The cosmetic conversation
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Dermatologists offer advice for educating patients about the full breadth of available treatments

The demand for anti-aging procedures is burgeoning. For neurotoxins and dermal fillers alone, industry analyst GlobalData projects worldwide sales of $4.7 billion by 2018, of which the U.S. is expected to account for $2 billion. Yet on average, dermatologists spend less than 10 percent of their total patient care time on cosmetic treatment, according to the American Academy of Dermatology Association’s 2009 Dermatology Practice Profile Survey. Although nearly 60 percent of respondents reported performing some cosmetic treatments (mainly neurotoxin injections, collagen/filler injections, chemical peels, and cosmetic laser surgery), 51 percent of those said these treatments account for only 1 to 9 percent of time spent with patients.

Given their seminal role in the development and testing of the most popular cosmetic treatments — and the obvious consumer demand — why don’t dermatologists do more of them? Some may be perfectly content with their practice’s current mix of cosmetic and medically necessary care. But for those hoping to grow the cosmetic component, dermatologists who are successful in both areas say that a good way to start is to have the “cosmetic conversation” with patients who have come to their office for another reason. Understanding how to do that, when to do it, and with whom can help dermatologists strengthen their relationships with patients and avoid coming across as pushy or greedy.  [pagebreak]

Patient education

Patients can’t ask for anti-aging treatments if they don’t know their dermatologist provides them. “The worst thing is to find out that someone who’s been your patient for 20 years is going down the street for procedures you do, because they don’t realize you do them,” said Jeffrey S. Dover, MD, associate clinical professor of dermatology at Yale University School of Medicine and director of SkinCare Physicians in Chestnut Hill, Mass. “I’ve had that happen — every dermatologist has had that happen.” Thus, the first step is “educating patients as to what we do as dermatologists, whether it’s getting rid of brown spots or skin tags, or doing [botulinum toxin] or fillers, or blepharoplasties,” said Mark S. Nestor, MD, PhD, voluntary associate professor of dermatology at the University of Miami Miller School of Medicine and director of the Center for Cosmetic Enhancement in Aventura. “It’s what we’re comfortable in doing, and what we do better than anyone else. Many dermatologists don’t feel comfortable marketing, but they certainly feel comfortable educating their patients about what they do.”

In Dr. Nestor’s practice, the process starts in the waiting room, which is stocked with reading material explaining the cosmetic procedures he performs. In each exam room, a PowerPoint presentation runs continuously, showing before and after photos of patients who have had laser treatments, photorejuvenation, botulinum toxin and filler injections, and other procedures. While patients are waiting, “they’re enthralled to learn about the procedures, and then when I come in they feel comfortable saying oh, I just saw this, can you tell me about it?’” he said. “It’s very, very effective. In fact, what often happens is that a mother will bring in a child for acne treatment and end up having a cosmetic procedure right then and there because she saw it on the screen.” As part of the initial evaluation of each patient, a medical assistant asks the patient if he or she has any cosmetic concerns, “and that often yields a positive response.” If the answer is affirmative, Dr. Nestor follows up in the exam room; if not, he doesn’t initiate a discussion of cosmetic treatment. [pagebreak]

Dr. Dover’s practice developed a set of 20 single-sheet brochures and displays them in “custom-built, beautiful cherry racks in every exam room and in the waiting room.” When it’s evident that a patient has been looking at them, he takes the opportunity to ask if the patient has any questions about the procedures, providing the opening for a discussion of cosmetic treatment. Photo albums of patients before and after cosmetic procedures are also on display in the waiting room and in the exam rooms.

Amy J. Derick, MD, instructor of clinical dermatology at Northwestern University’s Feinberg School of Medicine and director of Derick Dermatology in Barrington, Ill., ascertains patients’ interest in cosmetic treatment before their first office visit. A staff member registers patients by phone, “and during that conversation we ask them if they have any cosmetic interests and basically give them options: skin care routine, wrinkle treatments, etc.,” Dr. Derick said. If a patient doesn’t indicate interest during the initial phone call, “I never bring it up unless they bring it up. Our focus is truly on medical dermatology, though we also do a lot of cosmetics. You don’t want people to say, I came in for a rash and they wanted to sell me [botulinum toxin].’”

Dr. Derick doesn’t display information about her services in the waiting room but does provide portfolios of before and after photos in the exam rooms, and remarked that the photos often prompt patients to inquire about cosmetic procedures even if they didn’t indicate an interest before. “For me, I don’t want to be seen as a product-pusher. I’m super-busy with my medical practice, and very happy with that. My cosmetic work is a nice addition.” [pagebreak]

A full skin exam can provide the opportunity for a discussion of cosmetic treatment that doesn’t feel forced or unnatural, said Tina S. Alster, MD, clinical professor of dermatology at Georgetown University and director of the Washington Institute of Dermatologic Laser Surgery. “I’m a dermatologist first and a cosmetic dermatologist second, so I perform a complete skin exam for every patient the first time they present for treatment,” she said. “I don’t simply point out their cosmetic deficiencies, but as I’m going through their exam, I will mention my findings such as solar lentigos, skin tags, or telangiectasias that can be treated, if desired, but that it’s not a medical necessity to do so.” Dr. Alster further elaborated, “In the course of the skin exam, patients will often point out cosmetic problems that bother them. And, if they don’t, I use that as a sign to back off. If you start cross-selling a lot of procedures or products without patient initiative or enthusiasm, it makes you sound like a used car salesman.” Dr. Alster also routinely outlines a skin care regimen for each patient and sells the products she feels are most cost-effective. Although the products are available online, most patients prefer to purchase them at her office “because it’s easier for them, especially if they don’t think you’re price-gouging or pushing products on them. Selling them isn’t high priority for us, but what is high priority is for patients to understand what the better products are and how to use them.”

One prominent dermatologist said there’s nothing wrong with suggesting to certain patients that they might benefit from cosmetic treatment, as long as it’s done with tact and sensitivity. “I take care of their medical concerns first, and as we’re walking out I might say, By the way, I notice you have a couple of wisdom’ spots on your hands. If it bothers you, we have ways to treat them,’” said Cherie M. Ditre, MD, associate professor of dermatology at the University of Pennsylvania and director of the Skin Enhancement Center at Penn Medicine Radnor. “I’ve done it a couple of times with patients, and they’ve said, I’m really glad you asked, I feel funny asking you.’” This approach doesn’t suit all dermatologists or all patients, however. “I don’t have a very aggressive personality; I do it in a very motherly, kind way,” Dr. Ditre said. “It’s not what you say, but how you say it. If you do it with concern and dignity, it’s more likely to be well received.” [pagebreak]

The patients most receptive to considering anti-aging treatments are likely to be those who “are very well-kept, dressed to the nines, nails done, makeup on perfectly,” Dr. Ditre said. “Although you can’t always make assumptions based on outward appearance — sometimes the down-to-earth, middle-of-the-road people are interested also.” Dr. Dover noted that women “are much more attuned to their appearance, so the pickup is going to much higher with women than men. But there is a whole new group of men who care very much about their appearance, and they’re very interested.” (See “The age of Brotox” in last month’s issue or online at

Elderly patients may be just as receptive as the young and the middle-aged, Dr. Dover pointed out. “We have a 90-year-old patient who showed up recently without an appointment, and she wants to do everything. She’s come four times in the past month,” he said. Dr. Ditre calls her older patients “my gems” because they have realistic expectations and tend to be very pleased with the results of cosmetic treatments. “I suggest starting with a simple treatment, like a topical,” she said. “They maybe you get a peel or microdermabrasion and see how that goes, then maybe build up to fillers and [botulinum toxin]. It’s less aggressive, and when they see that one thing is working, they’re more apt to have other things done.”

Timing is everything

Broaching the topic of cosmetic treatments at the wrong time is “a setup for disaster,” Dr. Dover said. “If the patient is in the office for a significant medical problem — for example, they think they have a melanoma, or a family member was diagnosed with melanoma — you just don’t bring it up, period. You wait for the next visit, or you just don’t do it.” Once the medical issue is under control, however, such patients may be very willing candidates for cosmetic treatment, he explained. “They’ve visited with you now a few times. You may have saved their life, if they had melanoma or squamous cell carcinoma. They’re relieved, they’re grateful. Then, if it seems appropriate, you can ask, While you’re here, is there anything else about your skin you’d like to discuss?’ And they might say, What did you have in mind?’ And at that point you say, not You have a lot of wrinkles,’ but We do a lot of other procedures in the practice, including taking care of skin as it ages. It’s something we can discuss next visit, if you wish.’” [pagebreak]

Prioritizing the health of patients over their appearance is essential, say the experts, and the priority should be made clear to patients. When a male patient of Dr. Ditre’s came in requesting a neurotoxin, she recalled that she had noticed some precancers on his previous visit three years prior. “I asked, Did you do anything about them?’ He said no,” she said. “Then I did an exam and found a melanoma! I’ve had a number of people come in who just want [botulinum toxin], and there’s a basal cell glaring at me in the glabellar area between their eyes.” On a similar note, Dr. Alster said, “I couldn’t sleep at night if I missed a melanoma on someone’s back because I was focused on the sebaceous hyperplasia on her forehead. That’s not being a good doctor.”

Dr. Dover noted that a Boston-area dermatologist gained notoriety when a newspaper reporter posing as a “mystery shopper” called her office and requested an appointment for evaluation of a possible melanoma. The reporter was told she would have a three-month wait. “She called back 10 minutes later, different voice, and said, I’m considering [botulinum toxin], do you have any availability?’” he related. “They said, How about later today?’ It was a fiasco, but when confronted, the doctor admitted that she prioritizes her cosmetic patients.” Dr. Dover’s practice employs “mystery shoppers” of its own to call the practice and make sure that anyone with a suspicious lesion is seen within 24 hours. “If you take care of new patients this way, you win them over and they become your patient forever,” he said. [pagebreak]

Almost any basic dermatology patient can become a cosmetic dermatology patient, Dr. Alster said, “but it does require time. Cosmetic dermatology patients require extensive explanations and hand-holding, even before a procedure is performed, because it’s all new to them. If you can’t provide ample explanation and education, hire someone who can.” Dr. Ditre concurred, adding that some cosmetic patients “just unleash with all their problems, and you feel like you’re doing as much psychotherapy as skin therapy. If you really can’t stand listening to that, don’t do it.” That said, dermatologists who avoid cosmetic procedures are “missing the boat,” Dr. Ditre said. “We can not only make patients feel better, but also feel better about themselves. And that’s why it’s such a blessing to be a dermatologist.”