Steven H. Dayan, MD, FACS

Steven H. Dayan, MD, FACS is a facial plastic surgeon practicing in Chicago, IL. He is Co-Chief Medical Editor for Modern Aesthetics® magazine.

Doctor I want a nice nose, I want it turned up and narrowed just a little, but not too much. I want it to look cute, natural, like this photo on my phone but I am sure you know what I want…You are the expert…Just make it perfect.”

Have you heard this before? Or better yet, how often have you heard it? Is perfection becoming increasingly expected? And if so, why? Is it unique to aesthetic patients, or is it just a symptom of a society that is becoming accustomed to nothing less than the ideal?

I am in my fifteenth year of practice and I believe expectations for perfection are on the rise. During consultations, patients often request their favorite movie star's nose, guaranteed outcomes and, for the first time ever, refunds if ideals are not met. My inkling is that this entitlement has been sparked by an over-served Gen X, and an over-nursed Millennial generation. Both generations seem unable to temper primal urges to create a virtually ideal moment at the swipe of the finger with their mobile phone and app-loaded camera. Photos that don't match the ideal can be immediately deleted until the right one is achieved. And if just shy of perfection, the chosen one can be morphed, filtered and contrasted until the perfect trophy of shadows, proportions and angles is realized. Just like that, a story is created and is ready for uploading to the social media façade of choice. Such an ability to quickly evaluate, manipulate and achieve the perfect version of “me” and my life perhaps contributes to an empowered consumer who has a deified right to always be pleased.

But are we partly responsible for our patients' inflated expectations? Are we promoting a false idealism with over promising videos, Instagram, Snap Chat stories and social media chatter?

Idealism Versus Pragmatism: A Historical Perspective

From Greece's Pantheon of Gods to Plato's Forms and Biblical Commandments to Leonardo DaVinci's Vitruvian man, idealistic values have existed, been desired, and promoted as a standard for which we should aim. But history's idealism has been tempered by gnostic sobriety recognizing that perfection was allegorical in nature. Even Moses, perhaps the most righteous man to have existed, was separated from perfection by two sins.

The desire for the ideal has always been preached, but even Plato knew we could only see the shadows of it. And perhaps it is our lack of perfection that fuels the idealistic philosophies of Buddha, Karl Marx and Immanuel Kant. Achieving pure idealism is rare in a world inhabited by an imperfect humanity. Perhaps for the very few enlightened, a life dictated by the ideal can succeed, but an idealism that is absolute along with the ideologues that preach the faith eventually break under the weight of their own narcissism. Look no further than Plato's Republic to Karl Marx's communism and Adolf Hitler's “Final Solution” to modern day fanatics of all religions, crafts and trades unwilling to welcome the pragmatic. Idealism leads to darkness. The literalist of the 5th Century arguably drew in a medieval age that saw idealism trump empiricism. A dogmatic cloud halted intellectual, cultural and medical progress for almost 1,000 years. Not until a reformation and an Italian rebirth welcomed in opposing thought and discourse did human culture awaken.

Cultural enlightenment is fueled by a pragmatism that bypasses the barriers set up by idealistic people and extremes. And while the idealist may receive immediate reinforcement and shiny accolades, a looming uncertainty always exists. The pragmatist, by contrast, is a marathoner defined in retrospect and nearly always celebrated for victories.

Pragmatics tend to be compromising and open to bending with a big picture focus. Many don't realize that President Abraham Lincoln, the ultimate pragmatist, signed the emancipation proclamation freeing slaves in 11 states and the territories, yet Tennessee was not included—an astute political compromise needed to keep Tennessee on the side of the Union. John F. Kennedy may have stared down the first Secretary of the Communist Party of the Soviet Union Nikita Khrushchev during the Cuban Missile Crisis, but he also agreed to remove US weapons harnessed in Turkey. Even former British Prime Minister Winston Churchill, a staunch idealist, softened his stand to forge an alliance with Joseph Stalin, then leader of the Soviet Union.

Keeping it Real

Today we seem to have a creeping neo-idealism that fuels populism. An idealism that is spouted by idealists who prey on the naïve, young and emotionally vulnerable by selling impossible dreams. While this neo-idealism is overtly seen served up by our media-savvy politicians feeding a ratings hungry 24/ 7 news cycle, it can also be seen more covertly by the bombardment of advertisements for Caribbean resorts promising blossoming romance and pills promising prolonged marital bliss. The perfect life seems within grasp. However we pragmatically know that the politicians rarely deliver on their promises, it occasionally rains in the Caribbean and meaningful love is not forged by a little blue pill.

In the practice of medicine, we as physicians might want to recognize the creeping idealism that tugs at our vulnerabilities, as well. Whether it is idealistic academics who team up with bureaucrats preaching new treatment paradigms, overpromising device companies promising happy patients and financial whirlwinds and consultants telling us how to run our practices not knowing the stresses and day-to-day burdens of making it work, the ideal is and always has been a figment of our imagination. The movie is never as good as the book and our vacations never as perfect as the family with the Facebook post in Fiji. Similarly, our practices may never seem to reach the level of proficiency that we envisioned or the standards set forth by the consultants, and our outcomes may not all be perfect. But that's OK. Aren't we the ones who say the enemy of good is perfect. More than anyone else, we in medicine have a duty to shoot for the ideal but recognize the pragmatic.

However, we have a consumer population increasingly accustomed to the ideal, perhaps fixated on perfection and highly susceptible to advertisements and promotions hawking the ideal. Beyond our fiduciary and ethical responsibility to do what's in the best interest of our patients, the material retribution of over promising the ideal includes false expectations, dissatisfaction and disappointment. It is human nature to desire the ideal, but it may not be possible. The future of our success individually, collectively and personally requires a path that is more likely paved by a sober pragmatism than a fleeting mirage of perfection.