WHY SHOULD YOU ADD NON- INVASIVE COSMETIC …

WHY SHOULD YOU ADD NONINVASIVE COSMETIC PROCEDURES TO YOUR PRACTICE?

ALTRUISM? INDEPENDENCE? FINANCIAL SURVIVAL?

David M. Duffy, M.D.

33nd Annual Superficial Anatomy & Cutaneous Surgery Course, July 11-15, 2016

Disclosures

I have no relevant commercial affiliations

This lecture incorporates PowerPoint slides and information abstracted from lectures and publications by both Dr. Duffy and Dr. Zimmett

Important Questions

Why aren't many qualified physicians carrying out non-invasive cosmetic procedures?

Why aren't non-invasive cosmetic procedures taught in most derm programs?

What does the future hold for "traditional" dermatologists? Missed opportunities for improvements in patient care and financial independence

Many Answers

Adequate training? Academic and colleague biases? Lack of interest? Costs?

Patient Benefits

No one is better qualified to carry out certain types of cosmetic procedures than trained physicians

Patients are being treated by poorly trained individuals in less than optimal circumstances, e.g., "Mall medicine" (sometimes with disastrous results)

The FDA has recently published warnings (regarding blindness with fillers, recommending that patients should be treated by well trained practitioners)

Benefits of Cosmetic Procedures for Your Practice

Protection from declining revenues and reimbursement cuts from managed care

Develop an income stream independent of insurance reimbursement

Taps into a growth segment Allows you to capture a large percentage of total

derm expenditures from your existing patient base

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Bad News From the Untrained

"Wrong Filler in the Wrong Hands"

The Future of American Physicians

More paperwork, less income, more oversight Declining revenues/reimbursement cuts MOHs

surgery compensation and indications are increasingly scrutinized; expect new limits. Elective procedures will become an increasingly vital component of common dermatologic practices.

Courtesy Joe Niamtu, M.D.

Training

Residency Realities

One dermatologist notes that when people came out of school who wanted to do "cosmetics" they were looked down on. At Harvard, they called it "Throwing pearls to the swine. Now in terms of survival it's what you do." Steinhauer J. N.Y.

Times 1/18/2000

Applicants for Derm Residencies Know Better Than to Show Any Interest in Cosmetic Procedures

Over 95% felt that they would have been rejected for residency programs if they expressed any interest in cosmetic procedures.

50% of dermatologic residents were unprepared for the type of practice they intended to have.

85% feel they should have had more training in cosmetic procedures.

Duffy DM, Torok H, Keeling J. Surveying Cosmetic Procedural Residency Training: Are We Short-Changing Tomorrow's Dermatologists? A Preliminary Report. Cosmetic Dermatology. Sept. 2008. Vol 21, No 9.

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What's not being taught in many

Residencies

No formal credentialed courses in cosmetic procedures in most derm residencies

No plans to put them in place The relevance of what you are learning as it relates to

the socioeconomic realities of private practice

What Isn't Being Mentioned

In fact, 90% of many dermatologic practices deal with issues of purely cosmetic importance: Warts, Acne, Hair Loss, Pruritus, Hyperhydrosis and other less than life threatening conditions Glogau

Lack of training and meaningful credentialing will inevitably lead to inadequate patient care and an increase in preventable complications

Quotes from Academia

Medical dermatology is threatened by "Cosmeticisization"

This trend runs the risk of "marginalizing dermatology in the eyes of both the public and other physicians" Wirth et al. Derm Clinics Vol. 19 Number 4

Oct. 2001

Patient's choose between health and satisfaction?

Academia Hello Dr. Freud "Cosmetic surgery is not really a requisite for good

health", "How does it justify its existence as part of a medical profession whose purpose is to promote health?", "Should patient satisfaction rather than health be the proper goal of medical care", a "contractual model is not necessarily appropriate for medicine." Ringel EW Arch. Derm Vol. 134, April 1998.

"Life As A Dermatologic Beautician"

"Fifty years ago dermatologists were considered to be `external doctors' with little knowledge with pathophysiology and whose therapeutic armamentarium consisted of slapping ointments on the skin. Lifestyle will again give us the image of being external." "From here on it's only a few steps to the beautician. The end result will be loss of reputation, loss of resources, trivialization, and marginalization of our specialty.

Klaus Wolff, MD, Vienna, Austria 2003

Blindness After Glabellar Artecoll "Simple Filling"

"It takes weeks or even days to learn simple filling" Klaus Wolff, MD, Vienna, Austria 2003 Obviously this physician took Dr. Wolff's advice to heart.

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Negative peer Perceptions Published Opinions

Academic Puritans. Satisfaction is incompatible with health?

"Cosmetic surgery is not really a requisite for good health", "How does it justify its existence as part of a medical profession whose purpose is to promote health?", "Should patient satisfaction rather than health be the proper goal of medical care", a "contractual model is not necessarily appropriate for medicine." Ringel EW. Arch

Derm, Vol. 134, April 1998.

Negative Peer Perceptions

Fifty years ago dermatologists were considered to be `external doctors' with little knowledge with pathophysiology and whose therapeutic armamentarium consisted of slapping ointments on the skin. Lifestyle will not again give us the image of being external." "From here on it's only a few steps to the beautician. The end result will be loss of reputation, loss of resources, trivialization, and marginalization of our specialty". Klaus Wolff, MD, Vienna,

Austria 2003

Reality Check

"There is nothing wrong with the pursuit of happiness as a goal of professional medicine"

"The cosmetic dermatologist reaches a therapeutic alliance with the patient" Glogau RG. Arch Derm Vol. 134 Oct.

1998

"There is nothing wrong with the pursuit of happiness as a goal of professional medicine"

"The Cosmetic dermatologist reaches a therapeutic alliance with the patient" Glogau RG. Arch Derm Vol 134, Oct. 1998

Is Cosmetic Dermatology Inherently Inferior?

Appearance is an essential component of health; a powerful determinant of success in interpersonal relationships.

No one ever died of acne, I've rarely found a dermatologist who is not willing to treat it.

Acne is not inherently abhorrent and vitiligo is not a deformity. Glogau 2005

Is Cosmetic Dermatology Inherently Inferior?

Appearance is an essential component of health; a powerful determinant of success in interpersonal relationships.

No one ever died of acne, I've rarely found a dermatologist who is not willing to treat it

Acne is not inherently abhorrent and vitiligo is not a deformity.

Real Problems with Cosmetic Dermatology

Peer reviewed literature often presents unrealistic assessments of new technology which cannot be verified by impartial practitioners

There are no established criteria for training or incorporation of new technology/procedures

Fundamentally dishonest and intentionally misleading advertisements are commonplace

Plenty of "hired guns" who promote questionable cosmetic devices and procedures

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The Cosmetic Patient

You will be dealing with a different kind of patient BDD can be as high as 15% in cosmetic patients Training for yourself and your staff Many procedures are demand-driven There may be an impact on general derm patients

Risk Management of the Cosmetic Patient

Beware of overly demanding patients who were dissatisfied with previous results in other offices. Endless questions

Under promise! Discuss risks, show before and after photos Consent forms Be artful in handling complications

Patient Selection

Expect some reluctance, but not conflict Are they exaggerating their problem? Do they have endless questions? Don't be afraid to "flunk" a patient and send them

out to think it over

Wide Spectrum of Non-Invasive Aesthetic Treatment Options

Spectrum of Aesthetic Treatment Options

Some require less commitments of time and resources

Every Dermatologist or qualified physician should carry out at least a few of them

Spectrum of Treatment Options for the Aging Face

Pre surgery

Post Surgery

Injectables, fillers, neurotoxins

Wrinkles, Volume

Lasers RF

Ulthera Fillers,

Laser RF

Neurotoxins

Texture, Laxity, Neck, pigment tone brow

Maintanence

Ulthera

Three D's of Aging Skin

Deterioration Fine lines Brown spots Telangiectasias Loss collagen

Deflation Volume loss

Descent Laxity/sagging

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American's are Getting Grayer And More of Them Are Seeking Help for It

Neurotoxin procedures up 5,407% since 1997 Skin Rejuvenation 1997 ? 2014 up 2,900,838%

Cosmetic Procedures are a Growth Industry

Percent of Total Nonsurgical Procedures by Age as of 2014

Future patients -

Healthy retirees Men of all ages People of color

Cosmetic Procedures A Growth Segment

Growing Demand for Cosmetic Services

From 1997 to 2010 there has been a 700% increase in the number of non-invasive procedures according to ASDS and ASAPS

The Challenges of Volitional Medicine

New role of physicians Patient satisfaction is important but must be

balanced with ethical practice Success comes from a sound business model as much

as from sound medical judgement

Youthful Face

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