Want to make REAL money?

Cosmetic medicine may not be the answer.

 
People both in and out of the medical field often comment on how much fun I must have at work.  And I actually do have a lot of fun.  I enjoy my job and I enjoy this field of medicine.  But it's still work.  And there are still problems as there are problems in any line of work.  But I always get a chuckle when people assume that since the office looks like a day spa and since our patients pay out of pocket, that any physician who works in cosmetic medicine must be rolling in the money.  I even hear that from other physicians.  My own ob/gyn is soon going to add cosmetic services to her practice so she "can finally get out of debt."  And while I think there are a few clinics out there that do exceptionally well.  For the most part adding cosmetic services to your current practice is like starting any new business.  For every Microsoft, there must be 5,000 others that fail.  Those odds of success and failure definitely apply to the field of cosmetic medicine.

Course most people think that all doctors are rolling in money.  I think most physicians earn a decent living, but when you take into account all the years in school, tuition, and the residency "stipend" that works out to be about minimum wage....well, I think there are a lot of easier ways to make that same amount of money.  Which is why I'm happy that I enjoy my work.  If I had entered medicine just to make money, then I might be disappointed that I didn't decide to become a plumber.  My plumber makes between $200 - $300 / hr and doesn't have to spend thousands on malpractice.  And he's so busy that his voicemail says don't even bother leaving a message if you are a new client.  He's already got all the work he needs.  And then he takes off to Mexico for 3 months out of the year.  Not that I'd want to muck around in some of the stuff he does.  But if you are only interested in money, then perhaps medicine isn't the right calling for you.  And if you are really interested in money, then cosmetic medicine may not be the pot of gold at the end of the rainbow that you think it is.

In fact, perhaps you should head straight onto Wall Street.  Monday's (November 27,2006 Lure of Great Wealth Affects Career Choices) New York Times had a front page article about a hematology/oncology physician who was making about $150,000/year in clinical medicine.  But then he straddled over to Wall Street and is now earning over $1-2+ million a year.  He launched from "decent" money to "insane" money.  

We often hear about Drs. X, Y, and Z entering this field from all different types of specialties.  And I'm sure they are lured by the predictable hours and lack of insurance wrangling.  But if they are drawn by the ideas of wealth and grandeur, they might be sadly disappointed. 

Lips and Silikon 1000...a good combination?

Grandma...is that you?

A good friend of mine recently confessed to me that she had seen one of my competitors and gotten Silikon 1000 in her lips.  I usually treat her for Restylane that we use judiciously in her nasolabial folds and her lips.  We also use a little Botox around her eyes.  She is 31 years old and has a beautiful face.  Her lips are full, but she wants "luscious!"  Her assistant had had it done with Dr. T and "she looked amazing."  And when my friend went to his office, his entire staff of young women all had gorgeous bee-stung lips. 

Now, for a moment, just forget all the stories of granuloma risk and inflammation.  Let us pretend that Silikon 1000 in the lips is 100% safe.  I actually do have Silikon 1000 in my office.  But I've only used it in a handful is situations.  One woman had been "butchered" (her term, not mine) by a oral surgeon and felt it left 2 divots in her lower lip.  I carefully filled these in.  Another woman's right upper lip dropped lower than her left from lingering Bell's palsy.  I used it to even out her lips. 

I have two patients who want to look like Angelina Jolie. I can't seem to put enough Restylane into their lips. One of them is from Texas and she said to me, "Honey, bigger is ALWAYS better!"  But the vast majority of my patients who want lip augmentation want only a slightly fuller look.  And so what happens when Angelina is no longer the superstar?  What happens when thin, straight, bead-like lips are in style?  Or what happens when all these young, beautiful woman with these mammoth sized lips get old and are grandmothers?  Their faces will continue to age in the normal, dynamic manner.  But those Silikon lips will be permanent!  I keep getting the visual of a faded tattoo on the side of  a wrinkled, sagging breast.   

Cosmetic Medicine: The Unhappy Patient

How to ask the patient to stop seeing you.

I shouldn't have even said "unhappy patient." I should have said the forever unsatisfied patient. Thankfully this is a very infrequent situation in our practice, but it happens every once in a while. And it leaves such a mark, that I thought I'd ask how other physicians handle these scenarios in their own practice.

Last year I saw a patient (56 year old woman) and treated her with a little Botox between her brows and some Restylane in her nasolabial folds and the lines above her lip. She came back to see me 2 weeks later and fell into tears in my office. In fact, I was moved to tears since it truly seemed like I had ruined her life (there's where I should have seen the first red flag, but I missed it). She felt like she had all sorts of new wrinkles, her brows had fallen, etc. Unfortunately (and let this be a lesson that some of you might learn from my mistake) I hadn't taken "before" photos of her. And that was unusual since I really do take pictures of almost everything I do. Especially the first time I treat a patient. And now I absolutely do! Anyway, I couldn't see any "lowering of her lids" from the Botox. In fact, the Botox did exactly what I had expected and had informed her beforehand that it would do. I assumed she just didn't like the effect. But in terms of the Restylane, she saw all sorts of new lumps, new horizontal wrinkles and changes to her original appearance.  In her defense, I did seem some minor areas I could fix and so I did so at no charge to her. And this time I took photos. I also added some Botox to her lateral brows hoping we would see a little lift there to alleviate what she saw as "drooping."  But there was no ptosis or any of the potential complications that could occur from Botox.

She returned to see me again in another two weeks and again was still unhappy. I had ruined her "girl's weekend" in Vegas because she couldn't leave her hotel room looking so "horrible." Again more tears. But I managed to take some more photos and compare them to the ones we had taken on the last visit. Her brows were elevated a bit and her lip lines and nasolabial folds looked great. We even zoomed in to take the closest look possible. But she was not swayed.  She was convinced she still looked horrendous and that I was to blame. So now I'm starting to notice a little bit of the flag. But it's still in my peripheral vision  I really listen and try my best to understand where she's coming from, but honestly I think she looks pretty good. Course it doesn't matter what I think, I still have a dissatisfied patient sitting in front of me. But I didn't think adding any more filler or Botox was going to improve the situation. So I ask her what she thinks can be done. And she comes right back, in a very matter of fact tone, and says that she feels the most appropriate next step would be for me to perform a thread lift on her at no charge. So right about now the red flag is waving frantically in front of my face....hopefully hiding the look of shock.  My mind is filling with all sorts of questions...like why would she want something more invasive, more long term? And if I'm the one who has ruined her life, why does she want me to do another procedure on her? 

Right about then I realized that she wanted more procedures done, but she just didn't want to have to pay for them. So in the nicest way I knew how, I simply said that I didn't think that I was going to be able to satisfy her needs.  I was concerned that there was little, including a thread lift, that I thought I could do to meet her expectations. And I wasn't sure whether she had unrealistic expectations or if I had promised the sun, stars, and the moon. But somewhere between what she wanted and what I could deliver, there was a great divide. But knowing that all our office offers are minimally invasive or noninvasive procedures, I routinely spend a great deal of time in the initial consultation. If a patient comes in to see me and has complaints that cannot be adequately treated with the procedures I offer, then I usually refer them to one of the plastic surgeons in the area. I try hard to communicate the strengths and weaknesses of what I can do in my office verses what a surgeon can do in the OR.  So I doubt I had given her the impression that a little Botox and filler were going to make her look like she was 22 again.

And I certainly didn't think it was going to be a good idea for me to be performing any more procedures on her given she already didn't like what I had done. Did I mention she had already spoken to her attorney? I think I forgot to tell you that part of the visit. At the end of my previous visit with her, she told me that her attorney had advised her to stop payment on the check that she had originally written for her initial services. I wasn't sure if that was even legal or not, but needless to say, that put a damper on our relationship. And then when I said I didn't feel it was in either of our best interests to do the thread lift, her tearful eyes quickly changed to scowling ones and she let me have it. I asked my office manager to step into the office with me since I wanted somebody else to witness the exchange. But now she turned from a weepy patient to an angry woman who was yelling and screaming at me.  Since it quickly became apparent that we could no longer communicate in a constructive manner, I let my office manager (who is extremely proficient in all situations) try to diffuse the tension. 

Cosmetic medicine is still medicine and needs to adhere to the regulations governing any practice. But are the terms somewhat different when it comes to patient "abandonment" and how to notify a patient that you no longer wish to be their provider? What happens when a patient wants you to do something that you don't feel comfortable doing? What if it gets ugly? Please share your stories or thoughts on these situations.

To learn more about how to end the Doctor-Patient relationship and the legal aspects or ethics involved, click here

How do you define "beauty"?

Beauty is in the eye of the beholder, right? 

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

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

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

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

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

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

What's a patient worth to your practice?

Most businesses exist to make money.  We've all heard the phrase "maximize profits and keep costs low." Among many factors, one of the major ways to build a successful and profitable medical practice is to reduce patient acquisition costs through a variety of patient retention techniques.

With that said, keep the following in mind: for an average company, it costs five times as much to obtain a new customer than to retain a current one. It can reach up to sixteen times as much to turn a new customer into one as profitable as a lost customer.   And that can be directly applied to most medical practices, especially ones that focuses on cosmetic services or charge fee for service.  Gone are the days when physicians could expect people to patiently sit for over an hour in the dull, dark waiting room with old boring magazines to read and then expect them to be grateful to even be seen.  Most of our patients are frustrated if they can't be seen within a day or two and will not tolerate waiting beyond 10 minutes in the waiting room.  And I don't blame them.  They are paying a lot of money for their treatments and are busy themselves.  Plus if we can't accomidate them, then usually there are at least 5 other physicians in the area who can do their Botox that same week.

What's a practice to do?  Treat the patient more like a customer and understand your practice through their eyes.   According to Marc Mertz  with The Horizon Group, a national health care consulting company, most patients base their level of satisfaction on two things: the front office staff and the office itself.  Can that be true?  You mean they don't seek out the best physician through hell and high water?  Actually patients tend to judge your clinic by the things that you likely take for granted.  And no matter how skilled you are as the doctor or where you went to medical school, they key in on a rude receptionist or the paint chipping from an exam room wall.  In fact, according to a survey of family practice patients, the front-office staff, ambiance of the practice facility, clinical support staff, and then physicians were ranked in order of importance as factors influencing patient satisfaction.

This is very important information and if you were suprised by it, then it was even more important for you!  Physicians tend to focus on their clinical expertise and think that staying abreast in their field is enough to guarentee a happy patient population.  And while that may be true in some fields, that is not the case in the field of elective cosmetic procedures.  So how do we adapt to this information?  One sure way to fail is to ignore it.  But offices who succeed tend to take it in, learn from it, and actually implement the changes necessary to keep their patients happy and, in turn, keep them coming back to them over and over again.

To read more about steps that you can use to improve your office, click here