Cosmetic concerns and considerations
First Person
By Mordechai M. Tarlow, MD, January 1, 2018
Q: Why didn’t the patient trust her dermatologist?
A: He kept making rash decisions.
Though this oft-repeated joke is somewhat corny, it strikes a chord in many, as some see in it a semblance of the truth. In recent years our specialty has been contending with “mixed reviews” among the populace. Quite a few recognize that we play a critical role in the health of our patients, providing expert treatment of the body’s largest organ. We must be supremely skilled diagnosticians, often consulting with or advising other specialists, and adept at prescribing various topical and many new and emerging systemic medications. We perform a range of surgical procedures, from basic excisions to Mohs micrographic surgery and elaborate reconstruction. And we are at the cutting edge of minimally invasive cosmetic enhancement. On the other hand, we have all, at various times, come across disparaging remarks in the media, Hollywood, and by members of our own communities.
There are multiple factors which play a role in our public image. However, our specialty’s evolution regarding our cosmetic component has been giving me pause. In my 15 years of practicing dermatology I’ve watched our general approach and attitude concerning cosmetic procedures undergo a dramatic change, and it’s becoming increasingly troubling. It appears that, at least in regard to the aesthetic aspect of our field, we have become increasingly more focused on the financial rewards, often at the expense of the truly valuable prize of proper patient care. Educational forums suggest “gateway procedures” to entice potential patients to purchase further cosmetic services, and these same forums often refer to them as “consumers.” We sell non-evidence based cosmetic products directly to our patients. Practices offer interest-accumulating extended lines of credit to patients who don’t have the means to pay for expensive elective procedures. Do we sometimes seem more like merchants peddling our services and wares than physicians partnering in our patient’s wellbeing?
Perhaps it is time for our collective specialty to take a step back and re-evaluate where we are headed in this regard. The following are some points to ponder.
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Mention is often made of studies showing the significant rate of patient satisfaction following cosmetic procedures such as injection of neurotoxins, fillers, laser resurfacing, and the like. However, a distinction should be made between “patient satisfaction” and “patient happiness.” Satisfaction can be used as a measure when a procedure was already desired and requested by a patient. When, however, a particular procedure is suggested to a patient who has not yet seriously considered it, satisfaction with the outcome is not necessarily an appropriate measure. In such cases, the patient is often seeking some more unformulated means of feeling happier with themselves. A more appropriate measure would be overall improvement in life satisfaction or happiness. Unfortunately, I am not aware of any studies which suggest that this indeed occurs after a patient is enticed to do a procedure they had not previously seriously contemplated. These patients are often seeking improvement to deeper life issues, and their quick-fix cosmetic procedure offers no lasting enhancement in this regard.
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What happens when a general dermatology practice is so busy that a new patient with a potentially serious medical concern is required to wait a number of months to be seen? In our specialty this is not unusual; it is particularly true in areas that are underserved or in practices that focus on quality encounters over increased patient stream. Most medical patients will reluctantly wait for the next available appointment. However, when a potential cosmetic patient requests an appointment, they will rarely be willing to wait that long, and will look elsewhere. The ethical challenge we are consequently faced with is, who do we accommodate? The temptation may be to nab the highly lucrative cosmetic patient by squeezing him or her in sooner. However, I personally don’t feel comfortable making a patient with a medical need wait longer so that I can see a cosmetic patient sooner. Blocking off a set of appointments for aesthetic patients may seem more just, but ultimately the same deference is occurring. Perhaps a first-call first-serve appointment queue (as we have) will avoid inappropriate preference to cosmetic patients, albeit at the cost of increased revenue.
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Numerous practices advertise and sell various topical cosmeceuticals to their patients. A number of these products do indeed have objective data to support their efficacy, and are therefore fittingly sold in a medical office. Many, however, have dubious evidence to support their use. Sure, they may quote a couple of studies suggesting support for their value. But in the context of a journal club review would we really agree that they have true benefit? While the marketing of such products is fitting in a department store or the like, a physician offering them for sale in his or her medical establishment is possibly inappropriately attesting to their effectiveness, and therefore improperly usurping the position.
These attitudes and practices are far removed from our mandate as physicians; indeed, I doubt that any of our colleagues mentioned doing elective cosmetic procedures in the personal statement component of their medical school application. To be sure, performing cosmetic interventions is a part of medical practice. However, when we either overtly or subversively entice patients with options to spend their money on enhancements that they had not otherwise been seriously considering, we are distancing ourselves from the lofty profession of medicine, and approaching that which early in our journey to become physicians we thought of as anathema.
I believe that we all need to take a thoughtful and honest look at what our primary motives are in the practice of medicine, and whether we are truly deserving of our patients’ trust as their doctor. If their best interest is our primary interest, we might tone down the suggestions of expensive procedures, and not be rash to offer extended lines of credit to those who don’t have the means to afford them.
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