Family Doctors, 8 Laws of Medicine

Solo Family Doctor: Laws of Medicine 

#1 Dinosaur offers these truisms for docs.

• First Law: The Art of Medicine consists of amusing the patient while nature takes its course.
• Second Law: It is impossible to make an asymptomatic patient feel better.
• Third Law: The urgency of the test is inversely proportional to the IQ of the insurance company preauthorization clerk.
• Fourth Law: No good deed goes unpunished.
• Fifth Law: A patient's acceptance of a screening test is inversely proportional to its necessity for that particular patient.
• Sixth Law: Trauma survival is inversely related to the patient's value to society.
• Seventh Law: Fertility is inversely proportional to intelligence.
• Eighth Law: The better the surgeon, the more reluctant s/he is to operate.

Medspa Doc: Do you know what your patients are reading about you?

Cosmetic patients are smart & educated consumers.

Many of the patients who walk through your doors have expectations that are set by previous patients. Often those patients setting expectations are not yours. Some are benign, some are positive, a few are downright nasty.

As an example, here are some posts from Well Past 50, a site for women.

• Thermage: No pain, some gain.
• Mesotherapy: Taking off the inches. 
• Tummy Tuck: Good, Bad & Ugly

Patients have access to more of this information and there will be a time in the not to distant future where your practice will be listed with patient feedback and ratings from your patients posted on the site. (If you've purchased on Ebay you'll know how possessive buyers and sellers are of their feedback rating.)

These types of systems produce negative reviews out of proportion since it's motivated consumers that go to the effort of praising or trashing your practice. But you'll still have to deal with it.

Patients have more information now than they've every had and it's changing the way they are able to research and evaluate you. How will you fare when all of your patients can intereact with each other without you?

Rosacea? Melasma? Acne? Building community sites around medical conditions.

Self Organized Patient Communities

Patients with medical conditions often turn to each other for support. The web allows them to build a community no matter where they're located or how uncommon the condition.

Rosacea Patient Communities

• Rosacea Support Group
• Rosacea, Yahoo Health Group
• Rosacea News (a blog about Rosacea)
  

If you read these types of community posts you'll discover that there's a lot if information, but there are very few if any physicians participation in the discussion, even anonymously.

I read any number of sites each day where physicians are disseminating information, but not in these groups. Curious.

Klaatu Burado Nicotine; Translation: "Ain't medical science wonderful."

 From Uncertain Principals

...There is, however, one scene that has become unintentionally hilarious over the past fifty-odd years. Two Army doctors are outside the room where Klaatu (Michael Rennie) is being held, and they have a conversation that goes something like this (paraphrased, from memory):

Doctor 1: How old would you say [Klaatu] is?

Doctor 2: Thirty-five, or thirty-eight.

Doctor 1: He told me his age yesterday when I examined him. He's seventy-eight. He says his life expectancy is one hundred and thirty-eight.

Doctor 2: How is that possible?

Doctor 1: He says their medical science is just that much better that ours.

And then Doctor 1 leans over and hands Doctor 2 a cigarette, and they both light up.

Cosmetic surgery demographics by patient age.

Cosmetic surgery market by age.

The cosmetic surgery market consists largely of white females who already are committed to the perceived value of such surgical procedures; 97% of them fall between the ages of 19 and 64, and nearly 1/2 of them will have more than one procedure (either different or multiple procedures, e.g., multiple face lifts).

The non-surgical market demographics are similar but with a pronounced skewing towards younger ages due to the popularity of laser hair removal and similar non age-related treatments.

How do you define "beauty"?

Beauty is in the eye of the beholder, right? 

To some degree that is true.  Beauty is subjective.  When a patient says to me, "Doc, you just do what you think I need" I quickly remind them that very little of the procedures I perform are things that people "need."  Rather I try to do what people want.  So what if somebody doesn't know what they want?  Well that's were your experience can really make the difference.

Most of the time people have a fairly good idea of what bothers them when they look in the mirror.  If they need some prodding, then I try to steer them into one of two categories:  color or contour.  Some people would like their skin tone to be more even by removing pigment from broken blood vessels or sun damage.  Others tend to be more focused on their wrinkles or the texture of their skin.  So one woman may love her crow's feet, but hate her freckles and it's the exact opposite for the next woman. 

Why is all of this important?  Have you ever read one of those magazines (Allure, Glamour, etc) where they send in the undercover journalist to have a consultation with the plastic surgeon?  She goes to see about 5 different physicians and requests information on a nose job, for example.  And she leaves with a laundry list of procedures she "needs" and the nose job has now morphed into the chin implant, eye lift, laser skin resurfacing, etc.   Now she may have left the door wide open for the surgeon to recommend all the things that he thinks would be in her best interest.  But, in general, the tone the author takes in the magazine article is as if she's just been to the auto mechanic and they have tried to replace everything under the hood.  And the reader gets the impression that all plastic surgeons are out to up-sell every vulnerable, naive woman who walks in their door.

Now some patients may want to hear all the recommendations and then make an informed decision on their options.  But a great many of them will be so overwhelmed that they leave your office running as fast as they can and feel grateful to still have their features intact.   My practice involves no surgery.  We specialize in all non-invasive or minimally invasive technologies and so we tend to attract patients who favor doing less over doing more.  So it is important to read from them what they are interested in doing and what they could do without.  And much of the time, my patients who start out only wanting to know more about sunscreen end up doing fotofacials, Thermage, or Botox as we develop a relationship and they learn to trust me and our practice.

The surest way to have an unhappy patient is to recommend or talk her into doing things that she's not intersted in or could care less about.  She'll never really be thrilled with her results if that particular area didn't even bother her in the first place.  If you stick to what is of value to them and give them all their options (including services you might not even offer), then she will feel most confident about moving forward in whatever she decides to do.  And she'll trust you which is truly the cornerstone of the doctor-patient relationship.

Read about one woman's experience visiting 4 different plastic surgeons.

5% cut in reimbursement rates for Medicare.

Via Forbs.com: 5 percent cut in Medicare reimbursement next year.

Doctors were not happy about the announcement, which they had expected. Nearly half of physicians face payment cuts ranging from 6 percent to 20 percent, the American Medical Association said.

For the great majority of primary care physicians, the overall cut "will negate any payment increases specific to physician office visit payments," said Dr. Cecil B. Wilson, chairman of the AMA's board of trustees.

New PDT skin cancer light treatment for home use?

Via Medgaget

Professor Ifor Samuel, a physicist from St Andrews University, along with Dr. James Ferguson, head of photobiology at Ninewells Hospital, have teamed up to develop a new way to treat skin cancer.

From the press release.

A new light-emitting 'sticking plaster', which will revolutionise the treatment of skin cancer, has been developed by researchers at the University of St Andrews and Ninewells Hospital, Dundee. 

The new device, which builds on established photodynamic therapy treatment (PDT) methods, not only reduces pain but has the potential to be used by patients in their own home.

The breakthrough, a portable lightweight light source powered by a pocket-sized battery, is the brainchild of St Andrews' physicist Professor Ifor Samuel, and dermatology consultant Professor James Ferguson, head of the photobiology unit at Ninewells Hospital Dundee.

The pair teamed up four years ago to combine their expertise in photo-physics and photodynamic therapy to create a new way of treating skin cancer. The result is a 'light bandage' which contains its own light source and is so portable that patients can go about their daily business while under treatment.

Professor Samuel said: "By adapting the latest technology to an existing treatment method, we have developed a compact light source for treating common skin cancers. It can be worn by the patient in a similar way to a sticking plaster, while the battery is carried like an iPod."

The light is generated by an organic light-emitting diode, (OLED) and is a spin-off of Professor Samuel's work on advanced displays. "It's very exciting to be have developed a new technology that helps treat skin cancer patients," he said.

Professor Ferguson said: "This new device will have a major impact on the treatment of skin cancers. The light-emitting patch is a low-cost, portable and convenient method of treatment. Our initial pilot trials have already shown its effectiveness and we find patients requesting this treatment over conventional methods."

The new approach is much more convenient and comfortable than conventional methods as lower light levels are used (reducing pain), and the patient can move around during treatment.

Science debunks bloodsuckers as a statistical impossibility.

Via Wired: Science Nips at Vampire Myths

Do vampires exist? Efthimiou, a professor at the University of Central Florida, points to surveys that show American gullibility for the supernatural, and he doesn't like it.

Using his calculator, Efthimiou proves that if a vampire sucked one person's blood each month -- turning each victim into an equally hungry vampire -- after a couple of years there would be no people left, just vampires. He started his calculations with just one vampire and 537 million humans on Jan. 1, 1600 and shows that the human population would be down to zero by July 1602.

What a crock. Everyone who's ever seen Bram Stokers Dracula knows that not everyone who's bitten turns into a bloodsucker. Most of them are just drained and left for dead.

Sounds like an undead coverup to me.

Top 10 reasons why loyalty programs don't work.

Medspas consultants will often promote loyalty programs as a way to reward your best clients and build their loyalty to the practice. But loyalty programs are often not all they're cracked up to be.

10 reasons whyloyalty programs won't work in your medical practice?

1. Loyalty programs are based on discounts, which ‘train’ existing patients to expect 'sales' and wait out your normal prices.
2. They attract your most loyal patients who would happily pay a premium.
3. They confuse patients and staff and create customer service problems.
4. they discourage new patients by making them feel punished or excluded.
5. they encourage competitors to retaliate with me-too programs.
6. they damage your perceived image by making you a 'discount' store.
7. they reduce profit margins from your best patients.
8. they reduce your ability to serve patients at the highest levels.

Ok, there were only eight. But the point is, patient loyalty can’t be programmed. As soon as patients begin to feel ‘stalked,’ they choose ‘fight’ or ‘flight.’ They either figure out how to game the system, or else they seek care elsewhere.

Chaos causes medical mistakes, not incompetence.

How to "survive" an ER visit.

(and as bonus: Complexity causes 50% of all returns.)

"The main culprit isn’t incompetence but chaos: The nation’s emergency rooms are overburdened and underfunded, treating ever more patients with ever fewer resources. "You don’t want to scare the public, because hundreds of thousands of patients get cared for very well in emergency rooms every day," says Gail Warden, president emeritus of Michigan’s Henry Ford Health System, who chaired a trio of studies of emergency care released in June by the National Academies’ Institute of Medicine. "But the system is stretched, and it could be at a breaking point in three to five years."

Federal law requires that ER doctors and nurses treat everyone who shows up, regardless of ability to pay, but there has never been enough federal money to cover those costs—and that money is dwindling."

And from Complexity causes 50% of product returns.

Half of all malfunctioning products returned to stores by consumers are in full working order, but customers can't figure out how to operate the devices. Product complaints and returns are often caused by poor design, but companies frequently dismiss them as "nuisance calls.

The average consumer in the United States will struggle for 20 minutes to get a device working, before giving up.

Most of the flaws found their origin in the first phase of the design process.

This last one might be viewed as the most important. During the design of a system program or product, most of the problems with interface or use that are going to crop up are built into the system. .

Retail Medicine: Why do doctors want to open medical spas?

No end to physician problems:

-- The top five factors contributing to low morale were identified by the survey respondents as: low reimbursement, loss of autonomy, bureaucratic red tape, patient overload and loss of respect.

"I think that it is safe to say that no physician is optimistic about the future of medicine at this point," one participant wrote. Others seemed downright hopeless: "One thing that rarely gets mentioned is that, unlike other industries that are cyclical, the practice of medicine continually gets worse and worse, more intolerable, more onerous, with absolutely no hope or reason for any optimism either in the near or remote future."

The free-market is forcing doctors to extend office hours

Extended office hours are now the norm.

"Suddenly, faced with less compliant patients and unexpected competition, more and more doctors are doing the unthinkable: changing their hours to accommodate potential customers."

The 5 Stages of Consumer Decision Making that all your patients use.

When patients buy your services, they all engage in a decision-making process. Research shows that one of the major problems with businesses is that they fail in supporting the customers in this process. By understanding your patients needs and concerns as they progress through the decision-making cycle, you can build better and more successful medical practice.

The consumer decision-making process

Imagine that you need a new cell phone. The first step is recognizing your need. (You can insert 'want' or 'desire' instead of need.) Though you may have an idea of which phone you would like to purchase, you research your options to narrow the possibilities.

If you're a male, you go online and investigate manufacturers, resellers, and independent consumer organisations. You ask friends and colleagues for advice, and you visit a few stores to "kick the tires." You compare you options and finally decide to purchase what seems to be the best alternative, based on criteria like design, features, price. For men, this is a linear process.

If you're female you go through a much different, non-linear, decision making process that takes into account different variables than males typically choose. Men perceive this process as introducing a lot of extraneous noise into what should be a straight forward decision about cost vs.. benefits. Women are actually much harder to please because they're also buying a cell phone based on: What color it is. How it fits in their purse. cute factor, etc. They're deciding how much 'faith or trust' to put in the business. One process is not 'better' than the other, they're just different.

Warning: This is where many men don't get it. Women are using criteria that men don't understand so men tend to disregard this process. While women are harder to please, they are much more loyal consumers if you can satisfy them initially. Men look for features, women look for faith. 

After your purchase, you assess whether it lives up to your expectations. You might find that the phone is able to do what the manufacture promised, but that the navigation is unmanageable. You decide that you will never buy this brand again.

Your decision-making process can be described as five different stages:

 
The customer decision-making process and its five stages

The complexity of this process can range from careful analysis to pure impulse. While an impulse buy, such as adding additional services or products to an existing appointment, can take place instantaneously, complex purchase decisions stretch over a long period of time. This buying process is an iterative process, where patients may collect information from different sources and repeatedly return to re-evaluate and compare the information they have found. Women are particularly adept at this and consider any number of points that you may not be aware of in this decision making process. One of the most important of these could be described as 'feel'. (Men typically descry this type of methodology, often causing them to dismiss what women see as the most important part of their decision making.)

The customer funnel

The Web is a great tool for information research. Studies show that the Internet is now the primary means by which people get key information. This counts for commerce in particular. People expect to be able to find information about products they are considering buying, even if a company doesn't sell its products online.

Considering peoples' high expectations about the information and services available online, it's disturbing to see just how bad commerce web sites are at selling.

Lets look at a study on consumer buying patterns online as an illustration: From their tests of consumer commerce, researchers from the usability consultancy UIE have discovered that the buying process acts as a sieve, where customers are inadvertently filtered out at each stage of their decision-making process. UIE's studies show that out of 100% of purchase-ready customers completely intent on buying, only 34% will actually make the purchase.

 

Studies show that  buying process acts as a sieve, where customers are inadvertently filter out at each stage of their decision-making process.

 

At the information search stage, 9% weren't able to find the products they were looking for because they couldn't identify the right product category or find product options. 8% of the shoppers who succeeded in finding products gave up because the product lists didn't provide enough information to identify purchase options, or because they were confused by going back and forth between product lists and product description pages in order to decide if the products would fit their needs.

UIE's researchers found that the major problems occur when customers want to evaluate alternatives. Only 25% of the shoppers who reached this stage proceeded to the next. Some stopped because they realized none of the products would fit their needs, but most because the product information was so inadequate that they couldn't tell if the products they were interested in satisfied their needs.

At the purchase stage, 13% dropped out because they didn't want to go through the required registration process or because they where disappointed by poor shipping charge policies.

UIE also found a surprisingly high amount of problems in the purchase evaluation stage. 11% percent of the shoppers where either so unhappy with a product that they returned it. Some of the shoppers told UIE that they returned a product because it wasn't what they expected, which suggest a failure in setting up the right expectations in the product evaluation stage.

Knowing the customers' decision-making process

The most interesting thing about the study is that while they observed critical usability problems because of inadequate or poor information:

• Customers couldn't identify purchase options
• Customers couldn't decide if the products would satisfy their needs
• The product presentations and descriptions raised wrong expectations, which made customers unhappy with their purchases

Businesses simply fail in supporting the consumer decision-making process by not taking their customers' information needs into account.

Recommended reading: Marketing to women.

As a Physician, you will have little chance of knowing exactly which information needs patients have when evaluating specific services or treatments. To support the ' decision-making process, you need to understand which needs and concerns they have when making a purchase decision. There will often be patients who unintentionally mislead you by discussing a number of issues that appear to be of equal weight when they really have an overriding concern. You need to recognize how to discern exactly what a patients hierarchy of wants is.

The most effective way of discerning what is motivating your patients is to ask a number of very specific questions during a consultation. Surface physicians are trained, sometimes through trial and error, to ascertain the specific motivations that brought a patient in so that they can support the patients decision-making process.

Information search

The basic prerequisites for patients making their way through the information search stage is that they are able to find services that fit their perceived needs, and that they can easily identify their available options.

In order to support the decision-making process at this stage, you'll need to know:

• How will potential patients be inquiring about purchase options?
• What basic information do patients need in order to identify purchase options?
• What information do patients need in order to decide which product criteria are important to them?
  

Evaluation of alternatives

The problem with the operations in most clinics is that there's systems in place to effectively solicit this information. We saw above how a large number of customers dropped out at this stage simply because the information provided was inadequate. They couldn't decide whether the products they were interested in would fit their needs. All of your staff (especially the physician) should be acting as a skilled educator, and have answers ready to any question or concern that the customer might have.

Some of the critical questions that you need answers to are:

• What information does the patient need when evaluating treatment alternatives?
• Which product evaluation criteria will customers be using and which are most important?
• Which concerns will the customers have and how can we address them proactively?
• How can we encourage patients to maintain contact with the clinic?

Purchase decision

At this stage emphasis should be on providing the easiest possible way for patients to carry their purchase through. In the UIE example, we saw how obstructive policies made the process difficult. Patients want an easy way to find out where and how to buy.

Purchase evaluation

The outcome of the post-purchase evaluation stage is a level of customer satisfaction or dissatisfaction, which is determined by the customer's overall feelings about the effectiveness of the treatment and the experience.

The number on effect on patient satisfaction is the management of patient expectations. Most patient dissatisfaction is a consequence of not encouraging accurate customer expectations at the product evaluation stage. In order to avoid this, we have to make sure that the entire system, from initial contact to treatment, sets up the right expectations.

Designing for customer decision-making

Once we feel confident about customers' needs and concerns, our next challenge is to decide how to present the information to the customers in a way that supports the decision-making process. This is as much science as art. It is common for physicians to inflate their abilities in this regard. It's been my experience that every physician can benefit from constructive criticism and  training in presentation. Patient feedback to physicians is clouded by the patient/physician relationship. The result is that physicians feel that they are perfect communicators when they are not.

Conclusion

The decision making process happens in every instance. When confronted with the poor state of customer service and retention in medical clinics, patient are left to choose between providers. At each step of the decision making process, these clinics lose patients because staff never perfectly addressed their perception of what would be a 'perfect solution'.

Your medical spa staff should  be supporting patients no matter where they are in the decision-making process. They should address their needs and concerns at every point. Understanding the decision-making process, and how specific customers engage with specific needs is a prerequisite for any clinic with an ambition to turn visitors into patients.

Plastic Surgery Celebrity Photos: The good, bad, and ugly of celebrity surgical results.

I stumbled upon this vicious celebrity plastic surgery web site. It's no great wonder why the paparazzi are so loathed. It makes you feel sorry for these poor celebrities.

What's more surprising is that even plastic surgeons get nasty and call it "entertainment".

I am a Board Certified Plastic Surgeon who has been featured on Dr. 90210 on E! The comments on the site are my opinion alone and should not be taken as fact. I have not treated any of the celebrities presented here and the information and opinions should be taken for entertainment value only.

Entertainment value? I'm stunned that this guy has any patients. This is truly base.

Warning: If you're a plastic surgeon in LA let's hope you don't see one of your patients.

Botox, Face Lifts, & Politics

From the NY Times: Botox and politics don't mix.

What was especially intriguing about Mr. Spencer’s off-the-cuff remarks, as reported in The Daily News, was his speculation that Mrs. Clinton had evolved from an ugly duckling to the presentable 59-year-old woman she is today with the help of “millions of dollars” of “work.”

And if she had: Would it matter?

With Americans spending $12 billion a year getting injected, stapled and snipped, cosmetic surgery long ago went mainstream. Yet there is one arena in which an accusation of having work done still stings, and that is in politics.

 And male politicians aren't immune from Botox prosecution:

In the 2004 presidential election, when it was suggested that John Kerry had undergone Botox injections to wipe away facial lines, the Democratic candidate did his best to furrow his brow and declare such talk nonsense. (No matter, his critics said, since he was guilty of something much worse: looking French.)

Medspas New Editor: Aesthetic M.D.

Aesthetic MD has joined Medspas Online and will be posting here.

You will be able to read everything she writes by clicking on the Aesthetic MD link under any of Aesthetic's posts. Feel free to comment.

Aesthetic MD is has been commenting on this site for some time and is a experienced and knowledgable. Her information will be added on the about pages but feel free to comment on her posts.

Note: This is not a forum for medical diagnosis. Aesthetic MD will be posting information for physicians.