Free Viagra makes men 'much happier'.

viagra-pill.gif"Since we started the free distribution of sexual stimulants, our elderly population changed. They're much happier," said Joao de Souza Luz, the mayor of Novo Santo Antonio, a small town in the central state of Mato Grosso.

But the program has also had the unforeseen consequence of encouraging some extra-marital affairs, Souza Luz said.

"Some of the old men aren't seeking out their wives. They've got romances on the side," he said.

To discourage such illicit canoodling, Souza Luz said the city had decided to begin distributing the Viagra pills to the wives of the men who signed up for the program.

"That way, when the women are in the mood, they can give the pills to their husbands," he said.

via: Kevin MD 

Top 10 reasons you know you've hired an aesthetician...

cp_photo_esthetician.jpgYou know you've hired an aesthetician when...

...most of your staff is now wearing high heels.'re constantly set upon in an attempt to cleanse your pores.

...microderm is referred to as real medicine.'re instructed that 'aestheticians know anatomy too'.

...there is now green tea and spring water in the break room. own a hot towel cabbie, a skin scope, and 'mood' music. have $30,000 of toner, cleanser, and other stuff that you don't use.

...the esthetician wants to get rid of all the old stuff that the previous esthetician liked because it doesn't work and buy another $30,000 of the new stuff that the new esthetician likes that really does work. hear 'detoxify the skin' for the millionth time. ask what the hell all these toxins are in the skin and how did they get there and hear the reply, 'toxins'. are now selling knock off purses in the treatment rooms.

...the amount of mascara used per employee quadruples.'re asked to carry lip plumping gloss in your practice. offer spray on tanning.

...MySpace is on the history list of every computer. start to chew gum.

This list is completely in jest and not meant to represent any individual or group, especially not any of my staffs who are wonderful, thoughtful, and intelligent. No, I mean your staff.

(No aesthetician was consulted during the formation of this list.) 

The Angry Physician Syndrome: Hostile MDs entering cosmetic medicine.

Hostile doctors and the clinics they run.

Having consulted with many physicians about incorporating some form of cosmetic practice into their clinic, I've noticed that one of the biggest problems that these physicians have is changing the way they 'think' of medicine. (Noticed is something of a simplification since 'beaten over the heat' is a more accurate description.)

Cosmetic medicine is a new world for doctors who are used to third party reimbursement, nasty collections letters, physician referrals and seeing 30 or more patients a day. Docs today are angry; Irritated by long hours, pissed at malpractice premiums, feeling unappreciated and defensive.

Dr. Charles is Hostile:

blockquote.gifThere's no justice in Germany either. A German court ordered an OB/GYN doctor to pay $769 a month in CHILD SUPPORT to one of his former patients - a woman who got pregnant despite the IUD (contraceptive device) he inserted. This is horrendous. Sue your doctor if you get pregnant? An unintended yet healthy baby is evidence of bodily harm? No contraceptive is 100% accurate! The article says that "the implant could no longer be found in the woman's body." This does not mean it was the doctor's fault. IUD's fall out in up to 7% of women in the first year of use. That's part of the reason they have a string that dangles out of the cervix into the vagina, meant to be checked on a regular basis by the woman to ensure proper placement. This is totally outrageous, uncivilized, and another reason why it takes serious courage to try to help anyone in this world of blame.
[update - thanks to the correction of a German commenter, it was not an IUD that failed but another device, probably like Implanon but I don't know what's available in Germany. The underlying principle is still unbelievable. Overlawyered has some more links to this, and a decent discussion starting in the commentary.]

The Trial Lawyers Association is changing its name to the American Association for Justice. George Orwell is smiling somewhere, the skies are getting clearer every day, and no child is being left behind.

A doctor acquaintance of mine just got destroyed with a $20,000,000 jury award in a bogus malpractice case. I typed it into google and found this page, which is unrelated. I felt nauseous reading the top guy's credentials. The best thing he's done is apparently winning "the largest medical malpractice verdict ever won in the District of Columbia ($24 Million), (which was) reported by USA Today, Dateline NBC, Jet Magazine, the Washington Post, the Baltimore Sun and affiliates of ABC, CBS and NBC." Way to go! I bet his pockets were full after that one! Those doctors on the other end deserved utter destruction, all those years they spent working 120 hours a week for $30,000 a year, all those hopes they had of helping people, of making a difference. All those efforts pale in comparison to the $24,000,000 he got the jury to cough up.

Dr. Charles is right.

But... cosmetic medicine is a different animal and angry docs fare poorly when the anger they have towards the system spills over into their interaction with patients and staff. (Yes, I know angry docs fare poorly everywhere.)

Whenever I'm interviewing a physician I ask myself if they're an angry doc. If I think they are, it's a non-starter. I can work with a lot but can't change the way that someone fundamentally views the world and their situation. I can't change the way that an angry physician deals with patients, staff, and me. It just doesn't work. It's true that there are lots of angry docs out there and you might know some that you think are successful and that the fact that they're angry doesn't hurt them as a business. I don't.

If you're thinking about entering cosmetic medicine because you're angry and think that someone owes you, get ready for more of the same. In cosmetics as in regular medicine, it's still all about them.

You might be a Medical Spa Entrepreneur if...

check.jpgA lot of physicians think that they have entrepreneurial experience. After all, they started or ran a medical practice, and isn't that what a physician entrepreneur does? Maybe, depending on your own definition. Well, here's mine. These are not all necessarily descriptive of the current situation, and they are not all things I'm proud of or would recommend. Most of them certainly were not intentional, but they are all taken from my personal experiences. Some are humorous, some are not.

These days I'm happy to say that the vast majority of these things are behind me. Much of what is detailed below was brought about by the speed with which we are/were growing. Nowdays I'm usually home at night,Surface clinics have excellent staffs that I adore and count as friends, and I'm starting to have some free time again to devote to other persuits. Life is good.

And now, without further ado...

You might own a Medical Spa if...

You've 80k in credit card debt from cards you never knew you had.

You've averaged 60-80 hours per week of work for the past seven years.

You can personally have the most advanced medical treatments available but receive the poorest quality care.

You've found yourself at 2am painting treatment rooms in your underwear.

You spend two days without sleep because you know you're going to have to fire someone even though you're firing them for stealing from you.

You're accountant calls while you're leaving for vacation to tell you that your newest location is 25k in the hole so far this month and checks are bouncing.

You have employees that make five times what you do.

You eat all of your meals off of paper plates using plastic utensils. 

Without trying you've succeeded in convincing all your employees to never try to start their own business.

When someone asks you what you're doing this weekend you say "Working, of course, just like any other day."

You go to the gym once every six months and kid yourself that it makes a difference. 

Every six months you see the same guy at the gym who's obviously in shape and think "How in the world does anyone have time for that?"

6pm feels like 1pm.

Your staff clocks out while you're having lunch.

You drive home in the dark every night of the year.

You drive 60k miles between clinic each year.

You're ear aches at the end of the day from having a cell phone pressed against it for hours.

When people ask what you do you answer," I answer questions all day".

You have a bet with yourself on how long after meeting a woman and telling her what you do she asks, "What do you think I should have done?"

You learn never to answer the above question.

You have the most overwhelming sense of Deja Vu every time a physician with any type of rinky-dink cosmetic practice tells you that he's thinking about franchising his business.

Your wife is reduced to tears at a fourth of July parade when a patient accosts her demanding to know why your physician, Dr.Y, has ruined her life.

The physicians complain that the front desk is booking too much time for something and changes the default in the schedule. The front desk complains that the physicians take that much time and change it back.

You've closed, locked the doors and gone home leaving a patient still sitting in a treatment room.

You walk into the clinic kitchen while the staff is discussing horror stories of performing Brazilian hair removal in graphic detail.

You wonder if the computers ever actually work when you're not there.

You have to chase down a woman who's attending a free seminar and trying to make off with $600 in product samples. 

You feel almost euphoric just thinking about what it would be like to not owe anyone any money.

You develop a deep and abiding hate of yellow page salesmen.

You wonder why, when every salesperson on earth is deeply committed to helping you 'grow your business', they're never around when you're signing payroll checks. 

You've told someone not to start a new medical spa on their own because you sincerely can't bear the thought of someone going through what you've been through.

Just closing the doors and moving to South America seems like a perfectly viable option.

You've worked multiple Christmas days.

A physician you've trusted and put in a position of power starts having patients pay him directly inside the treatment room and sets up a secret merchant account so that he can swipe a card and have the money deposited directly into his personal account.

After you fire the above physician, he breaks into the clinic and steals equipment. While you're on the phone the next morning with the police, his wife calls and leaves a hysterical message asking 'How you could do this to us?" and threatening to sue you.

A patient asks "Why is ________ at the front desk insisting that she deliver deliver products and take payment at my house?" 

You've paid the federal government more in business taxes than you've paid yourself.

A physician calls you and asks for your help since American Laser Clinics has an armed guard in his waiting room to prevent him from seeing his own patients while at the same time their performing treatments using him as their medical director.

The same physician tells you that he's been doing this for thirty years and know how to run a clinic better than anyone while dismissing reports showing his declining performance as a 'computer problem' and asking you for money so that his kids can continue to go to private school and he doesn't have to sell his airplane.

The same physician thinks that all his new patients are coming through excellent word of mouth and his superior charisma while dismissing the $16,000 you spent last month advertising his services.

You have to deal with this physicians office manager who's decided to get even with you for not hiring her so she takes every opportunity to sabotage you.

You find yourself expanding to a physician why you can't advertise in a fashion magazine using before & after images of extremely unattractive sagging bellies and thighs from 80 year old morbidly obese patients even though 'the results are good'.

You don't worry about filing taxes late because you know you're not in a situation where you could possibly owe the government any more money.

You've felt a sense of relief when an employee has quit because now you don't have to lay them off.

You're an expert on what does and doesn't count as a business expense.

You've slept on the floor of your office or on the couch in a waiting area more than once.

You've seriously considered buying a cot for your office.

You wonder where the last five years went.

You realize your wife must be a very special person because what other woman would put up with all this and still like you?

You have 6 horses you never ride, a gym membership you never use, children you hardly see, and family vacations you don't go on. 

You look at every medical spa you drive by in your car thinking, "I bet the guy running that medspa is making a lot more money than I am."

You have a surge of bile when you're at a medical convention and a consultant says to a packed room of physicians, "Of course you can make $250,000 per treatment room right now," and then proceed to tell everyone that the key is to 'not let any patient leave until they've bought product and booked another appointment.

You wonder how the above consultant got anyone to listen to her, ever. 

You're able to write a list like this in a half hour right off the top of your head.

This just a partial list of course. I may add to it. And of course these are all in the past.

The Biology of B-Movie Monsters

21701757_shrinkingman.jpgThe Biology of B-Movie Monsters 

Among the most interesting posts I've ever read.

Michael C. LaBarbera, professor in Organismal Biology & Anatomy & Geophysical Sciences at the College of the University of Chicago, has written an unbelievably interesting piece about the science behind horror movies like King Kong, The Incredible Shrinking Women, Them, and Fantastic Voyage. An incredibly interesting read.

In The Incredible Shrinking Man (1957), the hero is exposed to radioactive toxic waste and finds himself growing smaller and smaller. He is lost to family and friends while fending off the household cat and must make his own way in a world grown monstrously large. He forages food from crumbs and drinks from puddles of condensation. In one famous scene, he defends himself against a house spider by using an abandoned sewing needle, which he has to struggle to lift.

Stop the projector! Time for a little analysis...

...As for the contest with the spider, the battle is indeed biased, but not the way the movie would have you believe. Certainly the spider has a wicked set of poison fangs and some advantage because it wears its skeleton on the outside, where it can function as armor. But our hero, because of his increased metabolic rate, will be bouncing around like a mouse on amphetamines. He wouldn't struggle to lift the sewing needle--he'd wield it like a rapier because his relative strength has increased about 70 fold. The forces that a muscle can produce are proportional to its cross-sectional area (length squared), while body mass is proportional to volume (length cubed). The ratio of an animal's ability to generate force to its body mass scales approximately as 1/length; smaller animals are proportionally stronger. This geometric truth explains why an ant can famously life 50 times its body weight, while we can barely get the groceries up the stairs; were we the size of ants, we could lift 50 times our body weight, too. As for the Shrinking Man, pity the poor spider.

Physician Oversight & Scope Of Practice: What's legal in a medical spa?

int-05.jpgPhysician oversight & scope of practice in medspas.

We receive an ever growing number of questions about physician oversight, scope of practice, and other legal issues surrounding medical spas. What oversight is required? What can I do? What can't I do? Here's our opinion (ie. not a legal one.)

The quick growth of medical spas has led to something of a Wild West mentality. Many spa owners and even some physicians are trying to jump into this market. Unfortunately, this has landed a number of medical spas in hot water. Very hot. Medical spa professionals and many physicians don't understand the legal ramifications of what they're doing. What's legal? What's not?

Here's a sample: "Hello, I am an esthetician currently working in a day spa. My boss has decided to buy and train another esthetician and myself on the Thermage system. Since we are a medical spa, there is no practicing physician on the premises. My question to you is; how legal will our Thermage treatments be without an overseeing physician? By performing these treatments, will my license be on the line?"

Short Answer: Performing Thermage under the above circumstances is practicing medicine without a license.

Longer Answer: There are a couple of problems the question alludes to. First, the 'boss' appears to be someone other than a physician. Non-physicians can not purchase medical devices restricted by the FDA to physicians only. Second, if patients would be treated medically without an examination or being seen by a physician that is absolutely illegal. Third, 'no physician on the premises' is a big red flag. Doctors can not extend their licence to Thermage any more than they can extend it to surgery. It doesn't matter that a physician is directing that the treatment be performed or that your boss thinks it's safe. Fourth, Yes, your licence is at risk. Anyone performing medical treatments without adequate oversight is going to be between a rock and a hard place if anything happens. Thermage (and every other medical treatment) have potentially harmful side effects. Don't think for a moment that you, the doctor, or the business are protected by a physicians medical malpractice if a treatment is performed illegally. (Always check with an experienced lawyer.)

Physician Oversight

Physicians are responsible for every treatment performed under their medical license. If it's a medical treatment, the physician is responsible and liable for the performance of that treatment. The state medical board has jurisdiction as to scope of practice and physicians can't extend the scope of their medical license.

Aestheticians and medical spa technicians performing 'medical treatments' are doing so under the license of a doctor. If the doctor can't extend his license to that particular treatment, it's not covered by his licence and is being performed illegally. Anyone, including the physician, involved with treating patients without legal medical supervision is asking for trouble.

Post your question as a comment on this post and we'll add the answers here.

Question: I really appreciated this article. But I'm wondering, what are the issues involving an registered nurse or nurse practicioner, both of which are entering the esthetics industry? Does a spa offering Botox with a np need a doctor on site? What if that np is working in a state in which np's can operate as an individual business? What options does a spa have with nurses as opposed to a doctor or esthetician?   Spalady

Answer: Nurse Practitioners (NP's) and Physicians Assistants (PA's) in some states have the ability to operate outside of the direct supervision of physicians.

Both must have an arrangement with a physician to supervise them and enter into an agreement with their supervising physician that gives access to the doc. PA's are limited in that they can not open up a business by themselves and have to report more directly. (Which is one reason PA's are more attractive to physicians since they can't just open up in competition with you.)

Registered Nurses (RN's) do not have the ability to operate outside of the direct supervision of a physician in the same way as NP's.

It breaks down as this: NP's and PA's may have the ability to provide medical oversight if a physician is not physically on site, RN's do not. You should always, always, always, have your lawyer check with the state since they're the ones who will decide.

Good advice from a lawyer I know is this: write to the state detailing exactly what you are doing. Do not try to sugar coat it at all. Ask for a written reply from the state saying that they have no problem with you. Keep this as documentation if something goes amiss. That way you have a state regulatory body saying that you were performing within the scope of practice. Excellent advice.

Read the comments since there is some elaboration on scope of practice.  

Medspa Patient Analytics: Who's looking at you?

surfacemap.jpgWhere are your potential clients coming from?

This image shows where visitors to Surface Medical Spas web site originated over the last 24 hours.

(It's interesting to not that Cape Town, South Africa and Ha Noi, Viet Nam are among them.)

Our Park City location receives the most out of state visits. I'd tentatively place that number at around 5-8% of our total patient volume. Many of these patients have second homes in Park City or are regular visitors. 

If your site is static I can guarantee that it's difficult to find and will only grow harder to find as the market grows and 'real' businesses enter the market. 

Is medical advertising ethical?

nnm_ad.jpgThere 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.

How to blacklist patients with medical malpractice claims.

The website lists plaintiffs who have brought unsuccessful cases

blockquote.gifThe 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."

How To Run An Insurance Reimbursement Scam & Make Your Patients Hate You.

This has got to be a low point in patient service.

As health insurance costs skyrocket and more people turn to high-deductible policies, a key question is emerging: When you're paying out of your own pocket, what rate do you pay?

Is it a discount negotiated by insurers, or the provider's gross charges, which could be several times higher than the negotiated rate?

Case in point: Lisa Stamm of Kendall, who had a simple earache and got slapped with a $375 bill for about 10 minutes with a nurse practitioner. If she had no insurance, she could have paid $125. If she had a no-deductible policy, her insurer might have paid about $140, and she would have paid nothing.

But Stamm showed the receptionist at ER Urgent Care Center on SW 137th Ave. her Cigna insurance card, and that sparked the problems.

''This really made me mad,'' Stamm says. ``I called the insurance commissioner's office. I called my insurance. You'd think something could be done.''

But no. ER Urgent Care insists she cough up the full $375. ''We as consumers have to make our choices,'' said Trudy Herdocia, the firm's vice president of operations. ``And live by them.''

The crisis in Chinese Medicine: Get Sick And Die.

 The huge gap in Chinese Medicine.

Before we lament the plight of physicians in the US too much, read the article above.

A construction worker, his leg smashed in a bulldozer accident, sat all night outside a city hospital here, afraid to go in. A doctor told him to bring $600 cash - more than he earns in a year - and prepare for an amputation. His buddies wheeled him away on a flatbed tricycle.