In the medical world, the provider-patient relationship is one of shared decision making based on the principles of mutual trust, ethics and appropriate attention to needs. This guidance is of especially high value in an aesthetic practice, where the patient electively wants to achieve an enhanced appearance and improved quality of life based on physician guidance.
More than anyone else in the practice, the physician needs to display the highest standards very conspicuously, noted Tess Mauricio, M.D., F.A.A.D., a dermatologist and cosmetic surgeon with practices in San Diego and Beverly Hills, Calif.
“It starts at the top,” she continued. “Anytime you are doing any kind of rejuvenation or cosmetic improvement, ethics becomes very important. Even if you don’t have a set of published guidelines, the common sense and professional rule of thumb is to treat the patient with the upmost respect at all times.”
An aesthetic practice can maintain high ethical standards with professional guidance. For physicians seeking relevant ethics instructions and related documentation, a good place to start is with the major medical societies serving the aesthetic / cosmetic surgery / dermatology fields.
For instance, Gordon Sasaki, M.D., F.A.C.S., a plastic surgeon in Pasadena, Calif., follows the code of ethics created by the American Society of Plastic Surgeons (ASPS).
“In that guide, like others, the essence of the provider-patient relationship is described as one of shared decision making based on the ethical principles of mutual respect, courtesy, dignity, privacy and confidentiality,” he said.
This can be developed with the patient during the process of informed consent, when the aesthetic procedure’s nature, indications, financial commitment, expected outcomes, side effects, probability and severity of adverse events, and approval by relevant regulatory authorities, as well as alternatives, are deliberated and understood.
For the practitioner, “It is vital to remember that an aesthetic procedure involves patient care well beyond the improvement in appearance,” Dr. Sasaki expressed. “For us, the most desirable qualities include professional judgment, aesthetic judgement, ethical behavior and quality care during multiple consultations and aftercare.”
Essentially, the foundations of ethical behavior – honesty and respect for the patient – are based in the Hippocratic Oath, said Deepak Dugar, M.D., a facial plastic surgeon in Beverly Hills, Calif.
“Practitioners and especially surgeons have to be honest about what they’re good at,” he expressed. “I think that is something that is getting lost on surgeons as they enter practice. They end up focused on trying to make money and they just want to become a business. Under those circumstances, they may not be very comfortable with the surgery, but they might still do it,” he said.
Therefore, not everyone is ethical, Dr. Dugar added. “Everyone thinks that physicians are apropos, but that may not be how they actually practice.”
Currently, the idea of ethics in medical aesthetics is under assault from a few different fronts. One area is a kind of training that goes beyond just learning the best procedural techniques and having a good understanding of anatomy.
“Any specialist that can be educated can acquire good techniques, but for even the best-trained physicians, it is not second nature to be aware of the psychological status of their patients,” stated Dr. Mauricio.
“It is not instinctual,” she continued. “Many times, physicians will understand the anatomy and be very technical, but they also need to understand and delve into more of the psychological status of people, as well as recognize the psychological effect of what we do.”
Practitioners should try to make sure their patients have a healthy and well-adjusted psychological status.
“This is a big part of what is behind the ethics of what we do, because you want to make sure that the procedures are healthy for the patients. I have turned away many patients that want me to blow up their lips or overfill. In my personal view, doing that makes people look unnatural. So, I just say, no, I’m not the physician for you.”
Know when to say ‘No’
Knowing when to say “no” to the unreasonable, untenable, unyielding and / or unstable individual presenting with any number of neurotic mindsets, body dysmorphic disorder (BDD) or other emotional problems is a prevalent challenge for any aesthetic practitioner. These often signal deeper psychological difficulties that need addressing prior to doing any aesthetic procedure.
For instance, it is estimated that BDD affects between 1% to 3% of the general population. In patients presenting for medical aesthetic treatments, studies have consistently suggested that the rate increases to between 5% and 15%. And the evidence indicates that treating these patients can lead to significant harm for both the patient and the practitioner.
“It is extremely important that we perform thorough consultations in order to screen all patients and ensure that we not treat those that may have BDD, and instead refer them for psychological evaluation,” stated Dr. Sasaki.
The instance of BDD has been increasing rapidly, agreed Gregory W. Chernoff, M.D. F.R.C.S., a cosmetic and reconstructive surgeon in Santa Rosa, Calif. and Indianapolis, Ind.
“Every week, I meet patients and refer them to psychologists,” he shared. “I tell them to come back once they get the help they need. Later, they are grateful that we didn’t take advantage of them and, eventually, some may become good aesthetic patients,” he expressed.
Categories of red-flag patients include the perfectionist, the litigious patient, as well as the unrealistic, indecisive and fawning patient.
“The biggest example is people that come into my office bad mouthing their previous surgeon or injector. That’s a huge red flag for me,” said Dr. Dugar. “Another is the patient that had multiple procedures and they’re still unhappy. For instance, someone that had three or four nose jobs and is unsatisfied. I try to talk them out of doing anything on their face, because they’re probably not going to be happy with the next result.”
It can be dangerous when patients have a little bit of knowledge, Dr. Dugar noted. “If they try to guide the physician then it is a sign to turn them down. I don’t mind arrogance or a know-it-all attitude. But there’s a limit to their ability to understand. They haven’t gone through 15 years of training.”
Staff can be trained to give the physician a head’s up on a particular patient prior to the consult.
“Staff understands what I consider to be red flags,” said Dr. Sasaki. “They learn the triggers and recognize what’s good and not good. The biggest aspect to that training is that they just have to be cognizant of what they hear from people, but not too verbal. The patients are there to see me and to learn from me. They don’t have surgical training and they want to hear the details of it from me.”
One of the touchiest areas for aesthetic practices is coping with the increasing number of teens turning to cosmetic intervention to correct or even prevent perceived age-related or cosmetic flaws.
“This is a trend fueled by selfies, social media and increasing self-awareness and desire to fit in,” said Dr. Sasaki.
One example is the preventive or premature use of neurotoxins in young patients to avoid the effects of aging.
As noted by Dr. Sasaki, “There is no evidence-based data that the practice is safe. Long-term effects have not been evaluated. Many experts state botulinum toxins should not be administered to individuals under the age of 18 nor should treatments be sold to children.”
While some treatments for children and teens are considered appropriate in some cases, such as laser hair removal and otoplasty surgery to correct oversized ears, no matter what work is being performed, minor patients require parental or guardian consent, said Dr. Mauricio.
“Then, I need to evaluate their emotional and psychological maturity, and also their decision-making capabilities,” she maintained. “Have they thought through and looked at the different options? Is the child mature enough to proceed and is not being dictated by their guardian or parents? I only proceed when I feel there is a good, healthy relationship between the minor and the guardian.”
With some teens (and even adults), the line between fantasy and reality is blurring with the advent of social media platforms and apps like Snapchat and Facetune.
“It is definitely getting more common, with the way people use filters in their selfies,” said Dr. Mauricio. “What happens is the individual ends up distorting their image, which leads to a distorted perception of themselves. Others are looking at their photos on social media, but when they meet them in person they are disappointed or confused. That, in turn, puts extra pressure on that individual to make their false perception real via aesthetic procedures.”
This leads to Snapchat dysmorphia in the pursuit of unachievable “perfection,” stated Dr. Sasaki.
“Medical experts believe that this is a type of obsessive-compulsive disorder characterized by an obsession with perceived defects in physical appearance. Despite attempts to educate these patients, patient demands for such procedures are increasing. In an annual survey last year, plastic surgeons reported that 55% of their patients expressed their main reason for surgery was to make themselves look better in selfies.”
Police your practice
On a different front, ethics issues have tended to shadow the persistent, decades-long influx of so-called non-core physicians that enter the aesthetic field from other medical specialties. These include dentists, eye doctors, ENTs, gynecologists, internists, and others that are not necessarily board certified in plastic surgery, dermatology, cosmetic dermatology, etc.
A lack of good training and board certification are common reasons some in this group remain incompetent at their craft, noted Dr. Chernoff.
“I’ve been at this for almost 30 years now; this was a problem when I started, and it is still a problem. It will only get worse as managed-care continues to bite into practices, and physicians that are strictly insurance-based look for ancillary ways to earn income,” he said.
In addition, criminal minds already working within practices need to be identified and removed, Dr. Chernoff added. “We have to police ourselves, because of things like theft and embezzlement, etc. Another example would be an employee that steals neurotoxin and fillers from my office and then goes off to do basement injection clinics,” he added.
Nevertheless, nothing is worse than a medical director, practice owner or practitioner / physician who displays unethical behavior. For instance, the use of counterfeit or grey market devices to treat patients. As tempting as it might be to save money, the possible harm or injury to the patient caused by using an unproven or knock-off product, far unweighs any other consideration.
When contemplating the purchase of a new medical device or system, start by reviewing data from clinical studies and by conversing with colleagues. Study results will show that authentic devices demonstrate safety, effectiveness, tolerability and financial practicality.
As protection, practices need to establish ethical behavior, rules and policies for all staff, with clear direction regarding employee termination.
“In my practice, there are four ways someone can get fired,” said Dr. Chernoff. “One is to steal from me, two is to lie to me, three is they say something bad about another physician to the patient, and the fourth reason is to let any new patient in without a pretreatment photograph.
“That tells you the critical importance of clinical photos,” Dr. Chernoff emphasized. “Many of the results of the non-surgical procedures we perform are settled over time. You absolutely need a baseline photograph so that your patient can see that improvement over time.”
The practice must also maintain a collection of patient consent forms covering all aspects of the treatments, including release and/or consent for taking photos, videos and using those materials by permission.
“We are very protective of our patient’s privacy and we get special consents for photos, etc.,” stated Dr. Mauricio. “Even during intake, patients are asked if they are willing to leave their images with us. We have questions specific to internal or educational purposes, or whether it is for marketing purposes. I always reassure every patient specifically about giving us consent, and that it is subject to HIPAA compliance.”
On top of everything else, the federal government continually changes the guidelines for practices surrounding HIPAA, privacy rules and other ethical considerations.
For instance, the Department of Health and Human Services in 2018 released a number of points that will impact aesthetic patients, as well as practices’ services and procedures. Due to this, practices will need to revise their Business Associate Agreements and its Breach Notification Policy. In addition, new patient privacy disclosures should replace the current ones.
“Unfortunately, given the significant penalties associated with non-compliance, practices have no option but to fully comply with the new rules,” noted Dr. Sasaki.