Dealing With Anonymous Patient Reviews As A Physician

The internet is a double edged sword to the Plastic Surgeon.

Patients from near and far can read about and research our skill and services but at the same time a handful of malicious people can significantly tarnish a great reputation which we have strived to achieve and maintain.  

As a surgeon and as a human I have always strived to maintain the highest ethical and moral pathway. Most of us went into medicine to help people. What we do as cosmetic surgeons may not save lives but it does save quality of life and that is evident in our patients' smiles and behavior after successful cosmetic surgery.  As doctors we strive to achieve and maintain a pristine reputation but as in anything else in life, it is impossible to please all the people all the time.  

The internet has given a voice to everyone but it seems like angry, bitter, malicious people take advantage of this soap box and platform much more often than normal happy folks.  You can see this on comments on YouTube or blogs or chat rooms of all kinds - not just medical or plastic surgery related. 

But in our field, we depend on our reputation and while you may have thousands of happy patients, a small handful of unhappy ones can affect your reputation.  Personally I have seen that the vast majority of my negative online anonymous patient reviews or ratings are from people who I have either never seen in my office or have seen but refused to operate on as patients.  I recently had a "1 star negative review" on YELP from a person who has never even come to my office nor met me but decided that she did not want to pay $100 for an hour of my time for a consult and felt obligated to give me a negative rating for not offering free consults!  We have all had such occurrences.  But how do you deal with it?

My method has always been dealing straight forward with any and all comments.  If it is out there then it begs clarification and a reply from my staff or office managers or even myself.  There has to be accountability.  In the restaurant industry, restaurants can actually review and rate their patrons, not just vice versa! As physicians, we have to respect patient confidentiality and HIPAA but that does not mean we must be silent and let any anonymous person's comments go without a reply or clarification especially when most of us work so hard to do the right thing and practice with skill, ethics and integrity.

Resources for physicians:

• Frontdesk Patient Satisfaction Marketing
• Free Webinar: How To Protect Your Medical & Professional Reputation Online

How Does A Plastic Surgeon Incorporate Lasers Into A Primarily Surgical Practice?

One of the most common questions that other physicians ask me is “how do I incorporate lasers into my surgical practice?”

I am often called by a plastic surgeon, specializing in cosmetic surgery, who wants to know how he or she can begin to use lasers in their practice. It can seem exciting yet daunting to bring in a new procedure because of the level of knowledge and training required to properly treat patients and produce excellent results. And many times, physicians have limited time for further training once a busy practice has been established. In addition, lasers are expensive and most surgeons are not used to having to purchase expensive equipment beyond the initial investment in supplies to start a surgical practice. That being said, the laser procedures can help surgeons offer a much wider range of treatments that will benefit both the patient who has had surgery and the one who is not yet ready for surgery. I tell physicians and patients that laser procedures can be “insurance for your surgical procedure” in many ways. Laser procedures can help add to the result of surgical tightening by treating dyschromia, discoloration, texture, pore size, vascular lesions, and providing overall better skin health and appearance. One can pull the skin tighter with surgery, but the skin often needs surface treatment with laser procedures. Don’t just focus on achieving tighter skin, focus on overall better looking skin also. This may sound like a sales pitch, but you will hear me often say, “don’t put cheap tires on a Rolls Royce!” Surgical results will greatly benefit from maintenance laser procedures and good medical skincare. Finally, a laser procedure can often help a plastic surgeon treat a patient who does not really need surgery yet, so that the patient does not have to be referred elsewhere.

My advice always starts with telling fellow surgeons that

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Hospital Administrators Are Not Always Honest

Hospital administrators have an agenda that's not always aligned with yours.

I used to do emergency work at a hospital in a large chain. It was hardy profitable and became less so over time. When I moved an hour away I sought to limit my emergency exposure for obvious reasons. The hospital administration cited sections of the Bylaws and Rules and Regulations that mandated that surgical specialists take call. This was specified for Plastic Surgery and Orthopedics.

Later and entirely by accident, I found out that the Orthopedists were being paid to take this emergency call by the same administration that was citing those hospital documents. Essentially they were being paid to take call from 15 minutes away whereas I was required to take call for free from four times the distance. Needless to say I dropped that hospital after briefly entertaining legal action. So soon after my divorce I hardly wanted to enrich another attorney. They are much smarter about getting paid than physicians are. I did inform a contact at the local newspaper who passed on the story stating that the public doesn't really care if a doctor gets screwed over. I found that a bit amusing.

As the story evolved I extended my practice up the street not so far away and something similar almost happened again. This time the administration in my new acute care hospital sought to get into an arrangement with me to take call. They were very quick to stipulate that this arrangement was to be secret. It was to involve some kind of payment from the hospital. The thought left a bad taste in my mouth. Emergency call is a loser. I just stopped taking it.

The moral of this story is that you should not expect hospital administrators to be honorable people. Entering into any kind of business arrangement with them especially a secret one is liable to be unfair, unjust or just plain illegal. You might want to avoid that.

Laser Liposuction & Skin Tightening - Emperor's New Clothes?

Does laser assisted liposuction really provide all of the skin tightening benefits that the manufacturers claim?

We are in pursuit of many Holy Grails in plastic surgery, from scarless post-surgical healing, non-invasive liposuction and implant-free breast augmentation to non-invasive skin tightening. With the advent of laser-assisted liposuction (LAL) came the promise from the manufacturers that we have finally achieved a way of combining "minimally invasive" fat removal with skin tightening, sensationally treating two maladies with one procedure.

I been involved with LAL for many years, and it has been the primary revenue driver in my practice for nearly five years running. I began to perform the procedure when the machines became powerful enough to actually generate enough subdermal heat in a timely fashion to potentially create significant collagen remodeling and hopefully result in skin tightening. My case load quickly became large enough that I was asked to be a national speaker for one of the dominant laser companies educating other physicians on the use of LAL. As such, I delved into every published paper even remotely relating to heat-generated skin tightening and laser assisted liposuction. Over the years, I have been able to merge a huge surgical experience with the science behind the procedure and draw some fairly clear and simple conclusions on the issue of skin tightening.

Setting up a patient for potential skin tightening is fully dependent on generating ample subdermal heat to initiate collagen denaturation and subsequent remodelling. Generally, this temperature is felt to be between 40 to 45 degrees celsius.  At around 47 degrees celsius, skin blistering and burns occur.  With proper time, temperature-monitoring devices, and careful technique, adequate temperatures can be achieved. Getting the skin to this temperature range takes time and significantly prolongs the procedure. Additionally, the risk of seroma escalates the longer you spend with the tissues in this temperature range in my experience.

In about 15% of cases, I see clinically visible skin tightening which I don't feel I would have seen using other techniques. This skin tightening is not the equivalent of excision techniques, but typically limited and subtle. This is obviously purely my subjective opinion to be clear, and I cannot say that these same results may not have occured witht the same frequency had I used other liposuction techniques.

The science of LAL and skin tightening is clear that some tightening does occur and is quantifiable. But this does not predictably translate into clinical relevance. I have now performed nearly 1000 LAL's and no longer educate my patients that LAL is a good method of tightening skin. The limited degree of tightening I credit LAL for is not enough to call it a clinically relevant skin tightening procedure. The majority of new LAL consults in my practice present with the impression that LAL is going to tighten up their loose skin while removing fat. The notion is dominant on the internet and even in print ads. I politely educate them that although there may indeed by some skin tightening, this will be subtle at best. In my opinion, the advantages of LAL lie elsewhere, particularly in a somewhat easier recovery.

I continue to hear from colleagues who also use LAL that they believe in the skin tightening.  I don't know if this is a case of "The Emporers New Clothes" or not. I have pushed the envelope in terms of thoroughly heating up the skin to appropriate temperatures and length of time, but only see minimal tightening and an increase number of seromas. I continue to use LAL heavily but no longer tout skin tightening as being an expected end point.

Samuel Lam, MD, FACS: Plastic Surgeon, Artist & Entrepreneur In Dallas, Texas

Double board certified in facial plastic surgery and hair restoration, Dr. Lam keeps himself busy with his Ova skin care line and lecturing worldwide.

Dr. Sam Lam is a triple board-certified facial plastic surgeon who is world renowned for his pioneering work in facial rejuvenation and hair restoration. He is the owner of the 27,000 sq.ft. Willow Bend Wellness Center. He has authored five major medical textbooks, Comprehensive Facial Rejuvenation, Cosmetic Surgery of the Asian Face, Complementary Fat Grafting, Simplified Facial Rejuvenation, and Hair Transplant 360 along with over 150 book chapters and scientific papers. He lectures monthly nationally and internationally with well over 100 lectures to date. He is the 2002 winner of the John Orlando Roe Research Prize for his research on skin rejuvenation.

Name: Dr. Samuel M. Lam
Clinic: Lam Facial Plastic Surgery Center
Location: Dallas, TX
Website: lamfacialplastics.com, hairtx.com, ova-skin.com

That's interesting: After 2 years of research and development, Dr. Lam launched his new skin care line, OVA, that features plant-derived stem cells for skin rejuvenation, that is simple to use with only one morning product and one evening product.

He is an accomplished artist having completed all of the illustrations for three of his medical textbooks along with many drawings for his scientific articles and book chapters. He enjoys painting during his free time and has on display over 150 of his original paintings in the new wellness center. He's also a certified PADI divemaster.

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Dr. Tahl N. Humes: Vitahl Medical Aesthetics In Denver

With two physicians, 30 years of combined aesthetics experience, and inclusion in the top 1% of Botox injectors in the US, Dr. Tahl Humes is rocking it at Vitahl Medical Aesthetics in Denver.

Name: Tahl N. Humes, MD
Clinic: Vitahl Medical Aesthetics
Location: Denver, CO
Website: vitahl.com

That's interesting: Dr. Tahl Humes is a Laser Trainer and Spokesperson for Cutera Lasers. She is in the top 1% of Botox injectors and the top 5% of Juvederm injectors in the country. 

In addition to serving as Medical Director for VITAHL Medical Aesthetics, Dr. Humes practices Internal Medicine at Saint Joseph Hospital in downtown Denver. 

You're an Internal Medicine Attending at a hospital in Denver. How (and why) did you end up making a move into cosmetic medicine?

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Dr. Stephen Bresnick: Plastic Surgeon in Encino, California

Dr. Bresnick discusses how he balances his teaching career and private practice after 15 years as a plastic surgeon. 

Name: Stephen Bresnick, M.D., D.D.S., M.S.
Clinic: Encino Plastic Surgery
Location: Encino, CA
Website: drbresnick.com

That's interesting: Dr. Bresnick has published nine books in medicine and science and has authored over 20 articles published in medical journals.

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Dr. Sabine Zenker: Aesthetic Dermatologist In Munich, Germany

Dr. Sabine Zenker welcomes us to her clinic in Munich, Germany and she shares her thoughts on cosmetic dermatology, technology, and the operations of her clinic.

Dr. Sabine Zenker is a well know European dermatologist who has a passion for clinical research and teaching that we've been wanting to interview for some time. We finally got together to learn what this German dermatologist thinks. 

Name: Sabine Zenker, MD
Clinic: Dr. Zenker Dermatology
Location: Munich, Germany
Website: dr-zenker.de

That's interesting: Dr. Sabine Zenker is the consultant dermatologist for L'Oreal Paris and an internationally recognized authority on micro-invasive techniques. She is well known for her clinical research into both established and innovative technologies and treatments, teaching, training, and continuing professional development both in Germany and internationally.

She contributes regularly to medical journals, public press, print, TV and multimedia. Sabine Zenker is a member of a large number of national and international societies including DDG, AAD, ASCDAS, AAAACS, EADV, ISDS, DASIL etc. She serves as executive board member of ESCAD. She is also a speaker and clinical trainer on almost any recognized national and international congress in the aesthetic medical field

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Dr. Karen B. Vaniver: A Plastic Surgeon in Seattle

Breast cancer advocate, Dr. Karen B. Vaniver is paying it forward from her plastic surgery clinic in Seattle, Washington.

Name: Karen B. Vaniver, MD, FACS
Clinic: Seattle Plastic Surgery
Location: Seattle, WA
Website: drvaniver.com

That's interesting: Dr. Vaniver's essays on women in plastic surgery and the role of spiritual practice in plastic surgery have been published in the Journal of Plastic and Reconstructive Surgery. She has worked internationally with Interplast, a not-for-profit organization providing free reconstructive surgery for children and facilitates a support group named "Girltalk". She is the creator of Dr. Karen B. Vaniver Breast and Body Recovery Serum.

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Where Does Creating The WOW Factor Begin?

Have you ever been put in the bad situation of believing you need to fill an opening out of need? You post and ad and literally the first few people that respond and can walk and chew gum get the job.  How did that ever work out for you...

There is a real skill set to interviewing & selecting the "A" players that will create the WOW factor even without all the tech behind them. The question I'm most often asked is how to find them, interview them and hire them.  Here are a few tips to consider.

1.  Start with ad itself. Don't flour up the position or your establishment to make it seem like a dream job.  Instead, think of what you specifically need for the position you're trying to fill and use language that will weed out anything other than "A" players. In other words don’t talk about your wonderful environment. Talk about the demands of the position.

2.   Weed through the stacks of resumes and make piles of A & B applicants. All others can be put in a rainy day file for a possible another look. Now send an email to each of your A/B possibilities asking them to describe in specific terms what they can do for your organization. Then sit back and evaluate who you want to bring in for a face to face meeting. In order to hire a WOW employee they need to really impress you in this phase.

3.  At this point you're now meeting the applicants. Remember your job is to find the best "A" level player. Now you have to find out if they can think on their feet and react positively to pressure.  For myself I inform each applicant that regardless of what they are being hired for that every position also has three responsibilities.

   A.  Everyone is in Sales

   B.  Everyone is a Customer Advocate

   C.  Everyone is responsible for outside marketing activities and needs to bring in 5 new patient per month through those efforts.  In short they will need Evangelize how we are and what we do.

Now at this point you will begin to weed out the producers from the pretenders but for me, there is still one more test. I call it my pen test but feel free to create your own. I tell the applicant that I need them to role play for me. I tell them that I want you to sell me a pen and not just any pen. I want you to pretend that there are 3 other pen sales people in the waiting room all trying to sell me the exact same pen you're trying to sell me. I then count down from 5 and it's roll play time. 

What you're looking for is the applicant that can take the heat of the moment and find some way to shine. Funny thing is that I'd estimate that 75% of the over 1,000 people I've interviewed in my life fail this test. Some break down and cry, some stammer then shut down, some freeze and walk out and some hit it out of the park. I submit that if a candidate can't handle selling a pen how the hell are they going to sell aesthetic services?  If they can't handle the pressure of a simple role play how will they handle the irate patient we get from time to time. If that can’t sell you a pen that’s the same as 3 others how can they sell Botox & Laser treatments that are same at other practices in your area.   I’m constantly amazed at how few staff members at other organizations I meet can’t give a simple elevator pitch as to why I should buy from them vs. the competition.  If they lead or bring up price in the first sentence or two I can assure you the organization is floundering on failure.

So, seek out the "A" level players.  They exist but you need to attract them, hire them and retain them.  The last one might be another topic to discuss...

Effects of Changes in the Medicare Physician Fee System

Relatively newly practicing physicians may not know that the Medicare physician payment system changed pretty substantially in the early nineties. This was by design.

The perception of those who designed this new system was that certain services were overpaid and others underpaid. It likely had much more to do with ratcheting down the costs of health care. As physician fees constitute only 10-20% of the entire equation, the wisdom of concentrating on physician’s fees to change the system is perhaps questionable. This is what was done nevertheless.

A cornerstone philosophy of the new system was that procedure-based specialties were overpaid. The physician fee system prior to this was based on usual and customary fees. This newer one based payments on a model that paid for a service at a uniform rate regardless of who performed it. While this seems fair on the surface, it had predictable effects.

Why would a surgeon with much higher overhead remove a lump in a patient if the new payment system put the procedure in a revenue negative position? The practice of surgeons removing certain lumps gave way to family practice and dermatology physicians removing many of them. These were the only specialties that under the newer system could turn a profit doing so.

The Medicare fee schedule economically regulates procedures in medicine. It also indirectly fed the growth of cosmetic medicine and surgery as this was the escape hatch many practitioners sought as the Medicare boom feel upon us. Surgeons interested in turning a profit quickly figured on what paid adequately and more importantly on what did not. As my grandfather told me as a young child, everyone needs to make a living. It is perhaps unfortunate that doctors do not discuss these matters with patients when telling them why they cannot offer a service. Is it really ever wrong to tell your patients the truth?

Dr. Kevin D. Light: Cosmetic Surgery & Anti-Aging Medicine In Dallas, TX

Bio-identical hormone therapies, cosmetic surgery, aerospace medicine and battling insurance policies with Dr. Kevin Light.

After meeting Dr. Light at the Medical Fusion Conference last year, we decided that we wanted to know more about this former vet turned cosmetic doc.

Name: Kevin D. Light, DO, MBA
Location: Dallas, TX
Website: tifm.com

That's interesting:  As a board certified General Surgeon, he practiced internationally with the US Air Force for 8 years. He was also lucky enough to be selected to attend the USAF Aerospace Medicine program early in his Air Force career, so he also served as a flight surgeon, that put him in the back seat of T-38, F-15 and F-16 fighter jets for 8 years. He was one of the first medical teams placed in Saudi Arabia during Operation Desert Storm and has received two Air Force Commendation Medals. He was Chief of Surgery during extended assignments in Germany, the Kingdom of Jordan and Guantanamo Bay, Cuba.

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