Some patients avoid cosmetic and other elective procedures for reasons that sound a lot like fear of “karma”: "If I do an elective procedure, then something bad is sure to happen – the universe will punish my ambition and vanity."


Dr. Naomi Lawrence says she sees this kind of catastrophic thinking during cosmetic consultations quite frequently:

I see this often among patients who are considering a cosmetic procedure for the first time. One of the things holding them back is a feeling that they may have a bad outcome or that a bad outcome is inevitable because they are getting an unnecessary procedure.


There are many well-known psychological phenomena related to this common patient intuition. For example, omission bias is a common barrier to vaccination: the risks of commission (i.e., risks from getting vaccinated) are instinctively perceived as worse than the risks of omission (i.e., risks from not getting vaccinated).


Other psychological intuitions involved include illusion of control and the just-world fallacy. What to do about it?


Dr. Lawrence, of course, emphasizes to patients that risk and outcomes don’t work that way:

Of course I tell them the simple truth that a bad outcome, while possible, is highly unlikely. And of course I tell them that, no matter what, they absolutely do not deserve a bad outcome. But that kind of simple reassurance is rarely enough.


The more important message seems to be to remind patients of whole premise of your cosmetic business. It’s okay to want to look good. Wanting to look good isn’t always vain. And “natural” isn’t always better. Our faces age in many ways that we don’t like and it’s okay to both prevent those changes with good skin habits, and to undertake some safe, effective treatments if wrinkles or other skin features are bothering us.


As Dr. Lawrence puts it:

We do many things to “put our best foot forward” such as coloring gray hair, dressing in a flattering style, or getting our nails done. Trying to look your best is not tempting fate but rather making sure your appearance reflects your vitality.


Emotional reactions are inherent to human nature. But some emotional reactions, like catastrophic thinking, are not helpful, and are not grounded in fact. Managing those emotional reactions through a thoughtful articulation of your values is very important. Yes, physicians must share facts. But they can also help patients by appropriately sharing their own relevant, well-thought-out values, such as, “It’s okay to want your appearance to reflect your vitality.”

If a patient becomes initially interested in a procedure during an office visit, you want to do everything you can to capture that moment.


But patients are often unwilling to commit to expensive procedures without time to reflect, and without being 100% sure in their own mind about what the experience and the outcome will be.


Since dermatologists are so busy, and so scheduled, you may not even have time to fulfill a spontaneous request, let alone take time to give the patient the detailed personal explanation they may need in order to make a spontaneous decision.

The standard approach would be to give them some information to take home (e.g., before and after pictures) and some time to think about it (e.g., “Let’s schedule a follow up in a few weeks.”).


Dr. Shawna Flanagan has a better approach:

I do this a lot with laser procedures— I don’t have time to do the whole procedure but we do a “test spot” which gives a patient a feel for what it’s like. They pay a test spot fee which is credited to the full treatment if they do it. I would say 90 percent come back for full treatment.


It may not work for all procedures, but it does work well for laser treatments of rosacea, facial or leg veins, benign lentigines, or hair removal.


In his classic work Diffusion of Innovation, Everett Rogers identified trialability as one of 6 factors that reduce barriers to adoption of technologies.


Finding efficient ways to provide trial experiences for your patients is one good way to capture those initial moments of interest before they slip away into procrastination or distraction or forgotten intentions.


And if you know that you have this tactic in your back pocket, you may feel more comfortable being proactive in recommending effective procedures to patients who had not been actively considering them.

Physicians have to both reign in and broaden patient expectations.


Reigning in is perhaps the more familiar task. Patients can be in denial about the severity of their condition and unrealistic about probable treatment outcomes. So, often, you have to lower their expectations.


But broadening patient expectations is important too. Patients can be shy and embarrassed to ask about cosmetic or sensitive treatments. Patients can be unaware of what is possible with new technologies. And patients can be ignorant about how age and sun will ravage their skin without preventive, proactive care. Physicians can broaden patient expectations by frequently showing possibilities and inevitabilities. Show patients their options, even if they don’t ask. And show them their future, even if they aren’t currently worried about it.


But how do you do that without feeling like a salesperson?


Dr. Gary Goldenberg’s motto on this point is, “I don’t sell. I offer”. Here are some examples of how he does that. These quotes are paraphrased from our interview:


When he sees a patient for a skin check, and notices rosacea, he’ll say to the patient:

You may have noticed those red veins around your nose. That’s rosacea, and I can clear it up in two easy treatments. Let’s finish your checkup because your health comes first. We can talk about that fun stuff after, if you like.


When he sees a patient with dry skin he often makes an even stronger offer:

I ask, ‘what is your skin care routine?’ When they tell me they don’t have one, I say, ‘What do you mean you don’t have one, come on, you’re in a dermatology office. You need a skin care routine!’ At that point the patient is usually interested in hearing me out. I have these cards where I check off what I think they need. While I finish the exam, my assistant goes and prepares the items to show the patient after. This package was personalized for their needs and they appreciate that. They also appreciate that I don’t pressure sell any of it. I offer it. If they want it fine. If not, that’s fine too. But I intentionally and personally, offer!


On the cosmetic side of his business, he gets a lot of patients coming in with a specific interest in Botox. He makes clear that he has more to offer:

I will of course give that patient Botox if that is what they really want and need. But new cosmetic patients usually know so little about their skin and the available treatment options, so I try to do a full cosmetic consultation. I examine the surface of the skin, the deeper layers, the texture, and the dynamic muscle movement. I describe fat grafting. What I am doing is planting seeds. These are the things that are available. Let’s talk about immediate, short term, and long term options. I don’t sell these things. I offer them, so that the patient is informed and can make a good decision about how to spend their money, over time.


Good sales people put relationships before transactions. They don’t do pressure sales which can damage a relationship. But they are still very proactive. They offer – intentionally and personally. Dermatologists can do that too.

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