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:

• Read: Reputation Management Part 1: Understanding what not to do online.
• Podium Special Offer for Members

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.

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?

How To Use CT3+V: An Equation For Creating Facial Beauty

CT3+V = A simple equation for creating or restoring facial beauty.

We all know that "Beauty" is in the eye of the beholder. When it comes to creating and restoring facial beauty, we collaborate and negotiate with our patients (and sometimes their family and friends) to optimize the result and reduce the risk by using more conservative aliqotes of different techniques and technologies. Each practitioner brings their own unique skill-set and biases to the procedure room. We (hopefully) listen to the patient requests, evaluate what the underlying structure, tolerance for downtime and discomfort, economic consequenses and duration of effect is, to be able to offer the patient a scientifically valid, safe, sensible treatment plan. Then, we present a palette of procedures, techniques and technologies to consider.

What sets successful docs with many happy patients apart from the rest of the competition is attention to detail, listening to their patients (and sifting out the unrealistic ones) and having a plan that is recreated in some form (it's never the exactly the same twice) again and again.

My equation (tool) for discussing and creating facial beauty (or re-creating a more youthful appearance) is CT3+V = Beauty... short for Color, Texture, Tone, Tightness and Volume (in proportion or re-establishing proportion)

When the patient (on request) brings pictures of their face and neck that show them in yourthful repose, it is a strong tool to build consensus of what procedures and when in the scheme of possiblities, to pursue. Compare the old photos to current digital pictures obtained in 5 views-front-quarter and side views against a solid background with decent lighting and a portrait lens. Now diagnose the changes and educate the patient on the many ways you have to enhance and revitalize the issues you uncover in a systematic manner:

Color-pigment mottling and broken blood vessels respond well to various IPL's, NdYAG's, PDL's and KTP lasers depending on the patient's heritage (Fitzpatrick or Lancer skin type);

T3 (Texture, Tone and Tightening)-decide if the issues are epidermal, dermal or sub-cutaneous and treat with chemical or laser peels, focused ultrasound or radio-frequency and remember the skin looks better when "on-stretch", so Volume and surgery fit here too.  Toxins soften the dynamic wrinkles and shape the brow, but should be delivered in a artful manner that yields a natural, rather than "done" result;

Volume-Pierre Fournier, MD (Paris) taught us that "the look of youth is full" and the current saying "size matters" comes in to play here too.  Youthful features are generally softer and rounder, age makes them more severe and hollow.  Surgery helps take the luff out of the sail or the sag out of the jowl and neck, but does not effect volume very effectively.  Volume is at least as (and maybe more) important long term.  Fat and fillers (I prefer fillers for face) are a great way to go as long as you educate the patient as to how much it will really take and offer them permanent fillers (like Artefill in the USA) that can serve them well long term, once they find the look they want to preserve.

So-with every patient: define the issues, make a mutually agreeable long term plan, track the progress with digital pictures and keep an open dialog and flexibility, so that both you and your patient achieve happiness and WOW results long term. Happy patients refer their friends. Surviving aesthetic medicine these last 15 years is no accident....it's all been done with mirrors and this equation!