Cosmetic surgery is a very unique specialty as it is, for the most part, totally elective. No one needs cosmetic facial surgery and very few surgeons begin their journey as “strictly cosmetic surgeons.” A total cosmetic surgery practice is rare as many “cosmetic surgeons” perform other procedures based on their background training. For instance: plastic surgeons may also cover burns, trauma and reconstruction; facial plastic surgeons may cover ENT procedures and skin cancer; oral and maxillofacial surgeons may cover implants and wisdom teeth; dermatologists may cover acne and general dermatology; ophthalmologists may cover cataracts and corneal surgery, etc. Some practitioners enjoy the mix and others only perform the non-cosmetic procedures because they are asked to. If a surgeon is interested in transitioning to a totally cosmetic surgery practice, he or she will eventually drop the ancillary procedures and progress to total cosmetics. I, personally, have limited my practice to cosmetic facial surgery since 2004, and there are certainly pluses and minuses to this. First, I love cosmetic facial surgery, it is my passion and I love going to work; so for me, this specialization has been awesome. The only downside is that shifts in the economy can affect “luxury” purchases, which include cosmetic surgery. Other surgeons will list negatives as having to deal with the sometimes fickle, unpredictable, body dysmorphic, demanding, litigious, and elective patients, and those with unrealistic expectations.
The cosmetic surgery patient is truly different to many of the patients presenting in residency or in a specialty practice. The biggest difference is that these are elective patients seeking an upper-class luxury. When treating a patient for trauma or malignancy, they are most frequently grateful for your skills. Cosmetic surgery patients, on the other hand, are totally elective and paying a lot of money for services they do not actually need. Fortunately, the vast majority of these patients have a positive outcome and are happy with their treatment. Many cosmetic surgery patients may also have significant biopsychosocial implications that complicate normal interaction. Some of these patients have unrealistic expectations, some are body dysmorphic, and some are undergoing surgery for the wrong reasons. In these cases, they may be unhappy with a perfectly acceptable surgical result, and this is when things can get problematic. One of the best ways to become a great cosmetic surgeon is to choose the right patients. This is a skill that usually takes decades to master and will be addressed later in this chapter.
There is no more important aspect of the cosmetic surgery experience than the initial patient consult. As they say, you never get a second chance to make a first impression, and the first impression occurs when the patient phones the office to make an appointment. Unfortunately, this is when a lot of patients are lost. Having personable, friendly, energetic staff answering the phone can be one of your best referral sources. Patients often tell me they actually saw three or four other surgeons, but the professionalism and attitude of my staff persuaded them to come to my office. Many barriers between the initial phone call and the operating room can be eliminated by an astute front-desk person. A compassionate receptionist can alleviate many patient apprehensions and get the client into the office. I call this staff member “the patient representative.”
An exceptional patient service representative knows how to “answer the phone with a smile” and make patients feel comfortable. The first question they ask is the caller’s name, then they use it frequently throughout the conversation, as people often like to hear their own name. A great front-desk person can convert a question into a consult. If a patient calls to inquire “How much do you charge for Botox?” a poor employee with tell them “$11” and the conversation is over. An exceptional employee will ask the patient their name. The patient answers “Anne.” “Thanks for calling Anne. Have you ever had Botox before? Did you know Dr. Niamtu is one of the top Botox providers in the country and he teaches neurotoxin techniques to other surgeons? He also uses special techniques to make the procedure painless. Can we make you an evaluation appointment?”
This great patient service representative has now converted a patient with a question into a patient with an appointment. Great patient service reps are priceless and poor ones can run your business into the ground. Uncourteous staff has been shown to be one of the biggest contributors to patients switching doctors (16% due to procedure dissatisfaction; 68% switch because of uncourteous staff! Results from the 1995 American Society for Quality Survey).
Our patient representatives are familiar with every procedure we perform and can discuss them accurately with prospective patients. We make all receptionists spend time in the operating room observing procedures and we also cross-train all our surgical assistants to answer the phones and make appointments. This cross-training allows all employees to appreciate the work of their peers and also means that they can fill in easily.
The Physical Plant
If you perform cosmetic surgery, you have to have an office that is as nice as your biggest competitor. I say this because it is common for cosmetic surgery patients to seek multiple consultations. They are likely to see your competitors and if their office grossly outshines yours, you are already at a disadvantage. Having said that, a poor surgeon with a great office will not succeed, but cleanliness and presentation can go a long way. Always remember, these are elective patients seeking upper-class luxury surgery. They shop at high-end stores, stay at high-end hotels, and go on high-end vacations. They are used to being pampered and being in nice surroundings ( Figs. 2.1 , 2.2 ). The cosmetic surgery office needs to be set up with this in mind. Many of my patients are middle-class or blue collar, but they are spending outside of their means and expect the same environment as do the wealthier patients.
The cosmetic surgery office should be clean, pleasant, and in most practices, decorated to accommodate females, since the majority of cosmetic patients are women. Consider your experience at a very high-class hotel and try to duplicate that in your business. “Concierge care” is a new buzzword, but most successful practices have known these secrets for centuries. The entire goal is to get the patient’s attention; for them to come and go with positive impressions. They have to realize that you are special and “do it differently.” A patient greeter, providing drinks and snacks, assisting patients with paperwork, and having educational material available for perusal, underline your commitment to patient service. Conveniences such as computers or iPads and wireless connection are all amenities appreciated by patients.
If you are looking for a model of what to do, look at Las Vegas casinos. They know how to treat their high-rollers to keep them coming back. Cosmetic surgery patients are also high-rollers and successful practices know how to make them feel special. They have beautiful furnishings, great smells, comfortable temperature, extremely friendly staff, and everything is clean and bright. If you can make your patients feel special, you will succeed.
The surgeon and/or staff should regularly sit in the reception room and observe all the senses. Does everything look good, smell good, and sound good? Are the magazines current? Is the space spotless? Occasionally, our administrator has a “secret shopper” that none of us know about, who comes into the office to evaluate the entire experience. This can be very eye-opening, as we sometimes fail to see the negative things that are around us. Fish cannot see water because they are in it! Many practice management specialists say that there should be no magazines in the office, only promotional material about services offered. Personally, I think that patients need some diversion. Every one of them has looked at the website and marketing literature before getting here. Sometimes, it is nice just to chill and not feel you are getting “sold” at every angle. First time cosmetic patients are usually nervous, so I want them as relaxed as possible. They can use our computers, watch TV, or read a variety of magazines, as well as have drinks and snacks, which about 99% do.
One of the goals of a well-run office is to not make people wait for long periods. In my office, we have five evaluation and treatment rooms and a relatively small reception room. My goal is to get the patients out of the reception room and into an evaluation room as soon as possible. If you can break up the experience and keep the patient busy, their wait seems shorter. Once they get into the evaluation room, they have the company of a staff member, and also can watch TV or review our website, while waiting for the surgeon. We have 15 high-quality widescreen TVs in our office, and use them for many purposes, including recreation, patient education, anesthesia monitoring, and teaching.
Office Accreditation
In the 1970s, an uncomplicated facelift required a 4.5-day hospital stay. There have been huge paradigm shifts in hospital stays for all surgical procedures and, currently, most cosmetic surgery is not performed in a hospital environment. There are numerous reasons for this including exorbitant hospital costs, presence of nosocomial infections, lack of insurance coverage for cosmetic surgery, having cases bumped by emergencies or other surgeons running behind, and lack of privacy for elective cosmetic procedures.
Having a fully accredited surgery center in one’s office offsets the need to operate in a hospital and all the negatives associated with it.
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It gives the surgeon total control of his or her operating environment.
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There are no other surgeons to run late or bump your case.
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The surgery is much more cost-effective compared with hospitals.
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Safety is usually enhanced due to the fact that the same people do the same job every day, which eliminates shift changes and related problems.
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There is no worry about infections from other patients.
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Since cosmetic procedures are usually very personal and discrete, patients can come and go without exposure to the employees that work in a hospital environment.
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Small offices usually have one or two anesthesia providers that work on a continual basis and this prevents surprises that can occur with random anesthesia providers.
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Convenience for the doctor, staff, and patient is unparalleled. I used to spend a lot of time driving back and forth from the hospital and now my operating room is just several steps away.
Office accreditation is not a panacea and has relative drawbacks. First, the surgeon is the captain of the ship and responsibility falls on his or her shoulders. If an emergency occurs in the hospital environment, there are dozens of trained personnel immediately available. In your office, it is you and your staff. For this reason, the surgeon must use discretion as to which cases are not suitable for the office surgery center. I never take a chance and I cancel cases 5–6 times per year because the patient has a medical condition that may put them at risk. A big part of having a good reputation and being safe has to do with picking the right patients. Never take a chance with a patient’s health.
One of the best things I have ever done in my professional career was to have my office and surgery center accredited. I have hundreds of colleagues who agree. Many surgeons are hesitant to pursue this because of the perceived extra work and expense, and many surgeons mistakenly believe they have to physically rebuild their facility. In reality, bona fide accreditation is attainable for the average practitioner and facility, if the surgeon and staff are willing to meet the requirements. The biggest misconception is that accreditation is a bricks and mortar undertaking, when in reality it is more about policies and governance.
The basis of accreditation is to ensure a safe, efficient, and accountable facility to better serve patients, surgeons, and staff by meeting or exceeding nationally recognized standards. In effect, you are making your office function as a small hospital. It is a lot of work, mostly paperwork, and is not something to be undertaken casually, but it unequivocally will make you a better and safer surgeon with a better and safer staff, facility, and patient experience.
The most common organizations for outpatient, office ambulatory surgery center accreditation are: Accreditation Association for Ambulatory Health Care ( www.AAAHC.org ); Joint Commission on Accreditation of Healthcare Organizations ( www.jointcommission.org ); and the American Association for Accreditation of Ambulatory Surgery Facilities ( www.AAAASF.org ).
Some examples of changes to routine office protocols include the requirement to dictate all surgical operation reports; quality review studies for sterilization; malignant hyperthermia rehearsal; infection prevention and reporting; studies for patient waiting times; peer chart review; impaired physician; and operating room (OR) fire rehearsals and credentialing all users of the operating facility. This is all very paperwork intense. Trying to become accredited on your own can be a task of awesome proportions. I highly recommend that any practice interested in becoming accredited seeks the services of professional accreditation consultants. It is not expensive and they coach the office and staff through every step of the way, including a mock accreditation site visit. I can speak from experience that the consultant route is a good choice. Finally, one drawback to accreditation is the fallacy that the surgeon must do all the work. In actuality, the staff does 90% of the work and record-keeping and the surgeon is the team leader. Having one nurse or exceptional employee to handle all the accreditation work makes this task very straightforward. Since accreditation comes in 3-year cycles with office inspections, having a stable employee that will be there for a long time is preferable.
Cosmetic Surgery Staffing
I have always said that a surgeon can be no better than the sum of their staff. In elective surgery, there is no doubt that great staff will enhance the patient experience and a poor or apathetic staff will drive patients away. Choosing the correct staff is never happenstance. Cosmetic surgery is very different than many specialties, as discussed earlier. You need staff who understand and relate to the biopsychosocial needs of the clientele. My best cosmetic coordinators were not trained in surgery but rather worked at high-end women’s stores. They know how to talk to and sell to upper-class females. Some of my best front-desk representatives previously worked at hotels or travel agencies and are used to catering to people with elective money to spend that value exceptional service.
When it comes to building a great staff, the word TEAM says it all. We have a cosmetic team in my office and we all represent exceptional patient service with optimal safety and predictable and reproducible outcomes. Any winning cosmetic team, as in any sport, takes hours and hours of practice and working together. Each “player” must have a distinct job description and also understand the job of other team members. When you have this, you can achieve synergy. This is when the total is greater than the sum of the parts. You build a great team with everyone on the same page and success is greatly simplified. This entire text could deal with staffing but needless to say, we want team players that are “win/win” people. They represent health and beauty and should look the part. They should smile, radiate happiness, warmth, and compassion, and should be able to make conversation with anyone anytime. In interviews I look for bubbly conversationalists with a great smile. Their demeanor is much more important than their job experience. I want to hire a “people” person. The job of my staff is to make me look good and they do an excellent job. Germane to the team concept is consistent use of logos, trademarks, pictures, etc., for all office and marketing materials. This includes printed materials ( Fig. 2.3 ), promotional items ( Fig. 2.4 ), and scrub logos.
Cosmetic Surgery Staffing
I have always said that a surgeon can be no better than the sum of their staff. In elective surgery, there is no doubt that great staff will enhance the patient experience and a poor or apathetic staff will drive patients away. Choosing the correct staff is never happenstance. Cosmetic surgery is very different than many specialties, as discussed earlier. You need staff who understand and relate to the biopsychosocial needs of the clientele. My best cosmetic coordinators were not trained in surgery but rather worked at high-end women’s stores. They know how to talk to and sell to upper-class females. Some of my best front-desk representatives previously worked at hotels or travel agencies and are used to catering to people with elective money to spend that value exceptional service.
When it comes to building a great staff, the word TEAM says it all. We have a cosmetic team in my office and we all represent exceptional patient service with optimal safety and predictable and reproducible outcomes. Any winning cosmetic team, as in any sport, takes hours and hours of practice and working together. Each “player” must have a distinct job description and also understand the job of other team members. When you have this, you can achieve synergy. This is when the total is greater than the sum of the parts. You build a great team with everyone on the same page and success is greatly simplified. This entire text could deal with staffing but needless to say, we want team players that are “win/win” people. They represent health and beauty and should look the part. They should smile, radiate happiness, warmth, and compassion, and should be able to make conversation with anyone anytime. In interviews I look for bubbly conversationalists with a great smile. Their demeanor is much more important than their job experience. I want to hire a “people” person. The job of my staff is to make me look good and they do an excellent job. Germane to the team concept is consistent use of logos, trademarks, pictures, etc., for all office and marketing materials. This includes printed materials ( Fig. 2.3 ), promotional items ( Fig. 2.4 ), and scrub logos.
The Art of the Consult
Cosmetic surgery is my passion and I love to operate. If we could all go to our offices and simply operate, life would be perfect, but to have surgery, you must have consultations. The cosmetic consultation is usually the first face-to-face meeting with the cosmetic team and the surgeon. It is an extremely important appointment and many patients will see multiple providers, so making the best impression is paramount. Since most consultations begin on the phone, the front-desk patient representative can be a great adjunct. They can set the stage for great patient service, explain what will happen at the consult, and get some information in advance from the patient.
From the time the patient drives onto your parking lot they must be impressed. Are you easy to find? Is it easy to park? Are the grounds and building clean and classy? All of these small elements serve to add up to a final analysis and choice on the part of the patient.
When the patient walks in our door, they are greeted personally and our staff signs them in and serves them snacks and/or drinks (almost everyone wants some), and makes small talk. If we are running behind, the patients are informed and kept up-to-date. A new consult patient should not be made to wait; it sends a very bad signal, so it is important to schedule new patients at the predictable times when the office is not expected to run over.
The patient should be escorted from the lobby to the consult room by the person who will be assisting the doctor at the consult. Furthermore, this person should accompany the same patient throughout their entire surgical experience, and this one-on-one bonding is extremely powerful at building relationships.
The cosmetic coordinator takes the patient to the consult room to begin the process. This room should be the fanciest one in your office and should have a comfortable temperature and smell pleasant. Aromatherapy is a powerful stimulation of the senses. The first order at hand is for the cosmetic coordinator to bond with the patient by making small talk and helping them relax ( Fig. 2.5 ).
If the patient is serious about having a large procedure or is considering multiple procedures, it is frequently helpful to have their spouse at the consult. The spouse (usually the husband/partner) may have considerable concerns about the need for surgery, the finances, and other questions.
For many patients, meeting a new doctor makes them very nervous. With cosmetic patients, they not only have to meet a stranger, but they have to tell them about, and show them, their biggest physical insecurities. Many patients have problems with aging and do not cope well. This apprehension can lead to a patient who is literally perspiring by the time the doctor examines them. It is very important for the staff to relax the patient and to compliment the surgeon. They can make you look good without sounding arrogant. People want to know that they are seeing a compassionate, experienced, and popular surgeon, and your staff can really help with this.
The cosmetic coordinator also asks the patient what it is they wish to discuss and she can make cursory suggestions, such as, “I believe Dr. Niamtu will want to discuss eyelid surgery, cheek implants, and facelift with you.” She then displays our website on the widescreen TV and goes through specific procedure pages to discuss what we do and how we do it. She then shows the patient before-and-after pictures of relative cases. This interaction is important, as it gives the patient an idea of what the doctor will discuss and also provides them with information on the procedures and this can shorten the surgeon’s consultation time. Having awards, publications, charity involvement, and similar accolades in plain view can be useful for patients ( Fig. 2.6 ).
Meeting the Surgeon
After the staff “pre-consult” the surgeon is called into the room and introduced. This initial meeting can make or break the patient’s decision. I always shake hands with the patient and introduce myself by my first name. I believe friendly communicative contact puts patients at ease and subliminally enhances the doctor–patient relationship. A show of personal warmth, an unhurried attitude, and some small talk with the patient before getting to the cosmetic problems will be time well spent.
Most of our patients register online and are asked to bring a list of cosmetic facial concerns to the first appointment. Nervous patients often forget to ask key questions. Patients are also frequently asked to bring in younger pictures of themselves to see what they considered their strong or weak points and how they have aged.
The most important instrument used in the consult is a hand mirror. I ask patients to tell me what bothers them or what they would like to change and to show me in the mirror. At this point, I always begin with a compliment such as, “You have a great jawline” or whatever positive feature you can start the conversation with. Since you are going to be discussing negatives, it is best to begin with a positive. Occasionally a patient will say, “Doctor, what do you think I need?” The novice surgeon should never fall into that trap. It is imperative that the patient takes ownership of what bothers them or what they would like to change. A patient who cannot communicate their cosmetic problems may have other underlying problems. Some patients are embarrassed to discuss the topic and need some prodding. The other problem with answering this question is that the surgeon may suggest a problem that the patient has not seen and thus offend the patient.
Some practice management experts say that you should not hand a woman a mirror, as it is offensive to make her look at her flaws. An alternative to using a mirror is to take several pictures of the patient just before the consult and project those images on the widescreen monitor. This can have great impact when showing patients their aging changes. Also giving the patient a copy of the pictures to take home can go a long way in having them realize their aging problems, especially in the lateral view, which no patient likes to see. A more digital means of avoiding the mirror is to use an iPad to take front, three-quarter, and side views, and to share them with the patient. Using a free app such as Penultimate ( www.evernote ) allows the surgeon to write or draw on the photograph and this can also be e-mailed, texted to the patient, or printed ( Fig. 2.7 ). This allows the patient to leave with notes and drawings.
