Steven Dayan, MD, FACS, is in private practice in Chicago. He is a Clinical Assistant Professor at the University of Illinois and author of the NY Times bestseller Subliminally Exposed.
As physicians, we are bestowed with enormous responsibility to provide medical care to our patients. That is why ethics is ingrained in everything we do. To be engaged in ethical self-inquiry is part of what it means to be a physician. Every day in practice, whether we are fully conscious of it or not, we make decisions that change the lives of our patients. We come to these decisions based on an inherent set of values often rooted in our religious and familial upbringing, shaped by our peers, and crystalized during our training. Our decision-making values become seasoned with the knowledge and experience gained during our training, and lead to a decision-making process that is trusted to recommend the most appropriate and ideal course of treatment for each particular patient. And yet, as market demands and regulatory pressures continually shift the conditions of how we practice, it is incumbent upon each one of us to always ask: Are we being ethical?
The New Ethical Realities of Aesthetic Medicine
To be an ethical aesthetic physician has a variety of meanings. In the examination room, it is our responsibility to both honor patients' requests while also steering their expectations for what cosmetic treatment can realistically accomplish. Just because a patient is willing to spend more does not mean that you should be more willing to “try several options.” Financial limitations inevitably enter into the selection process, but our job as clinicians is to help patients identify procedures that are both sensible and cost-effective within the financial parameters that have been set. This involves being very attentive to their communication patterns and sensitive to their concerns.
While the exam room scenario is a fundamental way to examine our codes of ethics, in reality the patient/doctor dynamic is much more nuanced, as there are other factors that complicate it. Take, for example, the great pressures we now face regarding the Federal government's role in patient care. As Electronic Health Records (EHRs) become more integrated into healthcare, physicians are “encouraged” to follow certain evidence-based guidelines when it comes to what we prescribe and how much. So commonplace has this become that we may be under threat of losing the art of medicine. It seems at times we are dissuaded, dis-incentivized, or discouraged from thinking creatively or differently. What would have not too long ago been deemed an impossibility—the thought of one day physicians being defamed or even prosecuted for not practicing the standard medicine—is becoming a very real concern.
In addition to prescription plans being dictated by guidelines and formularies, our relationships with industry are regulated more stringently than ever. Indeed, there exists great potential for influencing in relationships of doctors and pharmaceutical companies, and unfortunately some clinicians have abused these relationships. However, the government's actions to steer clinicians in certain “clinically safe” directions while moderating our relationships with industry fundamentally undermine the enormous privilege and responsibility that the state bestows upon physicians. The reason we went through so many years of education and training was not because of extraordinary intelligence or superlative hand-eye coordination, but rather to learn to make difficult judgment calls. Each day we are called on to offer certain drugs or procedures and have to weigh multiple factors before making a decision. Sometimes the decisions may seem remedial to the lay, but all physicians know that any miscalculation— no matter how meaningless it may seem— can lead to a untoward outcome. I remember my first day of internship on Ward 60 at Cook County Hospital; while struggling with the decision whether or not to give a patient aspirin, I thought, “My mom gives me aspirin.” But all physicians can recount incidents where a single and unilateral decision they were entrusted to make had life-altering consequences.
That the government thinks we're going to be unduly influenced to make an irresponsible decision because of a pen with a drug name on it seems inconsistent with the gravity of critical decisions we are entrusted to make each day.
An In creasingly Demanding Consumer Model
While the pressures we face from regulatory bodies over how to treat patients can influence the manner in which we provide medical care, other interests also have the potential to affect our decision making processes. In aesthetic medicine in particular, where voluntary medical procedures are the basis of much of what we do, doctors have to carefully navigate the need to promote their expertise in order to keep the patient flow high. There is an old axiom that if you do good work, you'll be busy. Whether that holds up today is questionable, however, when the onslaught of media messages is at an all-time high. Patients are inundated with so much information (some from dubious sources). They also have the ability to seek advice and treatment that validates their own wishes. Philosophical implications for our specialty aside, the core lesson here is that our expertise and the quality of our work may not be enough to grow our practices anymore.
This new reality places emphasis on communication and honest promotion in addition to impressive credentials, superlative skill set, and a deep fund of knowledge. In fact, a study done at the University of Michigan in the plastic surgery out-patient clinic found that the communication skills and the efficiency of the office staff were two of the most important factors correlating to patient satisfaction, more so than the technical skills of the physician. 1 This may be contrary to what our well-deserved egos want to believe.
This mindset also carries over into the aesthetic industry. Consider, for example, the busy marketplace of aesthetic products and devices. Many arrive on the market and are hailed as “The Next Big Thing” by marketers and sales teams. But, particularly in the device realm, many companies do not spend the money to perform longterm studies for the efficacy of their devices. And while the academic wing of aesthetic medicine continues to push evidence-based medicine, many devices (and even some products) without the evidence to back them up are promoted in the same light as those that are proven.
While these realities render our ethical duties to patients more complex and difficult, it's worth noting that sometimes what's right ultimately wins out. Any product can find success in the short-term with a powerful marketing campaign, but in the end quality wins out. However, it is also true that many good products without a significant promotional push may not take hold on the market, as perhaps we would like. It's a crowded market, and good products/devices can get lost in the fray if they aren't backed with a strong message and sales push. For a good product to survive and thrive, it must therefore also have a good marketing campaign behind it.
The same could be said for the “marketplace” of aesthetic clinicians. While strong promotional strategies and branding savvy are often linked to achieving success, they only carry us so far. The indisputable component to practice success is the quality of a physician's clinical judgment and work. And while we must never compromise on doing the right thing for a patient, the ability to find a comfortable and ethical coexistence between the financial interest of the practice and the fiduciary responsibilities to the patient is essential to the health of the practice. An ethical physician finds symbiosis between the two.
Finding Balance in “Retailicine”
In aesthetic medicine, being ethical should be placed within the context of the services we provide. While no less based in rigorous science and inquiry, voluntary cosmetic procedures demand ethical oversight from those that provide them. Without such oversight, the slippery slope determining a patient's needs may become a quandary. The nature of what we do is to straddle a line between medicine and retail, one that I like to call “Retailicine.” Not only do we have to be responsible clinicians, but as providers of services we have to be sensitive to consumer needs. This can be a very difficult negotiation. While there are no easy answers in this discussion, a willingness to explore ethical issues coupled with a heightened awareness of the shifting realities of healthcare represent an important first step in being an ethical clinician. Ultimately, if we live by the mantra of the Hippocratic oath to first do no harm, our pursuit of prosperity can be a companion to our responsibilities to our patients.
For more on ethics and aesthetic medicine, read Dr. Dayan's article “Are You Ethical” in the May/June 2011 edition of the Archives of Facial and Plastic Surgery, as well as the article “Retailicine, somewhere between retail and medicine,” which Dr. Dayan co-authored with Tracy L. Drumm in the November 2010 edition of Facial Plastic Surg Clin Nort Am (18(4): 491-8).
- Chung KC, et al. Predictors of patient satisfaction in an outpatient plastic surgery clinic. Annals of Plastic Surgery. January 1999; 42(1): 56-61
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