Essential Requirements to Setting up an Aesthetic Practice.

Aesthetic dermatology is becoming a vital and popular branch of medicine. This article aims to guide dermatologists to set up a professional and ethical aesthetic practice. Dermatologists should have an integrated practice of clinical dermatology, dermatosurgery and cosmetic dermatology. Ethical practice is the gold standard for any medical field, especially with dermatologists, who should avoid doing unnecessary procedures. Proper patient counselling and addressing the patients' concerns is imperative.

INTRODUCTION

There is currently no internationally accepted definition of aesthetic practice. The American Board of Cosmetic Surgery has defined cosmetic surgery as “a subspecialty of medicine and surgery that uniquely restricts itself to the enhancement of appearance through surgical and medical techniques. It is specifically concerned with maintaining normal appearance, restoring it, or enhancing it beyond the average level toward some aesthetic ideal.”[1]

According to the International Survey on Aesthetic/Cosmetic Procedures Performed in 2010 (revised – January 2013) by the International Society of Aesthetic Plastic Surgeons (ISAPS), the most common non-surgical procedure performed in India was botulinum toxin Type A injections followed by hyaluronic acid fillers, laser hair removal, autologous fat injections and intense pulsed light (IPL) laser treatment. In the United States, there were nearly 11.5 million surgical and non-surgical procedures performed, according to statistics from the American Society for Aesthetic Plastic Surgery (ASAPS). They also report that the number of cosmetic procedures for men has increased by more than 273% between 1997 and 2013.

Need for aesthetic procedures -

Several factors can be attributed to the increasing demand for aesthetic dermatology procedures, namely:

The desire to prolong youthfulness and self-image.

Economic abundance.

Technological and medical advances whereby new cosmeceuticals and devices have been invented to treat cosmetic disorders with minimal downtime and complications.

Media-driven demand and hype by high pressure advertising.

Professional compulsions to undergo cosmetic procedures.

Aesthetic procedures have become “need felt” and hence, this article aims to guide dermatologists how to set up a professional and ethical aesthetic practice.

Factors for Success [Figure 1].

Figure 1

The 14 Ps of aesthetic practice

Place: One of the most important elements of your a succesful practice is the location. You should research the geographic location that you would like to practice in to determine the demographics of your patients. Be familiar with all hospitals, dermatology clinics and other aesthetic centres around.

Purpose: Maintain a centre of excellence in all aspects. One should have an integrated practice of clinical dermatology, dermatosurgery and cosmetic dermatology. For example if an acne patient comes to the clinic, you would require to treat the active acne and plan to treat the acne scars or post inflammatory hyperpigmentation subsequently.

Keep up to date with the latest and recent advances so as to offer your patients the best possible treatment available. Remember, cosmetic procedures are not just about appearance and convenience but also about patients’ health and safety. Therefore, every case must be treated with professional competence and due care.

Practice and personnel: Physicians should see their practices from the perspective of the patient. Hence, take a walk around your clinic, observe each area, enter through the front door, sit in the waiting room, check the washrooms, sit and observe the front desk staff greeting your clients on the telephone and in person, your assistant clinicians and the treatment rooms. As everyone's time is precious, make sure patients are not waiting for a long time for consultations, procedures, and at the billing counter. Front desk staff should be well groomed, have knowledge of general office principles and be proficient at phone etiquette and customer service. It is preferable if they are dressed in smart and trendy uniforms.

Efficient handling of appointments can be done when the reception staff are adequately counselled and trained to handle appointments. Allocate sufficient time for the procedures that have to be done. For example, doing a laser hair removal for the lower limbs will require you to shave the hair before starting the procedure. Therefore, you should take into account the time needed to complete the laser hair removal and do not overlap with other appointments.

Patients: Be an aggressive listener and communicate effectively. Have a non-judgmental attitude and watch out for any signs of body dysmorphic disorder. It is always better to avoid doing a procedure on the first consultation with the patient, as this would give them time to think and to prepare themselves.

Always address the concerns of the patient. This will instill confidence in the patient. Call them for regular follow up and monitor the progress of the condition.

Procedures: Before doing any procedure, make sure you have explained adequately to the patient - the procedure details, alternatives available, risks involved, complications that can arise, outcome expected, duration of treatment and expenses involved.[2]

When one is beginning aesthetic practice, it is important to start with basic aesthetic procedures, gradually gain confidence and improve one's skill. For example, learn and master the art of basic chemical peels or toxin injections rather than beginning with complicated or advanced procedures.

As with lasers, it is often a sensible practice to rent or share a laser on a monthly basis with a group of physicians/dermatologists so that the financial burden is reduced and one can build up the laser practice to ensure a steady flow of patients before investing in a laser.

Photography: They say a picture speaks a thousand words; hence, good and standardized imaging is very essential. Good photographs help in monitoring the progress of a disease or condition help to communicate effectively with scientific communities during presentations and publications.[2]

Requirements:

DSLR/SLR cameras (Digital Single Lens Reflex and Single Lens Reflex) – definitely outscore the common point – and – shoot camera with good resolution.

Mobile cameras are not suitable due to the absence of dedicated close up/macro modes, difficulty in maintaining a standardized setting and therefore unsuitable for precision clinical photography.

Patient positioning: Photograph the patient in a fixed anatomical position.

Background: The best background would be a plain light blue, black or green non-reflective surface like a linen cloth.

Lighting: Broad day light is the best. If not possible, then use two main lights at 45° angle to the subject on a parallel plane to the frontal plane of the subject.

A tripod and photographic frames are essential tools for standard imaging.[2]

Imaging systems with standardized equipment and software are useful.

Professional skills: There are many fellowship programs that are designed to equip you with the necessary skills for practicing cosmetic dermatology. Working as an understudy to a cosmetic dermatologist will also help you to gain experience.

Performing evaluation trials: New machines that come into the market that claim to be effective in various conditions can be tested by performing evaluation trials before being offered to patients. Using good imaging methods and other devices (e.g., chromometer, mexameter) we can assess the effectiveness of the machine.[3]

Skin care products: Many dermatologists have their own pharmacy so that the products they prescribe are easily available.

Equipment: The first step would be to identify various vendors. Narrow down to a list of preferred vendors based on factors such as cost of the equipment and spares, trainings provided by the vendor, credibility of the company, after sales services and annual maintenance, system performance, warranty and extended warranties.

Patient records: It is essential to maintain a database of patient records. It not only becomes easier to remember past details of patients’ treatment and procedures, but also helps in building a rapport with the patient. One can use electronic medical records (EMR) to access details of the patients. Numerous online systems are available to doctors that allow patients not only to book appointments online, cancel appointments but also to get SMS reminders of the time and date of their appointment.

Publicity: One need not spend a fortune on advertising. Internet marketing and mobile advertising is the latest means of mass communication. However, this is a controversial topic and one needs to be ethical and follow guidelines defined by medical boards. An attractive and informative website is an important prerequisite. Ensure that all information is accurate and genuine.

Promote: Tell readers, listeners, viewers what's new in the world of cosmetic dermatology, so that any new technologies that have been introduced in the market recently can be conveyed to the consumers. Invite your audience to learn more by attending your online “Webinars” either through email, patient newsletter, social media or personal blogs etc. touch base with them. Tell them what's new in your practice and in the world of cosmetic dermatology.

Problems: Have a conservative approach. It is better to undertreat the patient. Also, make sure the patients have realistic expectations. If a complication arises, treat the patient sympathetically and gently, rather than ignoring the patient. Offer to see the patient more frequently to allay patient fears. Corrective treatment may be offered free of charge.

Protection: Property Damage Insurance coverage is a must following installation of the device. Electronic insurance plan should be taken for the system-that covers all the parts and electronics of the device. Many insurance companies offer electronic insurance that may be cheaper than the annual maintenance charges (AMC) offered by the laser companies after the warranty period is over. While taking insurance it is important to specify which parts are covered and mention it in the policy. Fire and burglary insurance and insurance for mobility from one clinic to another also need to be done.[3]

Professional liability insurance protects the doctor against financial consequences of an error or omission during the service or professional act such as aesthetic treatments and services. Indian Medical Association (IMA) and Indian Association of Dermatologists, Venereologists and Leprologists (IADVL) offer such a scheme to its life members. Sometimes in spite of sincere professional jobs being done and all possible precautions taken, things can still go wrong. Frank and truthful discussions with the patient can prevent unnecessary litigations.

CONCLUSION

Aesthetic dermatology is becoming a vital and important branch of medicine. To meet and anticipate patient needs, it is necessary to ensure that the technologies being invested in are tried and true and “work the way they say they will”. Practitioners must remember the words of Hippocrates “Primum non nocere” – First do no harm. Have a sense of proportion and stick to it. You can always come back and do more.