Kiva.org - microloans for third world entrepreneurs.

Kiva.org Kiva lets you connect with and loan money to unique small businesses in the developing world. By choosing a business on Kiva.org, you can "sponsor a business" and help the world's working poor make great strides towards economic independence. Throughout the course of the loan (usually 6-12 months), you can receive email journal updates from the business you've sponsored. As loans are repaid, you get your loan money back.

I've added a banner to the bottom left of this site. I've used Kiva and found it to be a reputable business/charity. Kiva lets you provide capital that helps an entire economy rather than a one time donation. And the loans get repaid.

Med Spa Advertising: Define your positon.

Mindshare: What do your customers think of you?

Your business is defined by its 'position'. (What it means in a potential customers mind.) Every successful business takes a position. If you're a plastic surgeon that specializes in breast augmentation, that's your positon; the breast augmentation specialist. Apple = cool and easy. Audi = safe. Listerine = kills germs.

If you don't have one, you're in trouble. If you're in search of a position, figure what the always is. Then do something else. Toothpaste always comes in a squeezable tube. Business travelers always use a travel agent. Politicians always have their staff screen their calls.

Figure out what the always is, then do exactly the opposite. Do the never. Think about what physicians 'never' do.

Doctors make you wait.
Doctors won't give you a direct answer.
Doctors talk down to you.
Doctors charge you for everyting they can.
Doctors want to sell you something.

While these may be generalizations, you'll recognize that they are not far off of what your clients perceptions are.

Surface offers a number of things that potential clients don't expect. Some of these we do just because they're unusual and other docs don't.

We offer flat pricing and we'll tell you on the phone how much something costs.
We offer 1 hour free consultations with our physicians.
We focus exclusively on education not sales.

When I ask physicians 'why' they're doing something a certain way, the most usual answer is that 'everbody else is doing it that way so it must be the way to do it'. Wrong. Doing what everyone else is doing is the way to make your business nondescript and mediocre. Do what no one else is doing in ways that work for your clients.

What's with the Medical Spa price wars? Cheap is no way to build a medical practice.

Medical Spa physicians always seem to want to offer the lowest price. Why?

I speak with a lot of physicians. One of the first few questions that I'm asked has to do with pricing. (read the MedSpa Business or Med Spa Advertising Q&A here.) Physician and medical spa owners seem to be highly agitated by not offering the lowest price in town. This shows directly a lack of competence and belief in their own abilities. If you can't imagine why anyone would come to you except that you have the lowest prices, you have big trouble.

Anyone who will choose you based on price, will leave you just as quickly. That's OK if you happen to be able to deliver services at substantialy reduced costs compaired to your competiton (think Wal-Mart) but it's certain death if your not the clear low-price leader (think K-Mart). Does your Botox, Restylane, Thermage tips, or staff cost significantly less that your competition? No.

The only sustainable business you can build is a reputation on something other than price. Make a decison about where you want to be and start moving in that direction. No woman ever recomended Surface to her best friend with 'they're the cheapest'.

From Seth Godins Blog:

Cheaper is the last refuge of the person who's not a very good marketer. Cheaper is easy and cheaper is fast and cheaper is linear and cheaper is easy to do properly, at least at first. But cheaper doesn't spread the word (unless you are much cheaper, but to be much cheaper, you need to be organized from the ground up, like Walmart or JetBlue, to be cheaper). They are, you're not.

Cheaper is a short term hit, not a long term advantage. Cheaper doesn't create loyalty, because the other guy can always figure out how to be cheaper still, at least in the short run.

Medical Spas Online hits 5000... So where's the beef?

It's something of a surprise to see that Medical Spas Online now has more than 5000 unique monthly visitors. I feel somewhat remiss in that I haven't been posting as regularly as I might. While I'm not big on excuses, here's what's been going on and a few things in the pipe.

• Surface inked a deal with a VC firm that's resulted in the creation of a new company, Surface SE (South East). This new company is headquartered in Nashville where the first SurfaceSE Beta site is about to go live. SurfaceSE is charged with a much larger roll out that should include a number of locations in the South East of the country. (There will be more on this as it progresses.)
• Blogging does actually take time and it's common for the occasional break to recharge the batteries.
• I've been devoting some time to two other start-ups that have resulted both from this blog and speaking to physicians:
• A business start-up book for physicians and businesses on how to conceive, open and run a cosmetic practice. The book will be available for download from this site when it's completed.
  
• And a consultation and training program for physicians in the aesthetic market. (You can read more about what I think of most of the current crop of consultants and franchises here.) I receive between 5 and 10 inquires for advice, training or consulting each week and have decided to put my money where my mouth is and build a program that works. I envision this new training program to be much more along the lines of 'mentoring' and consist of 'how to' training in the business, operations and marketing aspects of the business as well as medical training. You can send me an email (jeff 'at' surface-med.com) if you would like to be alerted when this system becomes available.
  
• There are a number of businesses that I'm either starting myself or advising others on. You can read more about these on my blog that deals with business outside of cosmetic medicine. You can read my Nimble business blog here.
  

If you haven't done so already, check out the Physician to Physician and Business Discussion areas. There's some great info.

Follow the medical spa money trail in Florida. A comment worth repeating.

An excellent comment from Denise Curtis (a PA) from a discussion thread on the new regulation governing medical spas in Florida.

Dear MDMan,

All PA's are required to be registered with their state medical boards and by law are required to have continuing education. In NC, the requirements are EXACTLY the same for PA's and MD's, meaning we have to have 100 hours of Category I CME's every 2 years. Furthermore, PA's must pass a national certification exam before practicing and must sit for this exam every 6 years to maintain their certification. Physician Assistant programs now require a BS degree prior to entering PA school and then grant a Masters upon completion. Unlike nurse practitioners, PA's have always maintained their dependence uppon physicians. However, this does not mean that PA's cannot practice independently of their supervising physician.

It is sad that there are many places in this country where a PA is only health care provider willing to work for very low wages to provide basic health care the those rural areas. In those situations, the PA may be the only provider for hundreds of miles. With the passing of these bills not allowing PA's to see patients independently in medical spa settings are they then going to require an MD to be present in all of those health department and rural settings? Think about this for a minute. Basically, they are saying that a PA is not qualified to do laser hair removal but that a PA can provide health care in lower socioeconomic settings. In some of these settings, the PA's run codes, put in A lines, triage critically ill patients, only because there is a lack of MD,s willing to work in those settings.

Do you think this country can afford to put such restrictions on health care? Furthermore, do you think that laser hair removal is more dangerous than running a code?

It is always about the money and control!!!!!

Denise Curtis 

Is medical advertising ethical?

There is a new discussion area: Advertising + Marketing

 
The prevalence of advertising for cosmetic medicine brings out the charlatan element. Plastic surgeons and cosmetic dermatologists have been in this arena for many years but the addition to the market of doctors who have never advertised their services before brings the ethical conflict up more and more.

Here's what the American Medical Association says about advertising medicine:

2.2 Advertising
a. Confine advertising of professional services to the presentation of information reasonably needed by patients or colleagues to make an informed decision about the availability and appropriateness of your medical services.
b. Make sure that any announcement or advertisement directed towards patients or colleagues is demonstrably true in all respects. Advertising should not bring the profession into disrepute.
c. Do not publicly endorse therapeutic goods as defined under the Therapeutic Goods Act 1989 (C’th), contrary to the Therapeutic Goods Advertising Code.
d. Exercise caution in publicly endorsing any particular commercial product or service not covered by the Therapeutic Goods Advertising Code.
e. Ensure that any therapeutic or diagnostic advance is described and examined through professional channels, and, if proven beneficial, is made available to the profession at large.

Botox for facial scars.

...an injection with botulinum toxin early after the occurrence of a wound = improved healing.

An anesthesiologist moving into cosmetic medicine.

I had occasion last Friday to be visited by an anesthesiologist from Denver, who is interested in learning more about Surface Medical Spas.

Dr. Nelson is currently a member of a rather large group of anesthesiologists (55). In choosing her residency, she had felt that anesthesiology was a good fit since it was procedure oriented, and a high paid specialty. She has since been slightly disenfranchised, and to be honest - bored. She is also not terribly excited by the fact that she does a lot of pediatric anesthesiology, and is on call as a junior member of her group so that she has interrupted weekends and evenings.

Dr. Nelson called me a few weeks ago to ass about Surfaces cosmetic and business training for physicians. I spoke with her at some length about what we did, and what I thought we might be able to help her with. I suggested she come visit us, if she felt so inclined, to learn more.

(I have found in the past that, speaking on the phone is great, as far as it goes - but, the amount of information that you can convey over the phone during a half-hour or hour-long phone call is just not that great. Whereas, six hours of speaking with sedition's and staff, and treatments performed, and consolations done, and how our office is run, conveys a huge amount of information, and has always been extremely beneficial.)

Dr. Nelson in on a Thursday, and had booked a plane ticket home on Friday at around 2:00 - which didn't give us much time. I met Dr. Nelson for breakfast, and we talked about both where she was as a physician, where she wanted to be, how she might go about getting there (moving from Anesthesia into cosmetic medicine, is still a bit of a stretch) I was impressed with Dr. Nelsons interest and drive. She had already spent a tremendous amount of time researching her options and had looked at several of the current batch of medspa franchises and licensing consultants. She half-jokingly referred to several of them as 'evil'.

Doctor Nelson and Doctor Bergstrom spent a brief period of time just talking and chatting about history and backgrounds before was invited into one of Doctor Bergstrom 's consultations.

(Surface consultations are performed very differently than what is typically done. First of all they are free. Secondly they are an hour long. Our patients are able to spend an hour of physician time discussing anything they want, including how much stuff hurts, how much stuff costs, whatever... )

After the consultation, Doctor Nelson had maybe about another hour that I spent talking to her before she had to catch her plane. She was, I think it is safe to say happy that she came. She expressed to me a number of times during that hour that she felt she had found her new home.  In fact, one of the direct quotes was, "I want to be Doctor Bergstrom," which I found both humorous and flattering.

It will be interesting to find out if or how she pursues both her contacts with Surface as well as any other potential avenues. We left it with her thinking about what her options might be in the near future. Whether she joints Surface in some capacity, or opens up a clinic of her own, I  wish her the best of luck.

Aestheticians And The Doctors Who Love/Hate Them, Part 2.

I first posted here about Estheticians and the doctors who love + hate them.

Since that first post I've received some negative comments from estheticians who think that they're a pleasure to work with.  You can read a thread of esthetician comments on medical spas and physicians here.  While they blast me as having a bone to pick, you'll notice that twice during the thread doctors are referred to as 'greedy bastards'. 

If anyone's still unaware, embezzlement is the number one problem in medical clinics.

Here are some memorable quotes: 

Well said, Nondy!! I have never worked with a doctor as an esthetician but worked with plenty of them as a nurse for 25 yrs. and yes, they are greedy bastards!  This is why I don't believe anything negative they print about our profession, our products or our equipment not being up to standards.  They just want all the business streamlined to them and will stomp on reputable esties to get it.

I will say not ALL docs fall into this category. It's just precious few, I have found, williing to think outside of the box and give credit where credit is due... Overall though, I found the article to be offensive.

The esty's were paid low hourly wages with no tips... If I go back to the treatment side, I think I'd prefer spa/resort and a percentage of the services/sales over my experience in medical.

How to blacklist patients with medical malpractice claims.

The website lists plaintiffs who have brought unsuccessful cases. 

The company, which says it’s based in the Caribbean to shield itself from lawsuits, hopes eventually to expand into a nationwide database. An information page for doctors on the site reads: "A physician may feel that a patient who has filed a medical malpractice suit and lost a trial before a jury of their peers harbors unrealistic expectations of their physician and probably of the health care system at large. Accordingly, a responsible physician who feels that a patient’s behavior demonstrates unrealistic medical expectations has both a right (and arguably a responsibility) to refuse elective care to that patient."

Thermage: Lunch with the VP of Sales.

Today I had lunch with Clint Carnell, Vice President of Domestic Sales for Thermage.

I  met Clint over at a local pub in Park City and we sat down to chat about Thermage and Surface. (Clint didn't know about this blog.)

Clint is a fairly recent addition to Thermage's management team as the Vice President of Domestic Sales. Most recently, he came from the company Bausch & Lomb, where he oversaw the turn-around of a 25M division of B&L. He has also worked for Johnson & Johnson and has a long resume of larger companies. Clint seems to be a really nice guy. I liked him tremendously and I thought he really understood the marketplace and what was taking place.

I have had problems with Thermage in the past, mostly having to do with the way that I think they were selling their devices to physicians. Over our pizzas, Clint and I talked about a number of problems that I think Thermage is facing and what's happening to the market and physicians. His answers were educational, not in the least defensive, and straight forward.

Themage has been saddled with a number of problems in the past; technician error, physician education, efficacy, pain, expense, and other issues have combined to cause a recession in what was initially a promising growth curve for the adaptation of radio frequency skin tightening. In my opinion, most of this had to do with the way that Themage sales reps were presenting the device to physicians as a fire-and-forget type of technology that you could have a technician performing in the back room while you saw other patients. No physician oversight led to a vicious cycle where, since the treatment was painful, technicians would continually turn down the treatment in order to get the patient through, the patient wouldn't see any results and would complain to the physician, and then the physician would get pissed off. This cycle has ended up leading to declining Themage sales and devastating impact to Thermage's reputation among physicians.

Starting in about September 2005, Thermage has experienced a rebirth of sorts, in part because of a new management team and sales force. They've introduced bigger treatment tips (effectively reducing the price per area) and they have a number of new areas including eyelids and body treatments. They're bringing out a number of additional tips that will go deeper into the dermis to treat cellulite, as well as some specifically for fine lines around the eyes.

This has resulted in Thermage actually starting to experience growth in sales again, which is both good for them and treated patients. They have retrained their sales force and are looking to not only offer additional treatment tips for their device, but potentially expand their offering. The end game of course is that Thermage expects to become a publicly traded company in the future. (Clint and I spoke about this, but since I'm unsure what he may consider confidential I won't go into details.)

Thermage is also supporting the top Thermage providers significantly better than they have in the past. Two years ago providers were treated exactly the same whether they provided one Thermage treatment a year or 1000. As a business, Thermage has decided that the top providers are both more lucrative as a business as well as potentially more beneficial to the patient since Thermage is one of those treatments that is very treatment dependent. It is not a push button technology and results can very dramatically depending upon the treatment levels and number of hits.

(One of the gems that Clint dropped was that they are not focusing more and more of their marketing efforts on those physicians who are actually performing Thermage and expect that other physicians in the market place will look to those leaders and as they become mass market adaptors of this technology.)

In discussing the medical spa market that exists now, Clint was pretty much in agreement with me about the state of the market including medical spa consultants and franchises.

Interestingly, when the discussion turned to plastic surgeons and dermatologists, Thermage (which had been focused almost exclusively on these two specialities in the past), is becoming more and more open to what Clint described as "Blue Collar Doctors" who are physicians that are treating hundreds or thousands of patients a year that might potential be outside of cosmetic medicine as a speciality.

It'll be interesting to see how the plastic surgeons and dermatologists respond to this since there was discussion also about the recent laws passed in Florida preventing non plastic surgeons or derms from overseeing outside clinics.

I talked to Clint a fair amount of time about what their competitors were doing, including Cutera's Titan,  Palomar's new Fraxel like head and a number of others, and asked him specifically as to whether or not Thermage was worried that some of the technologies were being developed could potentially cause Thermage problems. Clint responded that he expected some good technology development out of all of these competitors and I was pleasantly surprised to see that he didn't take the opportunity to bad mouth any of them, but he felt  that Thermage was still the "gold standard". Our own physicians tend to agree with that statement.

But Thermage faces significant hurdles Fraxel, Cutera's Titan IR head, Palomars Fraxel-like head, and a number of other technologies that are being developed and are getting better. Thermage is going to have to become more than a one trick pony in order to survive as the market consolidates and Clint expressed that was indeed their understanding as well. It will be interesting to see if Thermage is able to execute over the next 24 months.

I was impressed with Clint and if he's representative of Thermage's new look I think it bodes well for Thermage.

Thermage is comission. Titan & Fraxel are hourly.

As business models: Thermage is commission, Titan & Fraxel are hourly.

(Thermage + Fraxel discussion threads)

I had lunch with Clint Carnell, Vice President of Domestic Sales for Thermage today. While we were talking about the current state of the medical spa market he referred to the Thermage business model as 'razors and blades' and it triggered the thought that there was an analogy with commission vs. hourly employees.

Physicians seeking to minimize risk will often try to hire staff on commission with the hopes that they'll achieve two things; a motivated employee, and lower cost per treatment since they'll only be paying a percentage of treatments that are being performed. Nice in theory.

Here's the flip side. Commission robs you of success. This is a business that has very high fixed costs, but once those costs are met, there is a large potential profit to be made. As a business, its usually preferable to absorb those fixed costs if possible and keep the profit rather than have it diluted by paying commissions.

(That's why Surface has decided to grow as an entirely company owned business rather than persuing franchising with it's associated problems. If you have the capital, wholy owned businesses offer the most success while franchises offer the ability to grow the business using other peoples money.) 

Thermage made a radical decision to offer the 'box' (razors) for near cost, and focus on selling the disposables (blades). Smart enough. But Thermage is not charging 100% markup. Thermage tips probably cost around $12-$16 dollars to produce (that's a wild guess) but Thermage sells them for $450 or more. That's a helluva markup and it's led to a built in profit potential for anyone who can figure out a way around it as well as being a source of friction with those who have to buy them. (I have yet to hear any physician anywhere think that Thermage tips are a 'great deal'.) Refurbished Thermage tips came on the scene soon after Thermage launched and have even been studied for safety and performance.

Thermage faces a challenge in keeping providers happy with paying a commission on every treatment they perform. If they can, Thermage promises to be the gold standard for the foreseeable future.

Basement lipo proves fatal.

There's a question that's been posted in the discussion threads on what could happen if you get into legal trouble without medical oversight... here's the answer. A couple who performed liposuction in the basement of a home has been charged with practicing medicine without a license.