Thriving Under the Influence

Salvador Dali once said, “The secret of my influence has always been that it remained secret.” Sometimes that’s how it feels to be an aesthetic dermatologist. I want my work to be unseen; it’s my patients who shine. Most tell no one but their closest friends that they’ve had anything done, let alone who did it. My satisfaction comes from making my patients happy and enjoying the work itself. I enjoy our conversations and sharing information not only about medicine but everything from makeup to vacations to tricks to bolster self-confidence. I am proud of my reputation for honesty and credibility. My opinions carry weight. And the patients I send out looking and feeling better about themselves influence the way others see aging. Wow! Am I an “influencer”?

Nope. As physicians, we are indoctrinated in the importance of impartial clinical recommendations. What we suggest to patients should never be influenced by any quid pro quo with industry. We easily recognize pay-for-hire podium presentations for what they are, even without the obligatory disclosure of relevant conflicts of interest (COI). The recommendations of any key opinion leader who works with multiple companies and reports the good with the bad is much more meaningful to me as a physician, and, I’d argue, more meaningful to companies in the long run.

Personal ethics is not the only control of a physician’s influence in the US. COI in medicine is federally regulated. The Centers for Medicare & Medicaid Services’ Sunshine Act and public website reporting seek to shine a light on industry-physician financial relationships by making the data public. This—along with discontinuation of promotional pens and notepads—is supposed to reduce the chance of a physician promoting a drug or device purely for financial gain.

While there are cases of physicians acting as well-paid schills for pharma, which in turn reap the reward of government reimbursement windfalls, I truly believe those cases are the minority. For most doctor-educators, the work is the thing. We take our time to lecture, train, do research, and consult to have an impact on our fields. Lecturing and training others raises the level of care for everyone. We researchers get our hands on the next generation of drugs and technology and help guide the industry toward our patients’ needs.

We certainly don’t do it for the money. It’s not unusual to work for free, especially early in our careers. It is rare for a physician to be paid enough to cover office overhead, let alone what our time and opinions are actually worth, because typically it’s based on actuarial charts. (I had to convince one company that, based on the product and project, I should be paid at the same rate as a plastic surgeon, not a general dermatologist.)

Adding insult to injury, the reporting system isn’t consistent. Payments through CME or PR companies or paid into university funds can bypass regulations. Aesthetic procedures aren’t reimbursed by any government agency, but if the company that owns or distributes an aesthetic drug or device falls under the guidelines based on other products, even the aesthetic category must be reported. Reporting mistakes occur regularly. In 2017, a journalist called my office asking why a company paid several hundred dollars for food and beverages for me two days in a row. It turned out the dollar amounts were reported in foreign currency, not US dollars, and the amounts spent to feed me were indeed minimal. Since then, we’ve kept a close eye on the Sunshine Act website and have caught duplicate entries among other errors. That’s another regulatory burden I do not need.

While I am busy cross-checking records, filling out COIs, and defending my right to get paid, celebrity spokespeople get paid exponentially more by the same companies. That brings us back to the new celebrities: the influencers. It is true that money spent by industry to get the right influencer to boost awareness of a condition, product, or treatment will trickle down to physicians in the form of patient interest. That is a win for us. So why am I complaining?

Our years of training and experience as board-certified core cosmetic physicians made us uniquely able to recommend the best possible products and protocols to help our patients, colleagues, and industry. But when a physician and an influencer are hired to speak with the media, you can bet that payment to the latter is exponentially higher than to the former and, of the two, only the physician feels the regulatory burden. I want to stress that there are fantastic celebrity spokespeople whose authenticity is admirable. There are incredibly sharp influencers who pride themselves on being informed and selective about their industry partners. But I admit to disappointment that the public is quicker to trust their recommendations than their physicians’ and that a well curated Instagram page carries more weight than board certification.

I have no answer for the imbalance of influence in our field, and I fear it will only get worse. While I’m proud of my foray into social media, I am resentful that it is another financially uncompensated part of being a physician. I assert that at the end of our lives, we have only our name. I hope my name is associated with intelligence, expertise, empathy, ethics, and honesty. It would be nice for 48 hours to pass without hearing someone laud the health or aesthetic advice of someone without qualifications. But, I love caring for my patients, performing procedures, working with my staff, colleagues, and industry, and I make a comfortable living doing it. So I’ll be okay if my epitaph doesn’t include “influencer.”