A real eye-opener for physicians in the US... In this episode we discuss cosmetic medicine in the UK with plastic surgeon Mr. Adrian Richards.
Mr. Richards qualified as a Doctor in 1988 and for the last 12 years has specialised in plastic surgery. He has full registration with the General Medical Council No. 3286812 and is a Member of both the British Association of Plastic and Reconsructive Surgeons (BAPRAS) and the British Association of Aesthetic Plastic Surgeons (BAAPS), the leading British professional bodies for plastic surgery and reconstructive surgery. He is an author and has written a best-selling textbook ‘Keynotes on Plastic Surgery’. He is founder of Cosmetic Courses, a company accredited by the Royal College of Physicians, which provides training to medical practitioners entering the aesthetic market and was the lead investigator in recent clinical research into the use of Botulinum Toxin A (Botox) for cosmetic purposes.
In this episode we're discussing cosmetic medicine in the UK with Adrian Richards. It will probably come as something of an eye-opener for physicians in the US to learn that; most cosmetic surgeons in the UK don't really worry too much about informed consent, being sued by a patient is a rarity, filler injections are unregulated, and that physicians are routinely employed by non-physicians. I found the differences to be striking.
We also discuss how Adrian markets his services through social media, videos, and podcasts of his own as we delve into cosmetic surgery across the pond.
Some of what we talked about in this episode.
PODCAST 4: MR. ADRIAN RICHARDS MBBS, MSc. FRCS (Plast.) – COSMETIC MEDICINE IN THE UK
This is Medical Spa MD.
Andy: Hello there and welcome to the show. Well we give you the inside information and the word from the experts to help physicians take control of their medical practices and lifestyle even you’re clueless about running a business and you’re already working 60-hour weeks.
Medical Spa MD is brought to you by MedicalSpaMD.com, a worldwide community of physicians practicing cosmetic medicine. Hello Jeff!
Jeff: Hello Andy! How are you doing today?
Andy: I’m very, very well. It is episode 4, isn’t it?
Jeff: It is. It is episode 4.
Andy: So what’s been happening, Jeff in the medical world? I saw an interesting post here on Allergan. What’s the story on Allergan $600 million [pora? – inaudible – 00:55]?
Jeff: Oh yes. Well Allergan kind of got their hand caught in the cookie jar and the federal government decided to slam the lid down a little bit. Evidently according to the FDA, Allergan had been paying doctors millions of dollars and teaching them how to miscode the drug Botox to be able to use it for off-label treatments for which it should never have been approved.
Andy: Now, miscoding Jeff… Basically, how is it classified?
Jeff: What they were probably doing… I’ve only seen the news reports so I don’t know exactly what happened inside of the courtroom or whatever happened between the lawyers. But, they were probably teaching physicians how to code for something other than what they were using the treatment for. In the US, when you have a third-party payment system, the physician will code the treatment that he is performing. There is a code for literally every treatment. So there are things that Botox is approved for, migraine headaches and other kinds of things. But if you are treating somebody for wrinkles around their eyes and you are coding that as though you are treating for migraine headaches, that’s in effect miscoding that treatment.
Andy: Okay. So it is more to the way the drug is being used.
Jeff: Yes. Off-label usage is legal. A physician, once a drug has been FDA approved, can treat with anything they actually think the drug might be effective for. An MD or DO has very, very kind of white latitude as how to they kind of go about that, how they decide what’s something is going to be treated for. However, they kind of came down and that was the judgment over Botox and end up having to pay $600 million.
They are somewhat closer to a number of potential approvals for other uses, but that is a $600 million little slap on the wrist that Allergan got from FDA for sure. That’s going to hurt.
Andy: Yeah. It actually will hurt. Moving on… A bit later in the show you interviewed Adrian Richards, didn’t you? We’ll talk about Adrian in a minute, but one question for you. How much do you use social media and things on Facebook?
Jeff: Well we are actually using it a lot. In fact, the community, Medical Spa MD, is now extended and we’re now integrating with a number of other things. We have groups on Linked In and Medical Spa MD has a fan page on Facebook. But, we are also starting a number of groups on Facebook in order to teach or to involve physicians who are interested in a very kind of specific learning inside of the medium that we’re teaching.
For example, we have a group on Facebook that is called “Physicians and Facebook Marketing, How to do it Correctly?” And so our staff and as well as other physicians who are marketing on Facebook belong to this group and help teach physicians how to do Facebook marketing on Facebook. It’s very common that physicians now or medical spas or whatever will have a fan page or some other kind of thing because they realize that their patients, there’s now 500 million members on Facebook, all of their patients are on Facebook and it would be very appropriate and great marketing tool to be able to get in front of them. But, they do it very poorly, very, very poorly. You’ll often that might have had 10,000 members or 10,000 patients come through his doors in the last 5 or 6 years and they got 50 friends on Facebook, which is just pathetic.
The reason is that they’re not building a community. They’re not providing any value. They put up links that are endlessly… ‘Come in Friday and we’ll give you free bananas’. Whatever… I don’t know what they’re doing, but it’s just [inaudible – 05:31]. We got a lot of inquiries around this kinds of stuffs. We’re often when speaking with physicians they’ll also kind of talk about this just a little bit like: What should I be doing in Facebook? Is Twitter any good for me?’ that kind of thing. And so we decide to start a number of groups, this is the first one “Physicians and Facebook Marketing.”, on Facebook in order to kind of teach them how to do that. So if you’re interested and all, it’s not necessarily physicians only. We’re going to be teaching how to market on Facebook and how to grow your business that way, but our focus of course is for physicians.
Andy: And this is very early days, Jeff. How do you think it’s going so far?
Jeff: It’s going really, really well. I know that I’ve got a couple of people that are going to be literally teaching inside of this group that I respect a great deal. I’m going to be actually in there. We’ve been very successful with growing a number of businesses through Facebook and so we’re going to share that information with our community. The nice thing about it is that it extends the community past only MedicalSpaMD.com, which will probably always be the main portion, but you can literally go to Facebook and sign-up and become a member of the community and stay on Facebook and drive at least some of the value that all Medical Spa MD members get. So like the sign-up form is now on Facebook. We actually sign physicians who find us through Facebook and have never even seen the site. Those are the types of things that we’re also going to be teaching how to do for physicians wherever they are.
Andy: Interesting stuff. Right, let’s move on to that with Adrian Richards. Now, I actually have known for about a year now and he’s a very interesting guy. I suppose he’s a lot like the people you interview over here, but the English version Jeff because he’s very much in to social media side of things.
Jeff: That’s very true and there are some very striking differences between medicine in the US and medicine in the UK or the European Union and we talked about those quite a bit. One of the things that I thought was very, very interesting and have never really known this was a title for a surgeon in the UK is mister.
Andy: Aha… What do you call it in the US then?
Jeff: We call them doctor.
Jeff: And there’s just some very kind of striking differences that I think pretty much everybody would find very interested in this interview. And he’s a great guy. He’s really embraced social media. He’s got like 5 different podcasts that he does. I don’t know how big that clinic is, but they’ve got 4 or 5 locations. And I think it look likes 8 physicians, cosmetic surgeons and dermatologists working at these locations. So it’s a rather big practice and very interesting to understand how he goes about harnessing his marketing efforts, which he’s involved in because he likes it a great deal. And how he has kind of started that and what the results have been for him, which have been really good.
Andy: Okay. Well let’s have a listen to that interview now Jeff with you speaking to Adrian Richards who is a cosmetic, anesthetic surgeon.
Mr. Richards: First thing Jeff is that in the UK, I don’t know if your listeners know that, surgeons are actually called mister rather than doctor, which is different from the States, isn’t it?
Jeff: And how did that kind of come about? Because I did notice that on your site it looks like 8 physicians and they were all a Mr. except one who is a Dr. as a prefix.
Mr. Richards: Well basically over here, you either sort of side, after you qualify as a doctor, whether you want to go down a surgical route or a medical route. And if you go follow a medical route, maybe a chest physician or something, you stay as a Dr. If you go on a surgical route and you take a surgical exam, which is called The Fellow of the Royal College of Surgeons, when you get that you actually revert back to a Mr., or if you are a lady, a Ms. And the reason for that is in the early days, 400 or 500 years ago, surgeons who sort of amputate limbs were not medically trained. They’re often were sort of barbers. They would sort of do those procedures. So it’s sort of tradition. You know how we are in England. We are sort of very traditional and that’s the way it’s remained.
Jeff: So your patients refer to you as Mr. Richards?
Mr. Richards: Yeah. So I was a doctor. I qualified and become a Doctor for 6 or 7 years and I got my surgical exams and revert back to Mister.
Jeff: That’s striking to me because in the US, physicians are really trained in medical school to kind of take control of the situation and in effect set themselves slightly apart as an authority figure.
Mr. Richards: Well in the UK, in England, people know your surgeon would be a Mr. They would be worried if they’re operated on by a Dr. They just know… “Mr. Stanley is doing my varicose veins.” They expect to be a Mr. They associate the word Mr. with a surgeon. It’s a very different training. Basically, we start medical school at the age of 18 normally. We start earlier. So, we don’t go to a college. There isn’t really a college system. We would go straight into a university at 18, we spend 5 years at medical school and then after that, at the age of 23, we qualify as doctors, which I think is earlier than in America.
Then we do some sort of basic training to really find out what we wanted to do before you decide on your specialty. Our training would be longer. So for instance, I qualified in 1988, but I didn’t become a consultant until 2001, which is 13 years. So it’s 13 years after becoming a doctor until I become a fully qualified plastic surgeon. Although we start longer, our actual training to become a plastic surgeon is longer.
Jeff: So are there fewer plastic surgeons in the UK than in there per capita in the US? Do you know?
Mr. Richards: Oh yeah, way lower. Until about 10 years ago, there were only 200 over 60 million people. That’s how the sort of implications about the industry over here. One of the main differences in America, in the US there’s always been quite a few of very well-trained plastic surgeons. Each city has a lot of plastic surgeons. My father lives in Philadelphia and there’s way more plastic surgeons per capita than there are in the UK.
Jeff: So you’ve got universal coverage, which we’re just moving to in the United States. The fact that you’re in retail cosmetic medicine or elective medicine, how does that kind of fit in with the general practice of medicine in the UK?
Mr. Richards: Well basically we have a system called the NHS, which is the National Health System. It was set-up after the war, after the Second World War. After Second World War, the standard healthcare wasn’t very good in England so they set-up NHS. If you’re old or having a child, it’s all covered, no one pays anything you just go along… any sort of injury, whatever, you get paid. Now, there are things around NHL which is a bit blurred… [inaudible – 13:32] correction, breast reconstruction after cancer, varicose veins, hernias, carpal tunnel syndrome, those sort of things have traditionally been covered. Even I was training breast reductions, breast enlargements, those sorts of procedures were performed on the health system, but they’re tightening up a lot because it’s costing more money in the system. It’s very expensive to run so they’re tightening up a lot in these sorts of procedures, which aren’t medically necessary.
Jeff: So your practice’s predominantly cosmetic surgeries as I understand it. Is that correct?
Mr. Richards: Yeah. What happened in 2001 when I qualified as a plastic surgeon is you’re taken by a hospital as a consultant plastic surgeon. And then in those days I was taken by [inaudible – 14:30], which is one of the main regional plastic surgeons centers, which has a big Burn Center and a big Spinal Injury Center. So I used to deal with hand surgery, a lot of breast surgery, a lot of burn surgery and all of those sorts of things. Also, I have to work one half-day as a private surgeon externally to that. And I just found out that I was getting too busy with the other side so I sort of, after 5 years, left the health system to work in my own clinic, which is what I do now.
Jeff: So that’s entirely elective plastic surgery with very few plastic surgeons. What’s the demand like?
Mr. Richards: Well I have got too much work, to be honest, so I’ve been working the last 2 days. I operate 12 hours on Monday and 12 hours on Tuesday. And I think the other thing is that English surgeons tend to be a lot quicker than surgeons in the US. When I went to the US I did notice the surgeons. The procedures seem to take longer. On a typical operating day, I would maybe do 2 facelifts, 2 or 3 breast enlargements and a breast reduction each day. That would be my normal day and I would do that twice a week on Monday and Tuesday and again half-day on Thursday. So every week I would be operating on 10 significant size cases. And I’ve sort of reached my limit on what I could physically do so then what we’ve done in the rural clinics, which is the clinical side to our business, is we’ve taken on other surgeons. We’ve got a rhinoplastic surgeon, an ocular plastic surgeon who deals with eyelids, a liposuction surgeon… so what we were dealing is incorporating other surgeons with other sub-specialties.
Jeff: What is the typical waiting time in order to get in to your clinic as a patient?
Mr. Richards: Well, you can get a clinic appointment pretty quick, normally within a couple of weeks. To see me… you can normally see me… I’m pretty much fully booked for 3 months. The danger, you know Jeff, is if people ask you for operation then you say yes and then you find your list is getting bigger and bigger and bigger, you tend to be chasing your tail a bit. So I’m trying to be strict and limit the time I operate now.
Jeff: Would you say that the demand is outstripping the medical community’s ability to meet that?
Mr. Richards: I’ll tell you what it is, Jeff. So I was in a conference last week of the British Association of Aesthetic Plastic Surgeons and I was talking a lot with my peers. And essentially what they were saying is they are quieter. I know a lot of American surgeons are quite since the crash of economic problems and it’s the same in England. The amount of work I think is down. However, I think because of our efforts in social medium of communicating real information, we are getting busier. Although the pie might be smaller, our bit of the pie is getting bigger.
Jeff: Looking through your site it’s obviously that you really embraced social media and online marketing as part of your marketing mix. 2 questions… How much of your marketing advertising budget or time is actually spent online as opposed to more traditional marketing methods? And, how effective is that?
Mr. Richards: Right. All of it is online. I think it’s slightly different in America because in America, if you’re working in Pittsburgh or somewhere, everyone is coming from Pittsburgh really. They may travel over the States, I don’t know, but you are more big city like a hub with spokes going in and that was the same when I was in Australia. It was a similar sort of pattern. I don’t know whether surgeons in Pittsburgh need to be very prominent on the Internet in California. Would they Jeff?
Jeff: No, they wouldn’t. But, the truth of that is the competition in United States sounds as though it’s much more competitive and there are tremendous amount of plastic surgeons and dermatologists and now aesthetic physicians on one sort or another that are using technology as opposed to surgical procedures. But generally, your population drive is going to be a maximum of maybe a hundred or 200 miles away, which of course is England almost.
Mr. Richards: Yeah, that’s right. So essentially, I think the pattern is a bit different you see. I mean, if you’re in Philadelphia, there are many more competitors. London is very competitive, but outside London isn’t quite so competitive. So there’s a mixture of ways that people find success. Some of my colleagues are on the TV a lot. They’re on the radio a lot. They get most of there work on PR really, which is fine. That’s a good way of doing it. We tend to concentrate on online marketing. We do a little bit of offline marketing on our area within 10 or 20 miles of our clinics. I think we’re generally fine. The cost is better really for our online efforts.
Jeff: How have you approached that? I know you’re doing quite a lot of few things. You have some things that American physicians would probably find slightly concerning on your websites. When I say concerning I mean the fact that US medicine is very kind of litigious and you have, for example, patient forums that allow patients to go and ask questions and you are actually posting answers back online for other patients to read. That is something that most US physicians would not feel comfortable doing.
Mr. Richards: Why Jeff?
Jeff: The reason is because that could be construed as a medical advice. There is a tremendous sense of CYA medicine in the United States, Cover-Your-Ass medicine, which is don’t provide anything that could potentially come back and hunt you in 2 years when somebody has a negative reaction and their lawyer goes online to your site and sees that you’ve recommended something. Now, that’s a little bit of different obviously in your situation. First, why is that so? And then, how effective has that been for you?
Mr. Richards: I think we’re much lesser litigious society. In 8 years, I have been doing 400 breast enlargements a year, I do 50-60 facelifts a year and all my time I’ve never been sued, never.
Jeff: And that probably would be. And one of the up things that you were posting in your site is your complication rate and kind of a report card from a third-party. Is that something that all of plastic surgeons in the UK have?
Mr. Richards: Not really. What I view is really there’s a lot of marketing hype particularly in England. What basically happened in England was there weren’t enough plastic surgeons so business men came in and dominated the market. There was guy called John Ryan 20 years ago who came in, he was a marketing guy, and he said: “The worst people in marketing are British plastic surgeons.” And he basically started a company who transformed from nothing he dominated the cosmetic surgery market in the United Kingdom, sold it for multi-million pounds, bought a well-known football club and retired a very, very rich man and he didn’t start a company since then. But basically he put in place pretty simple sort of principles that wouldn’t be familiar to you guys in America that it is one being done in the England.
That’s gone on now. The majority of cosmetic surgery in England is not being done by plastic surgeons as you would recognize in America so they’re not board-certified plastic surgeons. They’re done by big companies who have clinics all over the country who have very big marketing budget. So, patients would go to them. They wouldn’t go to a named surgeon; they would go to a company with his name. They would see, sometimes in this sometimes not in this… they might see a sales person initially who would talk him through an operation. They might see a nurse. That person will take a deposit for the operation, especially on a [inaudible – 23:29] and would then see the surgeons for a period of time. These surgeons, because of European regulations, they could be from anywhere in Europe. They could be permitted, where the standards are arguably not quite as tough as in America, in England. So it’s much more of a factory sort of Henry Ford type production line with these companies where that model doesn’t happen in America or anywhere else in the world because you traditionally have more plastic surgeons.
Jeff: Well I think it’s that. And probably there’s more of them and physicians are organized. It sounds as though physicians are probably organized in their specialties to… I don’t know if I would say to a greater degree. but differently than how you’re organize. It might be that with as few plastic surgeons as you actually have that the lobbying power, the kind of ability to protect that market wasn’t there. Do you agree with that?
Mr. Richards: Yeah. Well they didn’t need to you see because there are only 200 on the country that have gone through the training. They basically have more work than they could throw a stick at. They have so much work and they have a good living. They didn’t have to market. They have big houses and they’re multi-millionaires, they didn’t need to do anything. And then things have changed now. Now, there are many more plastic surgeons being trained because they are cutting back on the Health System. There aren’t really sufficient jobs for them in the Health System. So the old way of you entering plastic surgeon for training, you got a consultant job, you had a job for life, which is well-paid, and you can have a private income… that was fine 10 years ago.
Nowadays, the 75 junior plastic surgeons coming out of training this year in the UK aren’t going to get jobs. So what they’re going to do? They are going to set=up privately like what you do in America, which never happened here, or they are going to go abroad. So I think it is changing… you becoming more like us and we becoming more like you, Jeff.
Jeff: Let me ask you this. What you’re referring to the factory approach is happening in the United States to some extent. There are chains opening up and really my feeling is that’s been driven by the development of technology that allow physicians or the delivery of medical services to move away from very high-skilled individuals. Meaning, physicians like yourself who has 12 years of plastic surgery training and is now kind of a realm of technology solution where you have an aesthetician firing a laser, running an IPL or some other kinds of things and that is a scalable model.
In the United States, there are a tremendous number of physicians who are looking to add Botox to their practice, who are buying an IPL and doing laser hair removal who are kind of moving into cosmetic medicine. And what has been since the 60’s basically a battle between plastic surgeons and dermatologists in the United States now has a in effect a third player in that and that is a internal medicine doctor, or a family practitioner, or an OB-GYN who is bleeding patients who are kind of on the lower levels that did not demand that kind of skill and training of a plastic surgeon.
Now, you can argue, I would say, that might be a more effective use of delivery of medical services and cosmetic medicine, especially in the United States, is where a lot of this kind of motion happens first because it’s a very kind of large market and there are businesses that are in this that try and adapt very, very quickly as oppose to a kind of classical, more conservative traditional medicine.
What has happened in the UK around that? The move into kind of technology solutions… Do you see that as a good thing?
Mr. Richards: Well it has been, but technology will only get you so far. I mean, someone [inaudible – 27:58] stick the liposuction [inaudible] or do whatever. So in our practice we have aestheticians and nurses who do some things, but only to a level. So you talked about three groups, the dermatologists and the plastic surgeons… In England, it’s also the business people who set-up clinics and employ plastic surgeons and dermatologists to their work of them and that is the pattern that is very prevalent in Europe in a business set-up, a clinic or whatever he’s very good at marketing, very good at those skills and then will get doctors in or get whatever medical specialties they need to do the work.
Jeff: So in the UK, a non-physician can employ a physician?
Mr. Richards: Oh yeah. These big groups.. They’re owned by businessmen.
Jeff: Well in the United States, that’s the case too. Hospitals or some businesses can employ physicians. But as an individual, that’s prevented. I can’t, as an individual, just go out and hire a physician to work inside my clinic. Is there any difference?
Mr. Richards: In the UK, you can. Absolutely you can. Basically, I own 100% of the company. The surgeons who… So a typical dentist in England… You have a chief dentist who owns the building, owns all the equipment blah, blah, blah. And you got associates come in and they will do the work there. So they just come in. They haven’t got any administrative concerns in marketing or anything like that. They haven’t got to worry about the equipment. It’s the founder, the principal who’s got the concerns of the equipment and then typically the associate would get 50% of any income owned. So he come in do the work go home… 50% to him, 50% for marketing, staff those sorts of things.
Jeff: Are most of these businesses run with physicians from different parts of the EU (European Union)?
Mr. Richards: Some of them are. Obviously here a business man you’ve got costs to be taken to account. So they would go for the cheapest. Well they would balance the quality versus cost. So they could probably go cheaper, but they are going to get problems, they don’t want problems. But, they don’t want to go really expensive either because their margin has to work both ways. So, often some foreign surgeons… because in Italy they’re traditionally way, way more physicians trained you see… So in Italy, many doctors can’t get jobs as doctors at all. So, they qualify as doctors, but they maybe working at advertising or something. So, there are more Italian doctors. If you can get someone who’s technically good, they’re willing to work for less money than perhaps an English surgeon would be.
Jeff: How does that kind of balance out? What is the recourse that a patient has in the UK if something kind of goes wrong? When traditionally it seems that technologies have been developed in the US and treatments…
Mr. Richards: No, that’s not right, Jeff.
Mr. Richards: A lot of treatments have been… It’s interesting where the latest advances come from. Now, they’re not all from the US. In fact in the US, in some things they lack behind the rest of the world. Now I’ll give you an example. The example is dermal filler treatments, which these are gels that you place under the skin normally in hyaluronic acid for treating winkles. Now, in the US these are classified.. They need to be approved by… Is it the FDA?
Jeff: The FDA yes.
Mr. Richards: So they are very, very stringent. Only some dermal fillers like Restylane and I think Juvederm now are recognized because of this stringent FDA regulations. Now in Europe, they’re not classified as what we called prescription-only medicine so they are completely unregulated, which is probably a bad thing to be honest, Jeff. But, physicians in Europe have been using these substances for much longer and they got much more experience of them than in America.
I go along the [sierra laston? – inaudible – 32:40] conference sometimes in New York and in some things America is ahead definitely, but in some things it’s behind. And it’s always a bit of surprise sometimes when you get in America because you sort of expect America to be ahead of everything and some guy puts up a sort of the latest technique and new sort of thing and we’ve been doing that for 10 years.
Jeff: Well, you kind of jumped ahead of me. What I was actually saying is that technologies are often developed first in the United States, meaning, a kind of a technology solution or something else. But, treatments are usually developed outside the United States. And really the reason is that you can’t do experiments on patients in the US. I’ll give you an example. I was in Medical Conference in Las Vegas and there is a plastic surgeon from Mexico who was talking about a treatment. And he went through this treatment and it became apparent that he was in effect modifying the treatment and experimenting on patients that would come in for a type of the surgery and he was doing different things in order to see the results and a bunch of other things. Now in the United States, that would open you up to all sorts of problems if there was a problem with the patient. After he was speaking, there’s a group of American physicians asking him: “What happens if the outcome is not good? What happens when somebody complains?” And he said: “Well, we call the police.”
You have to be an American physician to see how… It would never happen in the US. Well, it might happen in the US, but it would be big news kind of a thing. So, the liability is such. I would bet that there are less than 5% of American plastic surgeons who have done a number of treatments that you have that have never had any kind of legal issue.
Mr. Richards: Yeah. It is getting worse here. I think maybe we’re not anywhere like Mexico, we’re much more like you. But, I know the whole consent thing in America, recording conversations, getting people to really sign things, luckily were not at that stage yet, but we are getting there unfortunately.
Jeff: What happens with the patients when there is no regulatory body and anybody in effect are shooting people with hyaluronic acid? There’s got to be negative complications there. What happens?
Mr. Richards: Well, the companies won’t actually provide dermal fillers to anyone who’s not regulated. In our training arm, which is called Cosmetic Courses, we only train doctors, dentists, and nurses. You see, nurses can give Botox and fillers in the United Kingdom under the jurisdiction and the guidance of a doctor. So, we train those sort of people and they can sign up to get the Botox and the dermal fillers and things. But, the companies, the dermal filler companies, are really very keen for understandable reasons. Non-medically trained people aren’t getting their hands on dermal fillers. They’re trying their best, but it’s not legally enforceable because unfortunately they’re not classified as prescription-only medicines. So, it’s not against the law for them to do it.
Jeff: Now, why is that? I mean, there’s got to be some prescription-only medicines. Who’s the regulatory body that makes that decision? Are they just slow? Or, are they are going to have that regulated?
Mr. Richards: I think they should at it, Jeff. But, I don’t know why. I think it’s just the way it was developed. You know, sort of like vitamins and creams aren’t prescription-only medicine, are they? So, I think it just got missed out. I think when they were being developed they just weren’t put in the right category.
Jeff: Is there no consumer kind of advocacy group that pushes towards that? My guess is that if there are kind legal ramification, those are often both the precursor and the kind of motivator in order to kind of tighten those things up. I mean, that’s literally why physicians often operate in the United States the way that they do is because it’s not that you couldn’t do something. If you’re a physician in the United States, there are plenty of stuffs that you could do, but your malpractice insurance might not cover it and that would leave you personally open to liability if something goes wrong. Is that different in the UK?
Mr. Richards: I think you’re much cautious in the States for good reasons. Over here, because there’s much less litigation, I’ve never known anyone being sued for Botox for instance because it will only lasts for 3 months. Dermal fillers, as long as you use temporary hyaluronic, you’re very unlikely to get sued because it takes 3 years to get a legal court case room by that time it’s gone. So, I agree with you. I think any of my contemporary in America would be very likely to be sued. And I think being sued is such a horrible experience because as a physician all you really trying to do is do your best. You’re trying to help people and when people turned around and sue you it’s quite an unpleasant experience. You practice more defensively. Maybe that litigation changes the way you treat your patients.
Jeff: When you have a patient come into your clinic, what kind of paper work are they filling out? What kind of consent are they kind of giving before they actually have the surgery?
Mr. Richards: Right. Believe this Jeff, I am one the foremost people for consent out of all the surgeons in the UK. I did some work in Australia and I’ve worked in the States so I’ve some of those good practice and guidelines over. Basically… Are you talking about an operation or dermal fillers?
Jeff: Yeah. I’m talking about a surgical procedure.
Mr. Richards: Okay. So they would come in and see me. They would fill out a form of their medical history, their general practitioner and on the form I have a lot of checklist, which sort of say information leaflet, have I given them an information leaflet, have they watched our video, I’m developing DVDs to give them. That’s a very good tip. This is given to me by a guy called Daniel Fleming. He’s a very well-known surgeon in Australia. He develops his own DVD about breast enlargement, which he gives to the patient and ask them to watch with their family at home. And he’s pretty graphic in it. He also says: “If you’re not prepared for the risk of dying, this procedure is not for you.” And he gets them to sign. They have watched the video. So he doesn’t need to… If you’re talking to 5 people a thing about breast augmentation a day, you get bored saying the same thing again and again. So he’s done it. This video is an hour and a half. It’s a really good video. He’ll give it to you free if you’ll look up Daniel Fleming in the Internet.
So, I’m developing videos so when they watched those they sign, they’ve read them and they understand the complications. And then I go through… I’ve got a checklist of all complications I’ve discussed [inaudible – 40:30] all those sorts of things. And then when they come in to the hospital, they sign in another detail consent form and the private hospital have a consent form, which 90% of plastic surgeons would only use that and that is got 2 small lines which you can write about a maximum of 6 or 7 things and you have to fill those individually. And that is what 90% of the surgeons in UK use.
Jeff: Any kind of surgery that they do?
Mr. Richards: Yeah. They do a facelift. Typically, I’m more unusual because I do more, more consenting. But, some having a facelift… I mean, it’s a whole a lot of things as you know, Jeff, can go wrong with a facelift and eyelid surgery [inaudible – 41:14]. So, they may write 5 things that could go wrong, eye problems, pore scarring, eye symmetry, nerve damage, they might write those and the patient signs it. And for many surgeons that’s the only consent they have over here.
Jeff: And they don’t run any problems with that.
Mr. Richards: They have not run into problems, but I think they are going to run into problems. I mean, the American Association of Aesthetic Plastic Surgeons I think has developed consent forms, isn’t it?
Jeff: Sure. I mean, every clinic probably has their own consent forms depending on what they’re doing, but consent forms are something that are sought after whether all the complications that we’re going to need to list. I mean, the idea is not to terrify anybody, but it is to make sure that a possible complication that you are going to run into is going to be on that consent form of the patient who signed it.
Mr. Richards: I think your consent forms are so much better than ours and what I would like to do is introduce versions of them into United Kingdom because I think a lot of these surgeons are asking for a lot of trouble with these inadequate consents.
Jeff: Well, I tell you what… I’ll send you my consent forms for that as one… certainly get those in your hands. So, you train other physicians in cosmetic medicine. How did you get started in that and how does that help business run?
Mr. Richards: I think Jeff the answer is… when I was younger, I was impulsive and I thought this is a good idea and I’ll just do it. I think I’m still very impulsive, but I think as I got older perhaps I wouldn’t do these things like I used to do in the old days. You know when you’re young, everything’s going to work, nothing can fail unless you get a bit older you get a bit more [inaudible – 43:08]. But, I just came up with an idea. I was talking to a friend. The reason is when I started as a consultant I had to go to Harley street, which is the main street in London and I had to go and to learn to, me and my friend, I had to go in how to do Botox. And we had a lot of money for it. It was just 2 of us being taught by this guy who got a course and this was the only course that was available in the United Kingdom. So I thought there must be a…
Jeff: Now, what year was this?
Mr. Richards: This would have been about 2002…2003. So, I thought: “Well, we’ll set-up a course.” So, I had a friend of mine set-up a course with me and that went okay, but I think drove her crazy. So she said I was driving her crazy. Then I made a very good move and I got someone else to help me called [inaudible – 44:04] and she’s been great and she’s running it ever since. She does all the sort of admin, day-to-day running of it and I do some of the teachings. To be honest, I don’t do dermal fillers anymore. My nurses do that. So, we have a number of courses. We have a one-day course to introduce people to Botox and dermal fillers and then if they want they can come to further training as it needs to be.
Jeff: And so these are physicians just in the UK or are you training physicians…
Mr. Richards: No, we have people from all over, Cyprus, Greece, Iraq… I had a guy, last course, who came up to me and said, he was there with his wife, they’re both a very attractive couple… I think they’re obviously very wealthy people from Iraq and he said: “May I have your autograph, Mr. Richards?” And I said: “Why do you want that?” He said: “In Iraq, you are a YouTube star.” So my videos, I think, have been watched in YouTube and of course YouTube now is worldwide. We had over a million views of our videos in the last 8 months.
Jeff: How did you decide that you’re going to do that? Was that something that somebody had recommended or you’ve seen some success of somebody someplace that you’re copying? But, you’re releasing videos. You’ve got at least 5 podcasts that you are doing and social media and interactive media. How did that start?
Mr. Richards: I’ll tell you what happened. The day that changed my life Jeff… sounds crazy, isn’t it? I started listening to podcast called ‘Internet Marketing Podcast’, which is the one Andy White does with Kelvin Newman?
Mr. Richards: You’ve seen it. It’s got a RSS feed, the orange one, which highly rated in the podcast section. And that just really opened my eyes, to be honest, into the world out there of Internet marketing, which I didn’t know anything about it. I’m a physician. I mean basically Jeff, I’m not very good with money, I’m not a numbers person, I’m not an accountant person, I’m not driven by that. I like doing surgery I like Internet marketing and communicating. That’s what I really like doing so I got other people doing the money side of it. And it just sort of struck accord with me and since then they talk about… since I listen to a lots further podcast… that’s a very good one in America, ‘Good Internet Business Mastery’’, which you may have heard about, it’s really good. So, when I’m in a gym or I’m just on my car, I listen to this stuff. I wouldn’t in any way classify myself as technical, but I just sort of taken of really, which has been really good.
Jeff: So are you are producing these to a large extent yourself? Or, did you just hire somebody in order to get them to start doing them?
Mr. Richards: No. The other best thing I ever did Jeff is I bought a Mac. And I am not technical or sort of. For anyone who’s not technical out there I would advise you to get a Mac and it just makes everything so much easier. I edit the movies myself normally on iMovie and I taught myself how to do it. The beauty is, Jeff, you can pay these big marketing companies to do things, but they’re not doing anything that you can’t do. Any of your listeners who are physicians are more than averagely intelligent. They are in the top 20…30% of brain power. These things are not difficult. So if I can find out about them, you can find out about them and all you need to do… I mean, I produce my own videos. It’s not very difficult to do.
The podcast… I have a guy who helps me with them and he’s great. Basically, I record them and I send them to Andy who set-up a server for me with all the podcast. I shouldn’t say that. I don’t think he likes setting-up service, but I just transfer stuffs to him and he does the audio production, all the publicity and that’s it really. With videos… podcasts are good I think. I love podcast because I like listening while I’m on the move, but I don’t [inaudible – 48:27] podcast as quite as much as videos. It depends, Jeff, how people like consuming their media. Some people like reading, some people like listening, some people like watching. What would you be, Jeff?
Jeff: Well, I’m a little bit of all three of those for sure. You’re exactly right. It’s the consumption. I think that podcasts are best suited for, in effect, kind of longer conversations. That’s probably how they’re consumed. Where video is not… often it’s very difficult to capture somebody’s attention over a 20-minute video as opposed to a 2-minute YouTube video. So how successful has that been? Obviously, it’s made you a star in Iraq.
Mr. Richards: I’ve been interested to listen to another podcast you listen to actually, Jeff. Which ones are they specifically?
Jeff: So there is one called ‘Big Ideas’ out of the University of Toronto in Canada and it is lectures usually by well-known lectures and they might be anything from the demise of the dinosaurs to Picasso’s inner thoughts. There’s a very kind of wide range in that regard. There’s another out there in Stanford University called… Let me think… it’s their ‘Entrepreneurial Thought Leaders’ and it really has to do with technology start-ups and companies and that kind of thing. And there’s of course, I listen quite a bit to a podcast that’s put out in videos actually by Ted. I’m not sure if you’re familiar with ‘Technology Education and Design’ conference which is held once a year. I’ll send you a link to it. And we’ll put in a link in the show notes to each of these podcasts as well because it’s very, very kind of interesting. There’s another one that I like which is called ‘Hardcore History’, which is put out and these are sometimes 5 or 6-hour podcast that go through things like ‘The Punic Wars’…
Mr. Richards: You’re a [inaudible – 50:38]. I listen to [inaudible] Romans. That’s a great one. He takes you to right through the Roman Empire for about a hundred episodes and it’s a great thing to listen to. He’s an American guy. So basically, I think podcasts are great. However, I think to many people when you say the word ‘podcast’ and they just think geek. Would that be the same in the States?
Jeff: It’s a little bit yes. However, it’s very effective because people are hearing your voice. There’s a sense of warmth and kind of familiarity with a human voice that you often don’t get when somebody is showing images that has a text, description of the same thing. My guess is, and I’d be interested to hear what you’re going to say here, that this has been effective for you and that patients remark on this to you and they kind of come in. Is that the case?
Mr. Richards: Yeah, they come in sometimes and I said: “Hello! My name is Adrian Richards.” And they look at me in a sort of weird way. And I say: “Are you okay?” And they go: “I feel I know you. I’ve watched all your videos. I listened to all your podcasts.” They’ve basically spent hours with me, really a virtual me, and I’ve never known. Do you see what I mean?
Jeff: Sure. And this is, to be honest, a very effective marketing technique because when you walk in and you say something very personal to them or about them they trust you implicitly from that point. They wouldn’t have come in for the consultation. You’ve done all of the marketing and the kind of preselling and the elevation of your level of trust beforehand, in effect, in a way that scaled some super-effective I would guess.
Mr. Richards: Yeah, absolutely. I mean, I used to sort of say: “I would explain about putting the implant on to the [inaudible – 52:32].” And they got a [inaudible]. And I’m sort of: “Well okay, we’re going to talk about different dimensions and profiles of implants.” They got a [inaudible]. “Well, what do you want to discuss?” And they sort of say: “Well, could I just try them on and I’ll sign-up?” They know you. The podcasts I listen to, I don’t know what you feel Jeff… I feel I got good insight into what that person is like.
Jeff: The fact that they’re providing good value to you elevates the feeling of trust to that person and you like that person.
Mr. Richards: Yeah. And the thing that you like them and trust… And I think the other thing is, Jeff, really is just be honest. I mean, you know these things do go wrong. There are problems. Not everyone is happy. For instance, I think there is a bit of pressure on some guys I meet from Europe who run their own clinic. So, someone comes in and maybe it’s something you’re not comfortable doing for some reasons. Like for instance, I don’t do noses. I made a decision I don’t do noses. I think if you’re a one-man band and it’s money you maybe pushed, you may don things you don’t really think you should be doing. So, I tried to avoid that. Basically, if I don’t think that I can’t do a good job whatever reason I think someone else can do it better, I will send them somewhere else.
Jeff: Now, you’re fortunate that you actually have physicians that are specializing in those kinds of treatments.
Mr. Richards: I have them always. I have developed a team now, but sometimes you got to look at yourself and just say: “This may be in England 3,000-4000 pounds down I’m not going to get, but if I do this she’s not going to be happy, she’s not going to get the greatest results. I just need to say goodbye to that money and do what’s best for the patient.”
Jeff: When patients are not happy, how do you deal with them?
Mr. Richards: This is difficult. I mean, in England we are not really a complaining culture. So if they do complain, they’ve normally got a god reason to complain. There are some things that are unavoidable, let’s say developing capsule after breast implant. It’s not my fault actually… really. It’s just something that’s happened and it happens to 6% of people. So, within a year I have an agreement with the hospital that if anyone needs a redo surgery, it’s completely free for the patient within a year. So I don’t charge them and the hospital doesn’t charge them and that gets me out a lot of sticky situations because 9 out of 10 things that people aren’t happy with I can put it right. So some will have a facelift… it’s fine. You know with facelifts, swelling goes down a little bit so excess skin around the neck. If they’re not happy, I can redo it and it only costs my time. There’s no actual physical cost to me.
Jeff: So you’re doing all of your surgeries inside of a hospital, do you do any surgeries in an outpatient clinic, surgical center that is not inside a hospital?
Mr. Richards: Now, this is really something that is very, very different in the United Kingdom. I know a lot of you guys do office-based surgery with anesthetic technicians, with [inaudible – 56:07], or state sedation basically, don’t you? Regulations… I said they’re terrible in dermal fillers, but they’re very tough for hospital facilities. So, we would not be able to do the sort of procedures that you do in your offices in our offices. To do intravenous sedation like you guys do in your offices, we would not be allowed to do that.
Jeff: And what regulatory body that kind of offices that?
Mr. Richards: It’s the Healthcare Commission. So, anywhere you do operations in has to be a proper operating theatre, has to be regulated and it’s toughly regulated. So, there was guy I know, a very well-known plastic surgeon, who set-up a big hospital in London, west of London. He had a whole operating 3 theatres, whole operating team, all the equipment cost multi-millions of pounds… the Healthcare Commission, people came around and said: “Sorry, your light switches are wrong. You can’t open until we come back and examine it. We’re not coming back for 2 months.” So he’s got full expenses for 2 months and he can’t get any work. And then in 2 months time they may find something else is wrong. So, theatres are very well highly regulated here.
There is one surgeon I know who opened his own clinic and he’s doing very well. But, most surgeons would operate within an established hospital for most procedures, even breast enlargements.
Jeff: Now, you’re doing things like IPL and stuff inside of your clinic.
Mr. Richards: Yeah. You can do that, but in many procedures. So for instance, some of your listeners would be performing facelifts probably in their offices. People in the UK wouldn’t do that. They would do it in a proper operating theatre. We are behind you in that way.
Jeff: So what is the definition of a surgical procedure? Because you’re exactly right, there are a tremendous number of… You know there are old school facelifts that were much more invasive. But, there’s certainly a number of, probably at least a dozen, new kinds of techniques that are minimally invasive that are using [inaudible – 58:25] techniques, or you’re making just one-inch incision or those types of things. Do you have to perform those in the hospital as well?
Mr. Richards: I think some of them. I mean some of those Hollywood facelift techniques may be not. Now the question is, do they work? I mean just because the operation is a big operation doesn’t mean it gives you better result, but I think some of these mini operations are giving you mini results. So, that’s a whole other area we’ll talk about. I have a clinic. I’m sitting in my clinic now. We’ve got 4 consultation rooms, we’ve got nurses and aestheticians that work here, we got a back-up office and we got our training office as well. So the training people use the same room for training. The only thing I would only do in these rooms are [inaudible – 59:24]. I wouldn’t do anything that requires stitching. Fortunately a colleague of mine has got a clinic down the road, which is set-up for sort of operations. He would do [inaudible – 59:36] there, I wouldn’t. I do a lot of inverted nipple corrections. I sort of specialize in those. I got a really good technique for that, which we could discuss anytime. I would do a lot of those. I do some Permalips… those sorts of procedures I would do in that facility, but anything bigger from breast enlargements, eyelids upwards… I would do in a proper hospital.
Jeff: Okay. Well Adrian, we’ve got an almost an hour and I told you we were only going half an hour. I very much appreciate your time and this has been fascinating and I would hope you would entertain the thought of potentially doing this again. I would actually like to get in to specific treatments, the nipple inversion technique that you have and kind of discuss… there’s a lot of stuffs that I think can probably mine you for.
Mr. Richards: I think we’ve only just touched the surface. In fact, it’s really interesting for me. Since I started podcasting, I’ve learned more from just talking to people. You know, I mean like just talking to you today I’ve learned how things are in the States and how they’re different so I think just taking part in them is because it’s very easy to get stale… you do the same thing day in, day out and just talking to other people… You know you got compensation by talking to other people, but podcasting as well particularly talking to someone like you, Jeff, you get a different insight into how things work in different countries.
END OF INTERVIEW
Andy: Well that’s it for the show. Thank you very, very much for listening and hope you enjoyed it. Now, we’d like to hear from you, of course. So, if you got any questions and comments please send them along to our email, which is email@example.com or you leave a comment in the physicians’ forum on the website, which is MedicalSpaMD.com.
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Now as always, please consider we say to be complete conjecture and random speculation, not medical or legal advice. And laws & regulation vary everywhere so consult a medical or legal professional in your country before taking any action.
So it’s goodbye from Andy White.
Jeff: And Jeff Barson.
Andy: Wishing you all the best until we see you next time on Medical Spa MD.
END OF PODCAST