Medical Spa MD: Average 2011 Physician Income By Specialty
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Interview With Brazilian Plastic Surgeon Alan Landecker, MD
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Visiting Brazil with plastic surgeon Dr. Alan Landecker in his Sao Paulo clinic.
Physician: Alan Landecker, MD
Location: Sao Paulo, Brazil
Website: www.landecker.com.br
That's interesting: In 2005, Alan Landecker, M.D. specialized in primary and secondary rhinoplasty at the University of Texas Southwestern at Dallas, Texas, USA, under Jack P. Gunter, M.D. and Rod J. Rohrich, M.D. For a period of 2 years, he was part of the Adjunct Faculty at the world-renowned Dallas Rhinoplasty Symposium and participated actively in the production of the second edition of the Dallas Rhinoplasty: Nasal Surgery by the Masters book. This book is currently the world´s best-seller in rhinoplasty.
Brazil has some of the busiest plastic surgeons anywhere in the world and it's not uncommon to find those who have been trained in the US.
When did you decide to specialize in plastic surgery?
The attraction began during medical school, when I rotated in the Plastic Surgery Department. The precision, difficulty, and level of detail of the operations enchanted me. However, I believe that an important personality trait (visual attraction to beautiful things) contributed significantly.
Can you tell us more about your clinic and how your staff operates it?
The clinic offers last generation plastic surgery and cosmetic procedures that can be surgical or non-surgical to all age groups. Some of the latter include laser, skin treatments, and postoperative physiotherapy. The clinic is located in one of the most sophisticated areas in São Paulo and is run by professional managers. Most remarkable 'inside' the clinic is the contemporary architecture and interior design, offering patients a unique experience.
The clinic offers IPL for hair removal, dark circles around the eyes, and some vascular lesions. We also have diode laser machines for rejuvenation and hair removal. Our newest machine is a radiofrequency device that is combined with electromagnetic energy. This kind of machine is very popular because splendid body contour is a priority for both men and women in Brazil. So far all of them have worked well for us.
How are you finding staff?
We've had some real issues with staff and due to past problems, we currently hire using only professional headhunters. Although more costly, this increases the chances of getting it right the first time! All staff have top class working conditions and receive a fixed salary plus bonuses depending on how well they perform. The secret is keeping them motivated!
How do you market your clinic?
In terms of marketing, the best is always to do a good job. In other words, the most solid marketing consists of word-of-mouth referrals. Complementary strategies should include a good website with SEO, use of social media, internal programs, and good exposure in the press. If all these are well structured, precise, and especially ethical, good results are inevitable.
What treatments or services are most profitable for you?
Plastic surgical procedures are the most profitable, followed by Botulinum toxin (Botox) and dermal fillers. We are currently developing a high-end aesthetic center to give patients a more complete type of treatment.
What have you learned about practicing cosmetic medicine? What stories can you tell?
The most common situations involve patients who bring tons of photographs of their noses into the consultation. They flog themselves trying to find minute imperfections which are normally invisible to most of us.
On the 'most unusual' side, one patient actually brought the head of a clothing store mannequin to the office, wanting a nose just like that one. As a result, we took the head into the operating room and used it as reference during the rhinoplasty. (Fortunately, the patient was extremely satisfied with the final outcome!)
What advice would you give to other physicians?
Based on my experience, it is very important to get the best training possible and preferably in something that no other surgeon performs. That will necessarily include tremendous dedication and inevitable sacrifices but you just can't succeed if you only do what everyone else does and you don't have a reputation for being the best at something specific.
Physicians must always be ethical and honest, keeping in mind that the most important outcome is patient satisfaction. In other words, never make decisions based on financial factors instead of doing what is best for the patient.
About: Alan Landecker, M.D. is a member of the Brazilian Society of Plastic Surgery and the the prestigious International Society of Aesthetic Plastic Surgery (ISAPS).
Dr. Landecker obtained his medical degree and general surgery training at the University of São Paulo Medical School, Brazil. He was then trained in plastic surgery at the Pontifical Catholic University of Rio de Janeiro and the Ivo Pitanguy Clinic, where he worked directly with Professor Ivo Pitanguy for 3 years.
After passing the ECFMG/USMLE examinations, Alan Landecker, M.D., spent a total of 2 years refining his plastic surgical training in the USA. During this period, he participated in clinical rotations, Research Fellowships, and Clinical Fellowships with some of the country's best surgeons at the Universities of Miami, Alabama at Birmingham (UAB), Pittsburgh, New York (NYU) and Texas Southwestern.
This interview is part of a series of interviews of physicians running medical spas, laser clinics and cosmetic surgery centers. If you'd like to be interviewed, just contact us.
Interview: Stephen Weber MD, PhD of Lone Tree Plastic Surgery
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Sitting down with Dr. Stephen Weber of Lone Tree Facial Plastic & Cosmetic Surgery Center outside of Denver, Colorado.
Physician: Stephen Weber MD, PhD
Location: Lone Tree, CO
Website: http://www.lonetreefacial.com
That's interesting: Dr. Weber has participated in the "Face to Face" program where local plastic surgeons donate their services to the victims of domestic violence and has participated in the annual humanitarian mission surgical trips providing free care to medically isolated, indigent patients.
Profile: I am a double board-certified Facial Plastic and Reconstructive Surgeon practicing at Lone Tree Facial Plastic & Cosmetic Surgery Center in the Denver metro area. My practice involves all aspects of facial cosmetic surgery including facelift, browlift, blepharoplasty, rhinoplasty, otoplasty, facial implants, facial resurfacing and scar revision. Our office also provides comprehensive treatments for facial aging including Botox and Dysport to reduce facial wrinkles, dermal fillers to minimize facial lines and folds as well as fractional laser (Fraxel and MiXto) resurfacing.
Can you tell us a little bit about you and how you got started in cosmetic medicine?
I became a Facial Plastic & Reconstructive Surgeon by a very circuitous route. In medical school, I planned to become an Infectious Disease specialist and even obtained a Ph.D. in Immunology and Microbiology in pursuit of that goal. However, my first rotation after successfully defending my thesis was in head and neck surgery. I knew that first day that I wanted to become an Otolaryngologist (Head & Neck Surgeon, ENT). During my residency training in Otolaryngology and Head & Neck Surgery I realized that my goals of performing a diversity of procedures in a technically demanding sub-specialty made Facial Plastic Surgery a very well suited specialty. I trained as Dr. Shan Baker’s fellow in Facial Plastic Surgery at the University of Michigan and then entered practice.
Can you tell us more about your clinic and the services available?
My practice is a single specialty clinic. We have two plastic surgeons here at the practice, myself and Dr. Rick Schaler who is my partner and practice owner. We have eight other staff including one nurse, five estheticians, one front desk staff member and a billing manager. We offer the full range of facial reconstructive and cosmetic surgery. Our office has a fully functional operating room in which we perform all of our cosmetic procedures under IV sedation. On the medical spa side, we offer all of the available injectable treatments including Botox, Dysport, Xeomin, Restylane, Perlane, Juvederm, Radiesse and Sculptra. We perform laser services including Fraxel and MiXto (fractional CO2) resurfacing, vascular laser and laser hair removal treatments. We also perform a full complement of facial peels and facial treatments. Our patient population comes from the surrounding suburbs of Lone Tree, Highlands Ranch, Littleton, Parker as well as Denver proper.
How are you dealing with staff in your clinic?
Fortunately, we have not had the need to fire staff. The reason for this is that we’re very careful with the hiring process. The communication between members of our office is very clear. When we set out to hire a new member of the office we have a clear, articulated goal regarding our needs and the type of person we want to hire. Everybody in the office has a chance to veto a potential new member of the office staff. Each member of the office also has the opportunity to veto that potential candidate. We tend to hire from a pool of people already familiar to the office or from strong referrals from friends of the practice. We have avoided print advertising of open positions of late as this always leads to a huge response with relatively low yield of the type of candidate that we need.
For the front desk staff, compensation is hourly. For procedure or treatment oriented members of the office, including physicians, compensation is heavily weighted toward production. This is the most fair compensation method and encourages productivity. The formula is simple, clearly articulated and fair. Employees are paid a percentage of net collections. An employee can review their production at the end of each month, if requested. I review my own production at the end of every pay period and encourage the rest of our staff to do the same.
What laser technologies are you using now? How do you decide on new purchases?
We perform laser treatments including Fraxel and MiXto (fractional CO2) resurfacing, vascular laser and laser hair removal treatment. In terms of new purchases, laser companies really need to show us a substantial improvement in results before we will purchase new technology. We are marketed to by phone, mail, email and at conferences. I am interested in new radiofrequency technologies but I think the jury is still out and we’re holding out on making that purchase.
How do you market your clinic?
In terms of social media, we market on Facebook , Twitter, as well as LinkedIn. We’re trying to determine whether Pinterest can be leveraged with pre- and post-op photos and other images. We use social media to communicate with current and prospective patients with informational posts and product samples/ give-aways. Our email list of current patients is our most valuable marketing tool. Providing current patients with updates that they can forward to friends is invaluable. We also put on open houses and seminars that allow us to provide education, meet new patients and learn more about our current clients.
In the pay-per-click arena, we use Google AdWords with a relatively conservative budget. That has drawn a lot of traffic to our website and helped generate surgical cases. We have been testing the waters of direct mail and print advertising. Direct mail has had moderate result. Print advertising has been disappointing. We do not currently take part in Groupon, Living Social or any other daily deal sites. The main reason for this is cost and questionable ability to develop lasting relationships with users of these services.
What are the most coveted treatments/services in your practice? Have you tried removing some of your services?
The sun and dry air in Denver are the reason why people flock to this area. However, they wreak havoc on facial skin. As a result the demand for lasers and peels here is tremendous. On a volume basis, Fraxel skin resurfacing and Botox are the most common services in our office. However, the fixed cost associated with these services is significant. From a revenue perspective, surgery provides the greatest revenue and greatest profit for the practice. About 75% of our cases are elective in nature. We have not dropped any procedures recently. When I joined the practice, I introduced Sculptra facial injections and Radiesse hand rejuvenation and we’ve seen high demand for these treatments.
What have you learned about practicing cosmetic medicine?
I’ve developed a thicker skin and learned not to take things personally. In the past, when a patient booked surgery with a competitor I assumed that I had erred in some way or not provided excellent photos of patient results or …. I’m noticing today more and more patients that will meet multiple surgeons and come back to book surgery with me. When I’ve asked why, the answers that patients provide are incredibly vague. It really is a gut feeling that people have that you are or are not the surgeon that will provide what they’re looking for. All we can do is provide as much information and education, quality photos of surgery results, a top notch facility and a warm, caring environment to convince patients that we’re the right team for them.
Any last thoughts on advice for your physician colleagues in the cosmetic industry?
I would urge physicians, especially in the plastic surgery realm, to compete by providing exceptional service. With Groupon and other daily deal sites, there is increasing pressure to compete on cost. Some of these deals will temporarily drive patients into the practice. However, few are likely to be loyal patients when the practice down the road runs an even cheaper deal. The daily deal trend has provided consumers with cheap (not necessarily quality) services. However, this has come at the expense of sustainability for practices that jumped in without doing enough research. The bottom line is that daily deals will lead to a spike in volume composed of largely price-oriented patients. Further, the deal seeking crowd is unlikely to see the value in your services. Continuing to drive down prices when our costs are fixed is not only unsustainable but diverts your attention from providing services, such as surgery, that are the profit engine for the practice. When you offer services at cost, you CANNOT "make it up on volume."
This interview is part of a series of interviews of physicians running medical spas, laser clinics and cosmetic surgery centers. If you'd like to be interviewed, just contact us.
Realself.com
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Tom Seery of realself.com and I had a fairly long discussion a few days ago about both Realself.com and Medical Spa MD's approaches to the marketplace and strategic directions.
Of course one of the topics we touched on was realself.com's decision to remove all physicians from the site that were not board certified plastic surgeons or dermatologists.
Tom didn't get into much detail on this point other than to say it was a long story and that keeping only board ceritified plastic surgeons and derms was the decison they'd made, and they're going to stick to it.
While I don't really have a decision staked out on this I made the point that physicians get good at what the do a lot of. If I were a Botox patient I'd much rather have a non-core doc with a lot of experience shoot me up than a fantastic plastic surgeon who almost never does it. (Truth be told, I can't see the flaw in that logic.)
I can understand realself.com's decision on a purely business decision. Realself.com's looking for some level of credentials to make sure that the laymen who are the real target market of the site are getting at least some level of 'trained' physician.
Realself.com is great for patients who are researching treatments. The consumer-centric focus differs from our physician-centric community but there's some small overlap.
One of the thoughts I opined to Tom was that I could see it would be challenging for new physicians who were just coming on to the site to be motivated to contribute with the way their ranking system works. If you're answering a lot of questions you get greater visibility and promotion internally on the site. While it stimulates some docs to write a lot of answers, it's hard to see how any new physicians could come up with the number of answers to gain some placement. Tom says they're going to launch some new initiatives that will 'promote' new physicians. (This might anger some docs who have spent endless hours writing answer about Botox or liposuction.)
Anyone here have an opinion about realself.com?
Plastic Surgery Product Placement
/Be Born Again
To promote Dr. Kim's plastic surgery office, this life scale poster was placed at the entrance of his office and by the elevator in the main lobby of the hospital building.
via dfckr.com
A slick little promo for a plastic surgery practice. You have to love well done attention-getting advertising and medical spas and plastic surgery clinics are certainly rife with products that lend themselves to great advertising and marketing. I've got perhaps hundreds of these types of ads that I keep as something of a library.
PermaTox: Botox results that are permanent?
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PermaTox? I was sent a link to this page by a patient who was asking my opinion about this treatment.
Has anyone heard of this Permatox proceedure? The last line of this pitch discloses that it was developed by prominent cosmetic surgeon named Guillermo Blugerman. In looking up Guillermo Blugerman on Google it seems that he's a surgeon from Argentina.
Any plastic surgeons on the boards here heard of PermaTox or have an opinion on it?
Here's the pitch for PermaTox from a medical spa web site:
PermaTox – A Brand New Procedure That Promises Botox-Like Results That Are Permanent
Tired of frequent Botox injection visits? PermaTox might be the long-term wrinkle solution for you! A new procedure that promises to give you longer lasting results without the needles!
PermaTox - has been tipped as a possible future anti-wrinkle remedy that uses a thin surgical thread to sever the specific nerves that cause frowning, which results in less movement and fewer lines.
While PermaTox patients might still receive periodic Botox® injections in other forehead areas, sometimes keeping the glabella (frowning nerves between the eyes that makes that annoying furrow between the brows) relaxed can, over time, soften wrinkles in other forehead areas, as well.
An observed effect of this treatment has been that eyebrows gradually tend to become more elevated and horizontal forehead lines reduced, potentially eliminating the need for elective surgery or Botox injections entirely for some patients.
PermaTox , is safe and quick, taking only 30 minutes in the office to perform.
Dr. B_____ is the only one performing this procedure and trained by the prominent cosmetic surgeon Guillermo Blugerman, who developed this technique.
Interestingly, all of the Google search results for PermaTox are for pest control.
Medical Spa Special: Botox, Hemorrhoids & White Teeth
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As patients are tightening their belts and technology is delivering newer procedures that require less time off of work and less money out of a patient’s pocket, more cost-effective solutions are overtaking the once considered gold standard practices, such as liposuction and facelifts.
We’re all aware of the turf wars among plastic surgeons and dermatologists versus the “non-cores”. But a new turf war is spreading into other areas of what is deemed cosmetic practices. As dentists begin using Botox to subsidize their practice’s income, “non-dentists” are dipping into their area of teeth whitening.
Teeth whitening franchises can be seen available at almost every aesthetic trade show. Not only are other physicians adding teeth whitening to their practices, but day spas and beauty salons are also getting into the action!
While dentists are claiming that teeth whitening practices require specialized training in the anatomy of the tooth, trade show vendors will tell you that’s nonsense. They state it is not a dental procedure, but a cosmetic procedure which are more commonly preferred in salons and spas. At a trade show, I was told by a booth vendor that my receptionist could perform the teeth whitening with no medical supervision necessary.
Spas are advertising teeth whitening as “why have it done in a sterile office when you can relax in a soothing spa setting?”. Hmmm. In fact, they boast “why not have other spa services performed at the same time” so they can “take care of all of your aesthetic needs in just one visit”? Here’s a quote I found online from one day spa offering teeth whitening: “quell your fears and anxieties by relaxing in a massage chair, listening to soothing music or enjoying the aromas of scented oils wafting around the rooms. You might even hear the trickling of water from a fountain”.
Are you kidding me? Teeth whitening is hardly a procedure to get anxious about. In fact, the procedures take a maximum of 15 minutes to perform. By the time the aromas start wafting, you’re done!
Is this a procedure that is necessary for financial survival of a medical spa or laser clinic? Where will it end? Will we also be performing hemorrhoidectomies which only require a local anesthetic? Or, perhaps removal of an ingrown toenail?
Call me a cynical nurse, but I say leave the Botox to the cosmetic physicians, the hemorrhoids to the proctologists, the toenails to the podiatrists, and the teeth whitening to the dentists.
Author: Paula D. Young RN runs internal operations and training at Young Medical Spa and is the author of the Medical Spa Aesthetics Course and Advanced IPL & Laser Training course for medical estheticians and laser technicians.
Submit a guest post and be heard.
Plastic Surgery & Plastic Surgeon
/Very interesting discussion on the RealSelf.com has kicked out all non-core doctors thread.
TF and Botoxdoc have, er... differing postions on who is able to provide the best plastic surgery care. (Perhaps 'best plastic surgery care' is not the most appropirate term and I should use 'appropriately safe level of plastic surgery care'.)
Anyway, there's been a lively exchange of which the following comments are only a fraction.
Link to the RealSelf.com kicks out all non-core docs thread:
TF:
I have never claimed that plastic surgeons are the only ones who can do aesthetics, which includes laser work, botox and injectables, as well as surgery. I am very supportive of non-plastic surgeons who do botox, injectables and lasers. I have only made the point that plastic surgery training is currently the best method for training surgeons who want to do total body aesthetic surgery. It may not be perfect, but it's still the standard.
There are no shortcuts in learning how to be a master surgeon. Only those, like yourself, who seem to think that there are shortcuts.
Good luck to you - and your patients....
Botoxdoc:
While you say, I am wrapping my self in the cloak of the "free market" flag and have forgotten the fundsamentals of being a physician "doing no harm", nothing could be further from the truth. I only take cases in which I am proficient. I would never put a patient in harms way, nor perform a case which is not appropriate. I have refered many pts to a plastic surgeon when I felt they needed something more than I could provide them. (At the loss of significant revenue, I might add.) On the contrary, I beleive you are wrapping yourself in the cloak of "patient safety" . It is hubris to beleive I would not have the same concerns as you about patient safety. But because I am not a board certified PS or Derm, I must be, in your mind, a sub-par physician with no regard to my pts well-being, or safety. In fact there is absolutely no hard evidence that supports the argument that having Botox, or any other cosmetic treatment performed by a non-core physician results in more complications. Instead of me showing you my before and afters, why don't you show me a paper (randomized, case controlled, or even a retrospective study) that supports the commonly held belief that non-cores are dangerous. In fact, the complication rate in my clinic is better than what has been documented in the literature. While several months ago at a local hospital, a board certified plastic surgeon performing lipo under general aneasthesia penetraed the viscera and killed his pt. For that he received a reprimand. If I did that, I would probably loose my license or worse. Now I ask you, how fair is that?
In my opinion there needs to be a fundamental change in the system which will allow the acceptance and acknowledges "non-core" physicians performing aesthetics. Until that day arrives, those that judge my work will be my pts. and their families.
You want science - OK, here's some for you.
Subglandular breast augmentation has a higher rate of capsular contracture. Proven in multiple studies.
Subglandular breast augmentation has a higher degree of interference with mammograms. Proven.
Subglandular breast augmentation has a higher rate of unsatisfactory ripples and wrinkles, especially with saline implants. Proven.
Do you offer this procedure because it's the only one you can technically perform?
Do you even offer your patients a choice of sub-pectoral or dual plane techniques?
Do you give a truly informed consent about the other options....Or do you slant it your way, so you can get the patient to book with you?You claim you are all about patient care - and then you say it's fine to take a weekend course, and then practice unsupervised on the first 100 or so paying customers, so you can master it. Wow. That's messed up!!
RealSelf.com's blogged about how that site is only the 'dispenser of information' (my name not theirs) and has removed more than 3000 physician accounts because they were not boarded in plastic surgery or dermatology. I wonder what the majority of realself.com questions are about? Liposuction? Breast augmentation? Or, Botox? I don't think that there's any real disagreement that if you're looking for real plastic surgery you want a plastic surgeon (or cosmetic surgeon). The arguement arises over what is 'real' plastic surgery.
The inclusion of technology starts to blur the lines beween what a plastic surgeone does with a scalpel, and what a non-core doc can do using a laser, IPL, or RF technology. The boundries will only be blurred more as more IPLs and lasers are introducted.
RealSelf.com Doesn't Want You Doctor
/It seems that if you're not a boarded plastic surgeon or cosmetic derm, you're no longer wanted to participate on RealSelf.com.
I guess that eveyone who didn't identify themselves as a boarded Derm or Plastic found their account uncerimoneously deleted without warning. Nice. All the docs who worked to answer questions evidently weren't answering them 'correctly' or to Real Selfs satisfaction and they're out.
There's some lively discussion on the physician forums: RealSelf.com has kicked out all non-core physicians!
Cosmetic Dermatology from the Point of View of a Full-Time, Non-Core Cosmetic Physician
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I receive the occasional email from a derm or plastic asking me to post an article that they're not willing to post under their real name. Here's an email I got from a non-core doc practicing cosmetic medicine. It came with this introduction:
"I wrote this and would like you to post this. I don't want it posted under my name because I don't want to take the heat and wrath of the Plastics and Derms. I need to choose my battles. Please post this as if you got this forwarded from me and I received it from an unknown writer. The post should be from "A Full-Time, Non-Core Cosmetic Physician". Can you do this?"
In general I dislike ananymous posts or comments. While there can be genuine concerns and I protect the identities of all Members, the anonymous nature detracts from the legitimacy of the content and just isnt' as credible as identified authors. With that said, here's the post:
Cosmetic Dermatology from the Point of View of a Full-Time, Non-Core Cosmetic Physician
A physician’s clinical results are directly related to their clinical skills. These skills come from their ability, their training, their dedication to learning and their clinical experience. Gifted mentors along with a high volume clinical practice are also important ingredients.
Many of the best non-invasive cosmetic physicians are non-core physicians who have dedicated 100% of their professional activity to cosmetic dermatology.
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- What is Cosmetic Dermatology?
- Can Non-Core Physicians Practice Cosmetic Dermatology?
- What is a Cosmetic Dermatologist? What is a Non-Core Cosmetic Physician?
- Is a Cosmetic Dermatologist better than a Non-Core Cosmetic Physician?
- How many Dermatologists are Fellowship Trained in Cosmetic Dermatology?
- How many Cosmetic Dermatology Fellowship Training Programs are there in the United States? How many Fellows graduate every year from these programs?
- Why do we need Experienced, Expert, Full-Time Non-Core Cosmetic Physicians Practicing and Teaching Cosmetic Dermatology?
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1. What is Cosmetic Dermatology?
Dermatology that concerns cosmetic issues. Anything that is not Medical Dermatology, like skin cancer and other serious medical conditions. Wrinkles, Age Spots and Skin Tightening are cosmetic concerns.Cosmetic Dermatology also includes some medical conditions like Acne, Rosacea and Melasma. It also includes Acne Scars, other types of Scars, Unwanted Hair and Unwanted Veins.
2. Can Non-Core Physicians Practice Cosmetic Dermatology?
YES. Cosmetic Dermatology involves treating cosmetic conditions. Non-Core Physicians practice Cosmetic Dermatology when they treat cosmetic conditions of the skin. Non-Core Cosmetic Physicians are NOT Cosmetic Dermatologists. They are Non-Core Cosmetic Physicians.
3. What is a Cosmetic Dermatologist? What is a Cosmetic Physician?
A Cosmetic Dermatologist is a Board Certified Dermatologist who does Cosmetic Dermatology. A Cosmetic Physician is a Board Certified Physician who practices Cosmetic Dermatology. Cosmetic Dermatologists and Cosmetic Physicians can be full-time or part-time. Most Cosmetic Dermatologists are NOT Fellowship Trained in Cosmetic Dermatology.
4. Is a Cosmetic Dermatologist better than a Non-Core Cosmetic Physician?
Not necessarily. It depends on each doctor’s training and the experience. A full-time Non-Core Cosmetic Physician can be better than a Cosmetic Dermatologist who only practices Cosmetic Dermatology as a small adjunct to their Medical Dermatology Practice and has not been Fellowship Trained. A Non-Core Cosmetic Physician in a state like New Jersey is probably a better Laser Physician than a Dermatologist or a Plastic Surgeon who does not do the actual treatments but instead supervises Physician Extenders in their practice.
5. How many Dermatologists are Fellowship Trained in Cosmetic Dermatology?
Not very many. I am not sure of the exact number, but not very many. There is a big difference between a Cosmetic Dermatologist who has been Fellowship Trained and a Cosmetic Dermatologist who has NOT been Fellowship Trained.
6. How many Cosmetic Dermatology Fellowship Training Programs are there in the United States? How many Fellows graduate every year from these programs?
Not very many. I don’t know the exact numbers, but it is not very many.
7. Why do we need Experienced, Expert, Full-Time Non-Core Cosmetic Physicians Practicing and Teaching Cosmetic Dermatology?
Full-Time, Expert Non-Core Cosmetic Physicians are needed because there is an inadequate number of Fellowship Trained Cosmetic Dermatologists and an inadequate number of Cosmetic Dermatology Fellowship Training Programs. A physician’s clinical results are directly related to their clinical skills.These skills come from their ability, their training, their dedication to learning and their clinical experience. Gifted mentors along with a high volume clinical practice are also important ingredients.Plastic Surgeons, Dermatologists and Non-Core Cosmetic Physicians all start from the same point.Dermatologists are expert in skin physiology and pathology. The Plastic Surgeons and the Non-Core Cosmetic Physicians must become experts in skin physiology. The Fellowship Trained Dermatologists are the future of Cosmetic Dermatology, but until there are more training programs and more Fellowship Trained Dermatologists, they will not be the primary providers of Cosmetic Services to the general population. Many of the best non-invasive cosmetic physicians are non-core physicians who have dedicated 100% of their professional activity to cosmetic dermatology.
Signed, A Full-Time, Non-Core Cosmetic Physician
Dermatologists vs Plastic Surgeons vs Non-Core Physicians vs Non-Core Physician Extenders.
/The MAPA blog has a new post up with a number of comments about dermatologists, non-core Physicians and non-core physician extenders competing for cosmetic medical dollars. Here's a blurb:
For years, dermatologists and plastic surgeons have been arguing about whether noncore physicians have a place in cosmetic medicine. Now, it seems more competition is likely, as nurse practitioners (NPs) and physician assistants (PAs) are pursuing careers in this lucrative field.
One way to thwart this trend is to deny them access to MD-directed training.
(Name Deleted) MD, also gave his viewpoint. Just because more NPs and PAs are assisting physicians doesn't mean doctors should give them even more control, said the clinical professor of dermatology.
"The more you promote them, the more problems we'll see," said (Name Deleted), alluding to NPs and PAs who act independently without physician supervision. Others set up their own practices with a name-only doctor on the payroll. The result, said Dr. (Name Deleted), is the potential for increased patient complications and a watering down of the expert skills dermatologists provide.
Dermacare sues everyone on Medical Spa MD?
/It appears that Dermacare has thrown in the towell regarding it reputation.
I received this email from Dermacare and it's CEO Carl Mudd regarding a suit that Dermacare has filed. Since this is the first contact I've ever had with Dermacare, I'm a little surprised. It makes me wonder what's been going on on that Dermacare thread that has 700 comments.
Rather than engage in a back and forth or aim for clarity, which is what I would have recommended, or complaining to me that some of the remarks have crossed a line, (I have actually taken down many comments if they contain profanity directed at any specific individual.), Dermacare and it's CEO Carl Mudd have actually gone and filed suit. (I also received a PDF of the suit naming multiple John and Jane Does.)
Here's the email:
VIA E-MAIL AND U.S. MAIL
Jeff Barson
(I've removed my address here)
Re: DLC Dermacare, LLC v. John and Jane Does – CV2008-090071
Dear Mr. Barson:
My office represents DLC Dermacare, LLC (“Dermacare”) and its CEO Carl Mudd. I am writing in regards to the blog that you host located at www.medicalspamd.com . As you know, you have allowed numerous persons to post information related Dermacare and about Mr. Mudd personally on your site. The information posted is overwhelming incorrect and has served as a discussion board for Dermacare franchisees to not only discourage potential franchisees from partnering with Dermacare but to also promote the breaching of current franchisee agreements held by many of the bloggers on your site.
The comments that you have allowed to be posted on your site have evolved from mere discussions/complaints into actionable claims against the bloggers and possibly even you personally. Pursuant to our filing the above referenced complaint we are now seeking the Internet Protocol (IP) address and the Internet Service Provider (ISP) for each of the following bloggers on your site:
- Dermadoc
- Mr. Bob
- Just Another Ex
- Passive Conduit
- Pm
- Jennifer D
- Pengy
- Mr. Freeze
- Bastard Son of Dermadoc
- GH
- Maxwell Smart
- The Clinician
- The Real M. Smart
- John Galt
- George
- Max
- XYZAL
- Christmas
- Maxwell’s Silver Hammer
- The Passive Conduit
- The Riddler & The Joker
- DoubleDermadare You
- Mad Max
- Manic Max
- Mad as Hell in Dermacare Hell
- A current Franchisee
- FreeTheDerm@ yahoo.com
- WPS
- Insider
- Thomas Jefferson, Jr
- TF
- T. Jefferson, Jr.
- The Joker
- Curious
- Mr. X
Please provide the IP address and ISP for each of the above names no later than Friday, January 18th, 2008. Should you not provide the requested IP addresses and ISP by this date I will be forced to have you served with a subpoena to obtain this information. I have included a copy of the lawsuit that was filed in this matter for your files. If you have comments or questions please direct them to my office.
Sincerely,
John N. Skiba
One North Macdonald Road, Suite 201
Mesa, Arizona 85201
Tel. 480.361.5643
Fax 480.704.3071
www.skibalaw.com
You can download the actual PDF of the Suit here.
I wasn't asked to keep any of this confidential so here it is.
So what's Dermacare and Carl Mudd doing?
This is what is know as a CyberSLAPP suite. Basically it's a way of intimidating critics by threatening to find out their identity and hit them with some kind of suit. (read below)
You'll notice that Dermacare and Carl Mudd are demanding that I turn over everyones ISP. For those of you who are not that technically savvy, ISP = Internet Service Provider, which I have absolutely no way of knowing anyway as far as I can tell. The IP address is different. That's a unique identifier and could be used to find out who someone is.
These kinds of suits have become increasingly common as a way of combating free speech on the internet. It used to be that if someone said something unkind, it didn't matter that much since only a few people would hear about it. The net changed all of that and now someone who's unhappy with you or your business can be found by everyone so those whe illicit a lot of negative comments tend to have a rougher go of it.
My guess is that this is intended to intimidate those who may comment in a negative way about Dermacare or Mr. Mudd, and to find out who everyone is. While anonymous speech is protected by the constitution, its still unnerving to have someone you've been talking about know exactly who you are, especially if you're in some kind of business relationship. By filing a real suit against 'everyone' in the form of John and Jane Does, it allows him to issue a legal subpoena to get information. (It's basically a cynical way of using the courts which is why some states like California have laws specifically against this.)
Here are some links about these kinds of CyberSlapp suits and where the law comes down on free speech and other issues around this:
Do you know your online rights? Have you received a letter asking you to remove information from a Web site or to stop engaging in an activity? Are you concerned about liability for information that someone else posted to your online forum? If so, this site is for you.
Defamation
The law of defamation balances two important, and sometimes competing, rights: the right to engage in free speech and the right to be free from untrue attacks on reputation. In practice, the filing or even the threat to file a lawsuit for defamation has sometimes been used as a tool to shut down legitimate comments on the Internet.
John Doe Anonymity
Do you post to a public message boards or discussion areas on websites such as Yahoo, AOL or Raging Bull? Do you use a pseudonym, fake name or a "handle"? Has someone asked the host of the discussion or your ISP to turn over information about you or your identity? If so, then the John Doe/Anonymity section may answer some of your questions.
Topic maintained by Stanford Center for Internet & Society
Protest, Parody and Criticism Sites
The Internet, which offers inexpensive access to a worldwide audience, provides an unparalleled opportunity for individuals to criticize, protest and parody.
The following is long but you'll come away with a much better understanding of what this all means:
About Defamation:
Question: What are the elements of a defamation claim?
Answer: The party making a defamation claim (plaintiff) must ordinarily prove four elements:
- a publication to one other than the person defamed;
- a false statement of fact;
- that is understood as
- If the plaintiff is a public figure, he or she must also prove actual malice.
a. being of and concerning the plaintiff; and
b. tending to harm the reputation of plaintiff.
Question: What defenses may be available to someone who is sued for defamation?
Answer: There are ordinarily 6 possible defenses available to a defendant who is sued for libel (published defamatory communication.)
1. Truth. This is a complete defense, but may be difficult to prove.
2. Fair comment on a matter of public interest. This defense applies to "opinion" only, as compared to a statement of fact. The defendant usually needs to prove that the opinion is honestly held and the comments were not motivated by actual "malice." ( Malice means knowledge of falsity or reckless disregard for the truth of falsity of the defamatory statement.)
3. Privilege. The privilege may be absolute or qualified. Privilege generally exists where the speaker or writer has a duty to communicate to a specific person or persons on a given occasion. In some cases the privilege is qualified and may be lost if the publication is unnecessarily wide or made with malice.
4. Consent. This is rarely available, as plaintiffs will not ordinarily agree to the publication of statements that they find offensive.
5. Innocent dissemination. In some cases a party who has no knowledge of the content of a defamatory statement may use this defense. For example, a mailman who delivers a sealed envelope containing a defamatory statement, is not legally liable for any damages that come about from the statement.
6. Plaintiff's poor reputation. Defendant can mitigate (lessen) damages for a defamatory statement by proving that the plaintiff did not have a good reputation to begin with. Defendant ordinarily can prove plaintiff's poor reputation by calling witnesses with knowledge of the plaintiff's prior reputation relating to the defamatory content.
Question: Can an opinion be defamatory?
Answer: No — but merely labeling a statement as your "opinion" does not make it so. Courts look at whether a reasonable reader or listener could understand the statement as asserting a statement of verifiable fact. (A verifiable fact is one capable of being proven true or false.) This is determined in light of the context of the statement. A few courts have said that statements made in the context of an Internet bulletin board or chat room are highly likely to be opinions or hyperbole, but they do look at the remark in context to see if it's likely to be seen as a true, even if controversial, opinion ("I really hate George Lucas' new movie") rather than an assertion of fact dressed up as an opinion ("It's my opinion that Trinity is the hacker who broke into the IRS database").
Question: Is there a difference between reporting on public and private figures?
Answer: Yes. A private figure claiming defamation — your neighbor, your roommate, the guy who walks his dog by your favorite coffee shop — only has to prove you acted negligently, which is to say that a "reasonable person" would not have published the defamatory statement.
A public figure must show "actual malice" — that you published with either knowledge of falsity or in reckless disregard for the truth. This is a difficult standard for a plaintiff to meet.
Question: Who is a public figure?
Answer: A public figure is someone who has actively sought, in a given matter of public interest, to influence the resolution of the matter. In addition to the obvious public figures — a government employee, a senator, a presidential candidate — someone may be a limited-purpose public figure. A limited-purpose public figure is one who (a) voluntarily participates in a discussion about a public controversy, and (b) has access to the media to get his or her own view across. One can also be an involuntary limited-purpose public figure — for example, an air traffic controller on duty at time of fatal crash was held to be an involuntary, limited-purpose public figure, due to his role in a major public occurrence.
Examples of public figures:
- A former city attorney and an attorney for a corporation organized to recall members of city counsel
- A psychologist who conducted "nude marathon" group therapy
- A land developer seeking public approval for housing near a toxic chemical plant
- Members of an activist group who spoke with reporters at public events
Corporations are not always public figures. They are judged by the same standards as individuals.
Question: May someone other than the person who originally made the defamatory statement be legally liable in defamation?
Answer: One who "publishes" a defamatory statement may be liable. However, 47 U.S.C. sec. 230 says that online service providers are not publishers of content posted by their users. Section 230 gives most ISPs and message board hosts the discretion to keep postings or delete them, whichever they prefer, in response to claims by others that a posting is defamatory or libelous. Most ISPs and message board hosts also post terms of service that give them the right to delete or not delete messages as they see fit and such terms have generally been held to be enforceable under law.
Question: Can an ISP or the host of the message board or chat room be held liable for
defamatory of libelous statements made by others on the message board?
Answer: Not in the United States. Under 47 U.S.C. sec. 230(c)(1) (CDA Sec. 230): "No provider or user of an interactive computer service shall be treated as the publisher or speaker of any information provided by another information content provider." This provision has been uniformly interpreted by the Courts to provide complete protection against defamation or libel claims made against an ISP, message board or chat room where the statements are made by third parties. Note that this immunity does not extend to claims made under intellectual property laws.
Question: Must an ISP or message board host delete postings that someone tells him/her are defamatory? Can the ISP or message board delete postings in response to a request from a third party?
Answer: 47 U.S.C. sec. 230 gives most ISPs and message board hosts the discretion to keep postings or delete them, whichever they prefer, in response to claims by others that a posting is defamatory or libelous. Most ISPs and message board hosts also post terms of service that give them the right to delete or not delete messages as they see fit and such terms have generally been held to be enforceable under law.
About John Doe Anonymity
Question: How is Internet anonymity affected by John Doe lawsuits?
Answer: Often called "CyberSLAPP" suits, these lawsuits typically involve a person who has posted anonymous criticisms of a corporation or public figure on the Internet. The target of the criticism then files a lawsuit so they can issue a subpoena to the Web site or Internet Service Provider (ISP) involved and thereby discover the identity of their anonymous critic. The concern is that this discovery of their identity will intimidate or silence online speakers even though they were engaging in protected expression under the First Amendment.
Question: Why is anonymous speech important?
Answer: There are a wide variety of reasons why people choose to speak anonymously. Many use anonymity to make criticisms that are difficult to state openly - to their boss, for example, or the principal of their children's school. The Internet has become a place where persons who might otherwise be stigmatized or embarrassed can gather and share information and support - victims of violence, cancer patients, AIDS sufferers, child abuse and spousal abuse survivors, for example. They use newsgroups, Web sites, chat rooms, message boards, and other services to share sensitive and personal information anonymously without fear of embarrassment or harm. Some police departments run phone services that allow anonymous reporting of crimes; it is only a matter of time before such services are available on the Internet. Anonymity also allows "whistleblowers" reporting on government or company abuses to bring important safety issues to light without fear of stigma or retaliation. And human rights workers and citizens of repressive regimes around the world who want to share information or just tell their stories frequently depend on staying anonymous – sometimes for their very lives.
Question: Is anonymous speech a right?
Answer: Yes. Anonymous speech is presumptively protected by the First Amendment to the Constitution. Anonymous pamphleteering played an important role for the Founding Fathers, including James Madison, Alexander Hamilton, and John Jay, whose Federalist Papers were first published anonymously.
And the Supreme Court has consistently backed up that tradition. The key U.S. Supreme Court case is McIntyre v. Ohio Elections Commission. http://www.eff.org/Legal/Cases/mcintyre_v_ohio.decision
Question: How do CyberSLAPP plaintiffs discover the identity of anonymous Internet critics?
Answer: CyberSLAPP plaintiffs usually get the personal information you gave an ISP or online message board when you signed up (name, address, telephone number, etc.). Some web sites that host discussion boards might only have your e-mail address, in which case a second subpoeana to the ISP that hosts that address will reveal your identity. In many cases, even more detailed information about your use of the Internet can be obtained; it's important to realize that when you go online, you leave electronic footprints almost everywhere you go. (With advanced knowledge of the Internet, however, there are ways to cover your tracks.)
Question: Don't judges review subpoenas before they are sent to ISPs?
Answer: No. The issuing of civil subpoenas is not monitored by the court handling the case. Under the normal rules of discovery in civil lawsuits, parties to a suit can simply send a subpoena to anyone they believe has information that could be useful. That information doesn't even have to be relevant to the lawsuit, as long as it could possibly lead to the discovery of relevant information. The only way that a court will evaluate an identity-seeking subpena is if either the ISP or the target of the subpoena files a motion asking the judge to block the subpoena. Unfortunately, in practice that rarely happens. That is because these subpoenas usually have a short, roughly 7-day deadline, and because many people never even find out that their Internet data has been subpoenaed.
Question: Isn't my ISP required by law to tell me if someone asks for my Internet-usage records and identity?
Answer: Unfortunately, in practice CyberSLAPP subpenas are rarely challenged becaue ISPs often fail to notify the individual who's personal information is sought. Even when they do, the short deadline (often as little as 7 days) does not provide enough time for the speaker to find and hire an attorney and the attorney to prepare the Constitutional arguments necessary to defend against the subpena.
Question: What is a "motion to quash" a subpoena?
Answer: This is a formal request for a court to rule that your information should not be given to the requesting party. This normally includes the request, plus a legal brief (sometimes called a memorandum of points and authorities) explaining why, by law, your information should not be turned over. Samples of briefs filed in John Doe cases are available at:
EFF Archive, Cullens v. Doe, http://www.eff.org/Privacy/Anonymity/Cullens_v_Doe/
http://www.citizen.org/litigation/briefs/IntFreeSpch/articles.cfm?ID=5801
Question: What should I do if I receive notice that my ISP has received a subpoena for my data?
Answer: First you should decide whether you wish to fight to protect your identity, Internet usage records, or whatever else is being sought. You might want to ask your ISP for a copy of the subpoena if they haven't already provided one. If you decide to fight it, you should inform the ISP immediately, and you may want to request that they delay compliance to give you time to find a lawyer. Then find a lawyer, who will file a motion to have the subpoena thrown out. (If your lawyer can later prove that the lawsuit was frivolous, you may be able to recover legal fees if your state has passed an anti-SLAPP statute.)
Question: What are the typical claims behind a CyberSLAPP suit?
Answer: The most common complaints by CyberSLAPP plaintiffs are defamation, trademark or copyright infringement, and breach of contract. Speech that involves a public figure - such as a corporation - is only defamatory if it is false and said with "actual malice." It also must be factual rather than an expression of opinion. In the US, because of our strong free speech protections, it is almost impossible to prove defamation against a public figure. Trademark and copyright complaints typically claim that defendants have violated intellectual property rights by using the name of a corporation or its products, or by quoting from some of their copyrighted materials such as an annual report. In reality, the First Amendment includes a clear right to criticize and discuss corporations and their products, and the law includes clear exceptions for the "fair use" of protected material for those purposes. Breach of contract suits often involve a claim that anonymous speakers might be employees who have violated a contract by releasing confidential information. Of course, the right to anonymous speech is meaningless if a corporation can unmask your identity at will because you might be an employee breaking a promise of confidentiality.
Question: How do judges decide whether to let a subpoena go forward?
Answer: This is a very new area of the law, and there are few well-established principles. The courts do have a duty to balance the right of anonymity against the need to prevent true defamation. So far there have been both good and bad rulings from judges; fortunately several have ruled that the plaintiff must prove that his case has at least a theoretical chance of prevailing before anonymity can be stripped away. Other cases have established a set of key factors to be used in judging anonymity-stripping subpoenas. In most of these the key factors are 1) that the party seeking the subpoena provide evidence that the identity is needed; 2) that the identity is directly needed for a key element in the case; 3) and that the identity information is not otherwise available to the party seeking it. While not yet firmly entranched in the law, these common-sense principles are clearly the right way to ensure that First Amendment rights are protected while still allowing identity to be revealed when there is a genuine need to do so.
Question: What are some of the important cases in this area of law?
Answer: Important CyberSLAPP cases include Dendrite v. Does, http://www.citizen.org/documents/dendriteappeal.pdf,
Melvin v. Doe, http://legal.web.aol.com/decisions/dlpriv/melvinop.html,
Doe v 2TheMart.com, http://www.eff.org/Cases/2TheMart_case/20010427_2themart_order.html,
Global Telemedia International v. Doe, http://www.casp.net/busted.html. Additional information about these and other cases can be found by searching the Internet or looking on the Web sites listed below.
Question: Can I do anything to help change this situation?
Answer: You can do several things. Be educated about your rights. Find out your ISP's policy on the handling of subpoenas, and encourage them - and any Web sites you frequent - to adopt good policies, especially a pledge to notify you of any subpoena before any private information is disclosed. Encourage your state legislators to pass legislation requiring such notice, and press them to amend state anti-SLAPP statutes to explicitly include Internet anonymity cases.
Question: What other resources are available?
Answer: Web sites dealing with this issue include:
www.aclu.org,
www.citizen.org,
www.eff.org,
www.epic.org,
www.johndoes.org,
www.casp.net,
www.cybersecuritieslaw.com,
cyber.findlaw.com/expression/censorship.html
Question: Can someone ask for my identity even if I am not the Defendant in the case?
Answer: Yes. The rules of civil discovery allow a party to a lawsuit (the plaintiff or defendant) to ask anyone for any information that may lead to the discovery of relevant evidence to their case. However, your ability to quash such a request if you are not named as a party to the lawsuit is the same as if you are named. You can still file a motion to quash. Below is a link to the case files for such a case:
http://www.eff.org/Cases/2TheMart_case/
Question: I am in California. Do I have a right to both resist such a subpena and to ask a court to throw out the case, right away, and award me attorneys fees?
Answer: Yes. California has a specific statute, called the anti-SLAPP statute, that allows an early motion to be brought to have a case dismissed if it is aimed at silencing protected expression and participation in matters of public concern.
Code of Civil Procedure § 425.16(b)(1) provides:
A cause of action against a person arising from any act of that person in furtherance of the person’s right of petition or free speech under the United States or California Constitution in connection with a public issue shall be subject to a special motion to strike, unless the court determines that the plaintiff has established that there is a probability that the plaintiff will prevail on the claim.
A legal brief explaining the California statute further in a case involving claims of online defamation is available at:
http://www.eff.org/Legal/Cases/Kesler_v_Doe/
Question: What are the key federal decisions involving anonymous speech?
Answer: 1. Buckley v. American Constitutional Law Foundation (1999) 525 U.S. 182, 197-200;
2. McIntyre v. Ohio Elections Commission (1995) 514 U.S. 334. In that case, on page 357, the Supreme Court said:
"[A]n author is generally free to decide whether or not to disclose his or her true identity. The decision in favor of anonymity may be motivated by fear of economic or official retaliation, by concern about social ostracism, or merely by a desire to preserve as much of one’s privacy as possible. Whatever the motivation may be, . . . the interest in having anonymous works enter the marketplace of ideas unquestionably outweighs any public interest in requiring disclosure as a condition of entry. Accordingly, an author’s decision to remain anonymous, like other decisions concerning omissions or additions to the content Amendment.
* * *
Under our Constitution, anonymous pamphleteering is not a pernicious, fraudulent practice, but an honorable tradition of advocacy and dissent.
3. Talley v. California (1960) 362 U.S. 60. (holding unconstitutional a state ordinance prohibiting the distribution of anonymous handbills)
4. Lamont v. Postmaster General (1965) 381 U.S. 301, 307 (finding unconstitutional a requirement that recipients of Communist literature notify the post office that they wish to receive it, thereby losing their anonymity);
5. ACLU of Georgia v. Miller (N.D. Ga. 1997) 977 F. Supp. 1228 (striking down a Georgia statute that would have made it a crime for Internet users to “falsely identify” themselves online).
Question: Aren’t people required to explain why they’re subpoenaing my identity and other information?
Answer: Not with the initial request. The reasons for the subpena are only provided if the subpena is challenged, through a motion to quash. In opposing the motion to quash, the person seeking the information must demonstrate, at a minimum, that it is likely to lead to the discovery of information that would be useful in a lawsuit.
Question: I signed a confidentiality/privacy agreement with my ISP that provides that they will not release my information. Doesn’t that protect me?
Answer: No. Most privacy agreements state that information will be turned over in response to legal requests, and a subpena is such a request. Even if the agreement does not say so, a legally issued subpoena overrides such agreements as a matter of public policy. Each ISP has a different policy about notifying users when their information has been subpoenaed, but they cannot simply ignore a subpoena under the law without risking legal santion themselves.
Question: What does "respond" to the subpena mean?
Answer: Usually, it means that the ISP will give the requested information to the requesting person. In some cases, ISPs have resisted requests for information on behalf of their customers, but this is not the norm. Unless specifically told differently by your ISP, you should assume that your ISP will turn over your information as part of its response.
Question: Can an ISP or the host of the message board or chat room be held liable for defamatory of libelous statements made by others on the message board?
Answer: No. Under 47 U.S.C. sec. 230(c)(1): "No provider or user of an interactive computer service shall be treated as the publisher or speaker of any information provided by another information content provider." This provision has been uniformly interpreted by the Courts to provide complete protection
against defamation or libel claims made against an ISP, message board or chat room where the statements are made by third parties. Note that this immunity does not extend to claims made under intellectual property laws.
Question: Can my ISP or the host of a message board be held liable for defamatory statements I make on the grounds that they are a "publisher" or "republisher" of the information?
Answer: No. Federal law provides: "No provider or user of an interactive computer service shall be treated as the publisher or speaker of any information provided by another information content provider." This has been interpreted to protect hosts of discussions between other people against defamation and libel claims as a "republisher" of the information. Note that this protection does not extend to claims under intellectual property laws.
Question: Must an ISP or message board host delete postings that someone tells him/her are defamatory? Can the ISP or message board delete postings in response to a request from a third party?
Answer: 47 U.S.C. sec. 230 gives most ISPs and message board hosts the discretion to keep postings or delete them, whichever they prefer, in response to claims by others that a posting is defamatory or libelous. Most ISPs and message board hosts also post terms of service that give them the right to delete or not delete messages as they see fit and such terms have generally been held to be enforceable under law.
Question: My ISP tells me it's been asked to turn over my name as part of a lawsuit against hundreds of "John Does" in a faraway state. What can I do?
Answer: You should probably contact a lawyer, and suggest that the lawyer take a look at arguments raised by the EFF, ACLU, and Public Citizen in one of these suits (e.g., http://www.eff.org/IP/P2P/RIAA_v_ThePeople/JohnDoe/20040202_UMG_Amicus_Memo.pdf)
Dr. Kenneth Beer: Physician, know thy place.
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Dr. Kenneth Beer is not happy. He posted the following comment on various discussion threads around this site.
Anyone who is not a dermatologist, ENT, oculoplastic has no business doing any aesthetic procedures. All PCPs, PA, RN whatever should be malpracticed out. Read the article in this last months issue, July 2007; Skin and Aging , www.skinandaging.com page 28: The Impact of Core Specialist. PCP's are NOT invited to the Cosmetic Boot Camp and this is the sole reason for blogs like these.
Kenneth Beer MD
PALM BEACH ESTHETIC CENTER
1500 North Dixie Highway, Suite #305
West Palm Beach, FL 33401
Tel: (561) 600-4848
Fax: 1.561.655.9233
Email: info@palmbeachcosmetic.com
The article to which he refers (and he authored) is here: The Importance of Core Specialists
Here are some more of Dr. Beers thoughts as expressed in this article.
Many who advertise themselves as aesthetic surgeons, cosmetic surgeons or even dermatologists, are in actuality instead boarded in pathology, emergency medicine, internal medicine or family practice. And while they may be competent in their own areas of specialization, it stands to reason that physicians who would cut corners to get into the practice of aesthetic medicine might be more likely to cut corners in performing aesthetic procedures than those of us who have invested years in training specifically for this specialty.
Unethical PracticeAs for the financial aspect of this issue, I do care that others in my community are willing to inject for half of my own fee for such procedures. Moreover, I believe that legitimate core specialists are less likely (as a group) to dilute product or substitute counterfeit than those who have cut corners. One prominent case in point: the counterfeit Botox scare in Florida. When the dust settled, it turned out that the product injected was not Botox and that the injections were not made by a medical doctor who was board certified in a “core” specialty.
In another instance that I documented, a local “aesthetic” physician who was injecting hyaluronic acids at a discount was telling people they were getting Restylane but was in fact injecting the less expensive Hylaform and Captique. This practitioner was trained in family practice and pathology, but had no core-specialty training.
...My point is that I believe those who make a habit of skirting the rules are more likely to do so in other aspects of their lives — especially their practices.
Patient Safety ConsiderationsWhat happens to patients who receive cosmetic treatments from self-proclaimed “aesthetic physician”?
They frequently have acceptable results when the treatments are straightforward and involve easily treated areas where knowledge of the anatomy is not needed and a cookbook approach is adequate. But sometimes they get burned — even literally when they are treated with lasers or chemicals by someone with no formal training.
Potential Crisis of Patient ConfidenceThere is now a segment of the population that has been harmed by cosmetic procedures performed by non-core physicians to the extent that they may well have sworn off Botox, fillers, and lasers entirely. For the corporations that have sown these fields by deputizing non-core physicians like my disgruntled colleague to use their products and train others to use their products, the harvest will be bitter.
As for the core specialists, we can only hope that by highlighting these differences to patients and the media, we can help to restore the integrity of our specialties. Perhaps as we begin to work together we can protect our specialties and our patients.
My guess is that in his gusto Dr. Beer didn't read that 'plastic surgeons and dermatologists' are also members of this site or perhaps brushing shoulders with the great unwashed masses of other physicians who are busy cutting corners just got the better of him. I'm guessing that he's also missed my opinion on the medical spa franchise model and like systems. Certainly his demand that PA's and RN's shouldn't be performing procedures would put any number of boarded docs right in the can.
It's just a guess here but I'm guessing that this is the type of language that was so effective in changing the laws in FL.
But of course, Dr. Beer isn't adverse to spreading his wings into other endeavors. He has a web portal selling over the counter skin care and even has a software package that he's about to revolutionize medicine with. From a press release:
Dr. Ken Beer's dream may look something like a cross between a Nintendo Game Boy and an Etch A Sketch, but he prefers to refer to it as "the future of medicine." Beer, an entrepreneurial dermatologist, makes software for doctors to run on tablet computers.
... Beer is seeking investors and partners to help him finish and market his first program, called Dermsoftware, which is designed for dermatologists; after that, he will expand in-to other medical specialties. At $24,000 to $32,000 per system (which covers the software license, upgrades, and a Hewlett-Packard server), Beer knows that he is asking a dear price. But he is convinced that medical practices will gladly pay it.
I too am the object of Dr. Beers wrath since when he signed up as a member of this site he tersely requested that I 'shut this site down immediately'. Heavens I'm becoming unpopular. Perhaps I'm the only one on the planet who could create an alliance between Beers and Mudd.
Dr. Beers is not only letting his obviously substantial ego run amok, he is chasing a red herring in this case.
"Anyone who is not a dermatologist, ENT, oculoplastic has no business doing any aesthetic procedures. All PCPs, PA, RN whatever should be malpracticed out."
Perhaps Dr. Beers misunderstood what the definition of dermatology actually is while he was career planning. Here's the first definition I found.
Dermatology: The branch of medicine concerned with the diagnosis, treatment, and prevention of diseases of the skin, hair, nails, oral cavity and genitals.
Dermatology wasn't designed to be 'cosmetic' medicine. It's the study of diseases of the skin. The 'cosmetic' aspects of medicine were inherited by dermatology and plastic surgery as they were the closest medical specialities.
So now you have dermatologists who identify themselves as 'Cosmetic Dermatologists' because there's an understanding that the cosmetic aspects of medicine don't fit under the disease aspects that really is dermatology.
Which brings us to the changes taking place in in medicine.
The physician of the future will be managing technology, not utilizing an individual skill set. Physicians are a hugely inefficient method of delivering treatments. They're expensive to train, they're slow, and they're expensive. Dr. Beer really is fighting city hall on this one.
What's better... technology.
Medicine is moving to technology solutions. That's what the market demands. That's what is happening and nothing that anyone says or does will change it. It's happening faster in retail medicine because it's not encumbered by the inertia of the third party payer system but it will happen in all of medicine.
A useful analogy would be the family farm. Everyone likes the romantic notion of the family farm. In fact, legislation is passed and moneys provided to keep family farms in existence. But if you think that the family farm will exist in a hundred years outside of a living museum you're mistaken. The family farm is inefficient and markets and progress demand efficiency. So the family farm will change to more efficient methodologies. Any effort to save family farms just forestalls the inevitable. It's the way of the world and nothing that you, I, my farmer friends, or Dr. Beers does will change the way that markets work.
And as new technologies are developed faster, it negates the 'training' that was needed to ensure the effective delivery of the treatments. I'll bet that there's not a dermatologist in the country who performs every bikini line hair removal treatment in their cosmetic practice. Where are these hidden hoards of board certified derms and ENT's that are ready to fill the cosmetic demand?
Dr. Beers position would not ring as hollow if he was focused on who could safely deliver services rather than the protection of a club to which he belongs. Certainly his position seems to be that any physician offering Botox who is not a boarded dermatologist is a quack.
I'd suggest that there's an argument that there is a strong ethical conflict for all dermatologists performing cosmetic treatments.
Skin cancer will soon become the most common cancer in the US. In most cases there's a two month wait to get in to see a dermatologist to take a look at a mole. It could easily be argued that any dermatologist performing cosmetic procedures is selling out needed patient care to cash in and make a buck.
I don't subscribe to this theory myself of course. It's just a thought.
Physician Ethics & Cosmetic Medicine: Are you a money-hungry whore?
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The post on LS, a dermatologist that's pissed at OBGYN's and FP docs in cosmetic medicine has 51 comments as I write this.
Certainly there will probably be more.
I've posted three comment from that thread here. Disenchanted is not generally happy with docs whose
Disenchanted thinks that physicians who are not plastic surgeons or dermatologists are 'money-hungry whores'. (emphasis mine)
As a second year resident having survived internship and still possessing a genuine interest in patients suffering from disease, this whole thread saddens me. No wonder the prestige of the physician has fallen, what a bunch of money-hungry whores. You can have all the lasers and cosmetics and make your money...better yet just trade in your MD for a cosmetology degree and think of all the lives you can make better and impact you will have on the world. Non-plastics/derms who do cosmetics have no professional integrity. All of the above posts are just sad justifications for selling out. I want an FP who will provide appropriate preventive care to my family (if you don't like how GME are reimbursed, spend the time/resources you put into cosmetics courses into a lobby for change). I guess since there's finally some awareness that Obs are cashing in on unnecessary C-sections (hysterectomies etc), need more ways to make cash money. My 2c, flame on brothers and sisters.
LH thinks he's somewhat naive.
Disenchanted, You probably are barking up the wrong tree. So what you are saying is it is OK for derm/plastics to do cosmetic procedures and anyone else that does is a money-hungry whore? I do not get the difference.
I think your opinion will change after you have done this for a while. I would like to speak to you in about 15 years when you have worked 70hours per week been up for 36 hours straight and delivering hundreds of babies in the middle of the night. You get about 1 week vacation per year and your family forget what you look like. All of this to continue to have to work harder to make the same income.
Also, you may want to understand that some of us actually enjoy the artistic side of cosmetic procedures. I also enjoy it because I get to spend more time with the patients.
So I have chosen to alter my career path and that makes me a whore in your eyes. I am OK with that and will not lose an ounce of sleep over it. It is much easier to change my path than the entire practice of medicine. I have fought many a battle including the political ones. It is best for you to look at the serenity prayer "God grant me the serenity to accept the things I cannot change, courage to change the things I can, and wisdom to know the difference".
If I may chime in here for a moment - I am guessing Disenchanted is a resident who went directly from high school to undergrad to med school to residency and has never had a real job or real responsibilities in his/her life. I have been through residency, built a practice, served the underprivileged, and spent many sleepless hours on call taking care of 'real' patients. And I still do because it is who I am. I find it more indicative of a poor attitude that someone in residency already has a grudge against people that may horn in on the money making territory as a matter of free competition rather than settle for our dwindling reimbursements, skyrocketing overhead and more and more demanding professional obligations. I've done my time and no one else is going to pay my mortgage but me. I am not abandoning my patients at al, I am simply making my life better so I can be at my best when they need me.
On the other hand, the medical field looks like crap these days, so I can understand a little bitterness on the part of a resident who has already put a bunch of years into training with a constant stream of bad news about their prospects for a decent lifestyle and working conditions.
So Disenchanted, don't take it out on us if we are in survival mode. Find what you love doing and do it regardless of the payoff. I thankfully have found that place myself. Not alot of cash but I actually enjoy what I do, and that is fine with me.
As for myself, I'll point out that Disenchanted's suppositions rests on a number of key points that are tenuous at best:
- That no physician should be able to change their mind or practice after deciding upon a specialty.
- That, for some reason, physicians who decide on a 'cosmetic' specialty like plastic surgery or cosmetic dermatology have somehow taken the high road (This one I really don't understand.) and since they chose one of these early on that they are somehow more ethical that physicians not 'core trained'. (Why Disenchanted gives them a pass on this I have no idea.)
- That physicians choosing to perform or offering cosmetic medicine are neglecting the obligation they have to their patients.
Since consulting, I've been approached by physicians from the following specialties: Plastic Surgeons, Dermatologists, Anesthesiologist, General Practitioners, Emergency Room Docs, Internist, Family Practice, Cardio-Thorasic Surgeons, General Surgeons, Psychiatrists, ENT, OBGYN, (I know I'm forgetting a lot).... and even a Pathologist. I've said no to many more than I've said yes to, and I have met a number of physicians who I felt were money-hungry and yes, even unethical. But not many.
I also have nothing bad to say about Plastic Surgeons or Dermatologists.
Certainly I understand how Disenchanted feels. But I'm afraid that the holes in the argument are just too big. I would have thought that Disenchanteds derision would have been more thoughtfully focused on Plastic Surgeons and Dermatologists performing cosmetic treatments. Certainly skin cancer should be the focus of Dermatologists and Plastic Surgeons should be performing cleft-palate repair. I would think that Disenchated should laud the Family Practice doc who frees up these specialist for their needed work since it's really not that hard to perform a Botox injection and the patient's right there for their flu shot anyway.
It brings to mind the following quote: "If you're not a liberal when you're twenty you have no balls. And if you're not a conservative when you're forty you have no brains."
American Academy of Cosmetic Surgery wins in California.
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As acknowledged by the American Board of Cosmetic Surgery and affirmed by the Superior Court of California, cosmetic surgeons include qualified physicians from the fields of Dermatololgy, Facial Plastic-ENT surgery, Oculoplastic surgery, General Plastic Surgery, Oral Maxillo-Facial Surgery, and General Surgery.
Via: Plasticized
The Academy has reported, via e-mail and through Newsline, the recent victory in California for cosmetic surgeons, whereby the Superior Court of California ordered the Medical Board of California to grant ABCS's Application for specialty board certification. This decision was recently challenged by the Medical Board, which filed a Motion for a New Trial.
...The ABCS allows for cosmetic surgeons, including ENT's, Oculoplastic surgeons, and cosmetic dermatologists to have certification for the specialized skills in which they are trained. Certification through ABCS is often acheived through fellowship training in cosmetic surgery, which occurs after a residency in a surgical specialty.
and Edward Lack MD isn't mincing words when he says..
"I would hope this will end the dispute once and for all and stop the needless waste of money and time over what is only a turf battle. As the number of board certified plastic surgeons who join the American Academy of Cosmetic Surgery and take board exams from the American Board of Cosmetic Surgery increases, the obstructionists who often hide their identities in the American Society of Plastic Surgery will lose more and more prestige as the public views them as the self-seeking propagandists that they are."
Should Non-Dermatologists Practice “Dermatology”?
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Via Skin & Aging: Dermatology vs. Dermatologist
The Importance of Specialists
However, there cannot be any misrepresentation on the part of the physician. Every patient should be given an option of seeing a specialist who really is a specialty-trained, board-certified physician. It is not okay, in my opinion, for any physician to call him/herself a “dermatologist” simply because he or she has an interest in the field, especially when this claim has purely financial motivation.
Dr. Goldenberg, Section Editor of Issues in Dermatology, is a Dermatopathology Fellow at the University of Colorado Health Sciences Center, Department of Pathology, in Denver, CO.
Vs: Seeing the Good Side of our Colleagues
I have tremendous confidence in the skills of my dermatologist colleagues. I regularly see their commitment to their patients and our specialty. Like Dr. Goldenberg, I think it means something to be a “dermatologist” and believe it is wrong for a doctor to try to mislead patients.
I wonder, though, if Dr. Goldenberg goes too far in impugning the motivation of medical colleagues in other disciplines. Is there evidence that “many physicians, foreign and U.S. medical graduates alike, claim to be ‘dermatologists’ even though they have no training in the field whatsoever”? Unless there’s good evidence to the contrary, I think it is wrong to suggest that other physicians’ acts are based on “purely financial motivation”; we all have financial motivations, but it seems to me that physicians are largely driven by a desire to improve the lives of their patients.
There is a strong tendency to see our colleagues’ mistakes and never see their successes. Such experiences seem to bolster the all-too-human tendency to think the worst of others. We’ll all agree it is wrong to mislead patients about one’s training and experience. It may also be wrong to believe the worst of colleagues and to assume a priori that they are acting outside of their capabilities and training.
Dr. Feldman, Chief Medical Editor, is in the Department of Dermatology at Wake Forest University Baptist Medical Center in Winston-Salem, NC.
