When is Enough Enough?

Steve Dayan, MD, is a facial plastic surgeon practicing in Chicago, IL and a New York Times best-selling author. He is Co-Chief Medical Editor for Modern Aesthetics® magazine.

Saturation: a point at which capacity is at its fullest, and any greater intake leads to no further effect and/or negative consequences.

When I ask friends, relatives, and colleagues if there is anything in life of which they can never have too much, I almost always get the same reflexive answer: “Of course! Money, love, or happiness.” But if the question is thought through deeply, even too much money and happiness can lead to an expanding potential for negative consequences. Saturation exists in food, chemistry, fun, light—in all aspects of nature and quite frankly there is little to nothing I can think of that doesn't eventually reach a point of saturation. The lone exception may perhaps be love for one's own DNA, either manifested as thyself or in one's offspring. But beyond this, most everything in nature has a point at which satiety is reached and any further intake will lead to no effect and likely negative consequences.

If this is true, could there be a point at which the number of aesthetically talented medical providers reaches saturation? When have we effectively recruited and trained all those that have the necessary prerequisite skill set to effectively deliver a positive outcome or experience and any further training leads to a downward trend in the product delivered?

Saturation in Aesthetic Medicine

I recently was teaching a resident class how to inject fillers. As any preceptor in any technically challenging field can tell you, those who have “great hands” are quickly identified. However, just as easily discovered are those lacking the hand/eye coordination, emotional intelligence, and/or judicious acumen to deliver aesthetic services effectively. Certainly, a determined minority lacking one of the prerequisites, with significant study and pounding practice, can gain proficiency overcoming congenital naivety and a shallow skill set to emerge as an excellent provider. But there is a vast majority who, despite all efforts, may never reach a level of proficiency in technical skill, judgment, or emotional reserve to excel. The result is that both an aesthetically seeking populous and the aesthetically dependent medical field suffers when these providers enter into the market.

Aesthetic medicine differs from traditional medicine in that those who succeed at the highest level need an ability to see three dimensionally, while visualizing that which doesn't exist, and then be able to create it. Also, even more highly specific for aesthetics is a retail affability woven with a fiduciary thread to treat and care for a vulnerable patient population. It is a pattern not necessary in other medical fields, yet we don't teach how to weave it. In fact, it is shunned, when we should be emphasizing how to carefully, respectfully, and ethically braid the strands. Without formal training, it can take many years and many regrets before achieving aptitude. But for the artisans who work past these obstacles and deliver the crafts of cosmetic medicine, the rewards can be grand: entrance into perhaps the last field of medicine in which a doctor/patient relationship is still sacrosanct. Aesthetic physicians are chosen based on reputation, not on a participating insurance plan. And yes, there can be financial upside and glamour for an aesthetic physician, but both are over-exaggerated. Yet this doesn't stop the masses from storming the gates wanting to enter the club.

Is there a saturation point of skilled aesthetic providers who exhibit the necessary technical, emotional, and judgment skill set to deliver an excellent product? Just like in other fields in which membership requires three standard deviations in excellence—not everyone can be a Navy Seal, NFL Player, or NASA Astronaut—few make it through. As both the NFL strike season of 1982 and expansion in baseball have proven, diluted talent leads to a diluted product and a disappointed consumer.

Even if a saturation point of aesthetic providers exists, does it matter? Maybe there will be a secondary market for less than talented technicians/doctors and outcomes? For example, minor league baseball does attract a sizeable following, especially in areas where the MLB games aren't easily accessible. However, will a collective aesthetic medical community and in general a society accept a second class of outcomes? The answer for a pharma company may seem easy, even if a saturation point is reached, then why not cultivate talent in the next level of deliverers. Extended providers (nurse practitioners and physician assistants) are a growing field with increasing responsibility and professionalism and a larger pool of talent to choose from. The unstated risk, though, is if a saturation point of providers is surpassed do we then shift the whole paradigm of results, and less than ideal outcomes become the norm?

Regressing Toward the Mean

The logical conclusion to more providers delivering more aesthetic services is a regression towards the mean. And the mean outcome is secondary to mass training based on educational platforms designed by industry to comply with FDA indications. Industry has the largest reach, resources, and incentive to train providers. However, the training programs that are conceived within industry promulgate outcomes that are not based on what looks more attractive or natural but rather on outcomes to gain indication. These studies have a different goal than that which is common to everyday practice. The Phase 3 studies are designed to deliver a noticeable difference. But a recognizable improvement in the nasolabial fold (NLF), glabellar wrinkle, or crow's feet leads to a result that may appear frozen or unnatural—precisely what the populous is begging us not to provide. And when the mean outcome from mass trained providers is an unnatural appearance, the whole aesthetic field suffers. The more we indiscriminately train, the more we regress to the mean. The more our field delivers a less-than-ideal product, the more we become commoditized.

In essence there are two issues, with a sizeable spread. One is protecting the public. The second is protecting the trade. Medical school, residency, and state licensing boards are tasked with assuring the public that providers reach a defined level of competency. However, there is no regulatory for effectively assuring the public and ourselves a level of superiority for delivering an aesthetic medical treatment. While board certification and CME are in theory mechanisms to assure competency, all those in the field know these hurdles have at best an arguable correlation with true clinical excellence. In the US we have a free market system that should serve as a de facto regulator. Those who deliver excellence should thrive, while those who deliver less falter. However, today's social media allows for less than ideal outcomes to flourish from less than ideal providers who master the art of appealing to a naïve populous.

What is the Solution?

As a Darwinian and a capitalist, albeit a cautious one, I support the state of nature with limited regulations but reject the shackles excess regulations bear down on creativity, society, and trade. So what is the solution?

To begin with, I don't profess to have the answer. But I believe that in any free market economy innovation, whether in product, technique, or thought, always leads the path out from under the herd. And the beneficially adapting mutation will most likely stem from an individual doctor serendipitously stumbling across a new way of exceeding patient expectations, leading to a disruptive selection and a break from the chains of commoditization.

As aesthetic medicine reaches a saturation point, outcomes will regress towards the mean and commoditization will ensue. The market will become stagnant. It will be incumbent on prosperity-seeking industry leaders and aesthetic societies to cultivate a fertile environment where progressive pioneers in innovation are welcomed, encouraged, and promoted. When the right elements from heterogenous populations and minds are allowed to mingle, new and more fit beginnings are birthed. The future of aesthetic medicine requires forward-thinking organizations and strategies to meet the imminent challenges of saturation.