act.
"The practice of flying Korean doctors into the country, for instance, is against the law," said director Akom Praditsuwan.
RISING DEMAND
Over the past decade or so, the healthcare sector has been driven largely by a surge in medical tourism, where Thailand has been ranked as a top global destination by several sources including Bloomberg in 2013.
Government statistics indicate 1.04 million visits by medical tourists in 2014, although there is no official data regarding the value of the medical aesthetics market.
Thailand has 1,458 clinics providing aesthetic services registered under the Health Service Support Department, representing 13% of all medical clinics in Thailand. Hospitals with Joint Commission International accreditation require board certified surgeons, meaning that non-plastic surgeons are mostly employed at clinics.
VR International Clinic, for instance, which claims it is "Thailand's first Korean-style surgical clinic", posted a job advertisement on www.thaiclinic.com for aesthetic surgeons for its branches in Sukhumvit and Rangsit, but did not make board certification a requirement.
For 30-year-old Bussarin Juthasompakorn, the right qualifications for a doctor, if she ever planned to undergo surgery, include being board certified.
Non-surgical aesthetic procedures would also have to be performed by a specialist, she said, adding that she always researches the background of the physician to ensure he or she is an expert in that area.
"I had a friend who tried to talk me into injecting Botox with a dentist, but I wasn't confident due to his non-expertise in the field," said Ms Bussarin, who now sees a certified dermatologist for her Botox injections. "What if my face suddenly turns stiff?"
The number of complaints related to aesthetic surgery has increased over the past three years, with 36, 185 and 373 complaints filed to the Office of the Consumer Protection Board in 2013, 2014 and 2015 respectively. The figures include medical errors from non-specialised doctors among the complaints, but the board does not provide a breakdown of the numbers.
Thai Medical Error Network president Preeyanan Lorsermvattana said her network has received complaints for the past 14 years from medical errors resulting from both specialists and non-specialists. But with the Thailand Medical Council on the verge of approving short-term courses for a variety of medical procedures, she is concerned the move may affect the safety of patients.
"The medical council tends to move forward with whatever they want and probably no one can stop them, so I am very concerned about the safety of patients," she said.
