All too often the “bean counters” are telling us how we are falling short. They come up with some scheme to get us to see more patients than we can reasonably see or how to “create” more procedures than are called for. This is bottom-line or practice-centered medicine and in my opinion is unethical and immoral. It is also outside of what we are called to do and is unnecessary and counter to a healthy practice. What I believe builds a healthy practice and is simply at the heart of doing what is right for patients, is the patient-centered consult. This type of consult is designed to get to the root of the patient’s issues and do all one can do to help them achieve their health and aesthetic goals.

In this age of population-based medicine we have all been told to do the minimum, but that doesn’t change the fact that our patients are concerned with optimal health and results. Olympic athletes do not win their contests by training to the minimum nor will our patients be served by providing the minimum. Let’s look at an example of how population-based medicine is creeping into the exam room in a way that is not fully understood by physicians and yet has great impact on the individual (many similar examples can be seen in medicine today):

The drug companies tell us that Plavix is about 30% better than aspirin. What they do not tell us is that it is relatively 30% better. In absolute terms it is about 1% better. What does this mean? Well, in one study on CVA the relative risk reduction was quoted as 25% but the absolute reduction was 0.9 for ASA vs 1.2 for Plavix or about 0.3% (1). Now Plavix costs $5.00 per pill and ASA is about $0.05 so to the individual on a fixed income is the absolute difference of 0.3% worth $4.95 per day? Maybe, maybe not depending on many factors. Certainly it may be worth it to society but society is not paying the bill…the individual on a fixed income is. This is the confusion between population based and individual medicine. Some have even advocated taxing or eliminating Aesthetic procedures to reduce overall health costs in the US. This may help some number followed by economists but is it serving the individual who is interested in a specific goal?

So what is the patient-centered consult? Medicine is complex and in particular, Aesthetic Medicine is complex, yet it has been reduced to sound bites on TV. Commercials ask the question “Is it better than Botox?” or “Is it better than a Medical Peel?” yet they do not give the answer or any real helpful information. Patients have, in general, no realistic idea of what can and cannot be done for them. The patient-centered consult is an educational experience for the patient that helps them understand what is realistic and what is not.

It starts with gaining a detailed understanding of what the patient’s concerns are, not what treatments they are interested in. Most aesthetic patients come in thinking they know what they want. As an example many think they need an upper lid blepharoplasty but what they really need is a brow lift. Other come in asking about fillers but really need Botox or vice versa. The understanding of what they are concerned about is found not by asking what they are interested in but rather, what their concerns are. We start in a conversational manner. Most often a patient will start by saying something like “I think I need Botox right here.” My answer is generally something like, “Well, that is certainly something we can do, but what is it that makes you want Botox?” The next several questions are directed at helping the patient target the real issues behind the concerns such as texture, tone, tightness, wrinkles, poor size, volume etc.

I use a consult tool I call the $10,000 mirror. We have a simple hand mirror that has no magnification on one side and 3 to 5 times magnification on the other. I hand it to the patient with the magnified side facing them. The interesting thing is that most people when given the mirror will start looking very intently at themselves and even start picking and brushing at things on their face. I then have a checklist of items I ask them about. We go through the checklist item by item and discuss its impact on the overall appearance of the face. Once this is completed, I formulate a plan of all that can be done for them, that will include things I can do but also things others may be able to do. As an example, I do not do face lifts, but if the result they are after is best served by a face-lift, I put that on the plan. It is rare that we don’t do most of what they will benefit from.

Remember this is patient-centered not practice-centered. This will also build trust in your patient, as it is proof to them that you have their best interests at heart. Something the bean counters seem to never think about.

Once the plan is composed it will generally be a list of several procedures. I then go through the list, from most comprehensive to least. So it might be a list that includes a referral for a face-lift, a laser peel, a non-ablative laser treatment (also discussed as a part of maintenance), Botox and fillers. The list is prepared so that the patient will go home with it. It is positioned as a “wish list.”

As an example, one of my “I need Botox” patients left with her list. Upon leaving she said “Well I am ruling out a face-lift as that seems like to much, but I am going to do the laser peel along with the Botox and after my tax refund, start the maintenance program you have outlined.” As you know, with the ever-increasing cost of Botox it is essentially a lost leader, and at best, a breakeven event. The easy thing to do would simply have been to give the patient Botox, but with the consult, we went from a lost leader to a multi-thousand-dollar procedure with the probability of many thousands more in future procedures and maintenance programs. This was done in a patient-centered way. The patent chooses the procedures - you do not sell them. This is not an attempt to avoid the discussion about money…in fact money is at the center of these consults. Patients want an honest and upfront discussion of cost and we give it. Remember, without a margin you have no sustainable mission, so do not be afraid to discuss money.

The face consult is just one example - we go through the same checklist with body contouring consults. A patient may come in interested in abdominal liposuction. After they understand how one area of the body is related to the next, they may find that for optimal results what they really need is upper and lower abdomen and flanks for a better definition of the waist and three dimensional profile. But again they are not told that what they want is wrong; rather they are educated about how what they think they want actually fits into a broader plan for optimal results.

Over the years this approach has been responsible for the most of the growth I have seen within aesthetic medicine practices. Not only will it almost always result in bigger or a greater number of procedures, it will also be responsible for many referrals. When you take the time to do a meaningful consult, your patients will tell their friends. We even get referrals from the friends of friends whom we have never met.

1) Steinhubl SR, Berger PB, Mann JT, et al. Early and sustained dual oral antiplatelet therapy following percutaneous coronary intervention: a randomized controlled trial. JAMA 2002; 288: 2411-20

Autism is certainly one of the most controversial issues plaguing the medical world. One of these issues involves the use of supplements being beneficial to children with autism. A number of medical organizations have already released findings stating that supplements can help improve the development of an autistic child because of their inability to produce natural chemicals that can aid in this growth, as well as their incapacity to get the proper nutrients from the food that they eat. One of the nutrients that can supposed help an autistic child is the fatty acid. Unlike other essential substances, fatty acids cannot be produced by the body, so it relies on food for its fatty acid supply. However, due to a number of reasons, an autistic child can properly digest these fatty acids, so they cannot use these nutrients even if the food they take contains this substance. But fatty acids are essential to the body—not just for people with autism, but also for everyone else—so they need to get it elsewhere. But why can’t autistic children absorb fatty acids? And why are fatty acids so important?

The type of fatty acid important in a person’s development is the essential fatty acids. Essential fatty acids, or EFAs, have several functions, particularly in affecting inflammation, mood, and cellular signaling. A book titled Know Your Fats: The Complete Primer for Understanding the Nutrition of Fats, Oils and Cholesterol stated the importance of these essential fatty acids in the body, although many contests that these nutrients are only conditionally essential or can be replaced with other nutrients. A criticism on the essentiality of these fatty acids state acids may not be very important for healthy individuals. And, of course, children with autism cannot be qualified as “healthy.”

A number of studies regarding the effects of essential fatty acids on autistic children have been conducted, with promising results. Nordic Naturals conducted a research involving 18 children. These children were given essential fatty acids and were evaluated for 90 days. They were assessed using basic language and learning skills assessment procedures. The results showed that their learning skills and language skills improved during the supplementation of the essential fatty acids.

But why is it beneficial? Essential fatty acids affect the development of inflammations in the body. Even one has a substance amount of ESA in the body, inflammations can be prevented. Remember that the brain of an autistic individual is inflamed. Essential fatty acids also affect a number of aspects in the function of the brain. If you intend to use essential fatty acids, you might be asking yourself if essential fatty acids can be harmful. Fortunately, they aren’t, although you have to get your essential fatty acids from manufacturers who produce these products especially for autism patients.

The cause of autism is still debatable, but the benefits of essential fatty acids are as clear as day. Essential fatty acids, with their functions in the brain and the human development, prove to be just that—essential and beneficial.