The world of medicine has changed. As short as 25 years ago things were different for the practice of medicine. Cosmetic surgery was performed only by a few specialties. Advertising was banned by the American Medical Association. Doctors were paid so well that revenue and income was an afterthought. The idea of pushing a product, treatment or surgery on a patient was conferred a nauseating idea. Certainly, it was one that any doctor would avoid and if they did do it, would actively deny doing it. The world of medicine and specifically plastic surgery and cosmetic treatments have changed things and definitely not in good way. Today, one can see ads in magazines for Botox, Restylane and other treatments. Groupon has specials on "lunchtime lifts" and "eyelid lifts". There are marketing books designed for cosmetic medical practices. These books don't focus on improving patient outcomes or improving safety. Instead, they focus on maximizing revenue and profit. Those are ideals that the field of medicine has shied away from for decades..until now.

There are several reasons for this change in cosmetic surgery's approach to patients. The first is simple: A change in the approach to cosmetic medicine that is different than traditional medicine. Traditionally, doctors prescribe medicine and treatments without regard to cost or profit. The goal was to solve the problem as quickly as possible. Insurance usually covered the patients costs so the best treatment is recommended without regard to cost. In cosmetic treatments and services, the patient is paying out of pocket and may not be able to afford the most expensive treatments. They may elect to have a cheaper alternative. Additionally, the doctor themself is offering the treatment and looks at the profit on the product. This was never done before. Second, non-physician providers have entered the market. For any doctor who has worked with a business person in a medical setting there are three words that they only care about: revenue, costs and profit. The traditions of a physician with providing care without regard to cost are not as present in non physician providers where it may not be part of the culture. Several states haves laws actually preventing non physicians from owning medical entities though it has not been strictly enforced. The third reason reflects a change in the model of medicine itself. Medicine has moved from a paternalistic model of care where a physician thinks of the best interest of the patient to one of a "peer" model. A peer model incorporates more of a "buyer beware" approach to cosmetic procedures. If a patient isn't happy with a procedure the provider has more of a "well you asked for it" approach not seen in a traditional medical model.

In my practice, myself and my partner see a lot of first, second and third consultations. Patients come in requesting many different procedures and treatments. Many patients have an identifiable problem that can be improved but a few do not. I have had consultations by patients who want me to inject botox or perform eyelid surgery who look completely fine. They have no signs of aging that need to be treated. There are four words that I tell them " you don't need anything". Often there is uncomfortability there as the patient has disappointment that i didn't often them a treatment or surgery. They may spend time looking for photos from their phone for specific instances when they are not "exactly symmetrical" or "perfect". At that time, I try to educate patients of the imperfections of us as humans. Social media, edited photos and magazines display an image of humans as perfect. Treating in my career actors, members of congress, models and athletes I can tell you that what one sees on TV and what is in real life are two different things. Patients who look great who focus on small imperfections have a false sense of expectations of what is "looking good".

There is a dark side to this as a doctor. There are doctors who will have a patient like this and offer an option. They know deep inside, that there is not solution the patient will be happy with but decide to proceed ahead with a procedure for mainly one reason: revenue. The second reason is ego. As a surgeon shouldn't I be able deliver anything to anyone. The answer is no but inside as surgeons we want to help everyone and their problems. It takes some experience to realize that you may end up harming the patient with unrealistic expectations by performing a procedure on them. I will often tell patients "I am financial incentived to do some procedure on you, but I have to live with myself. I can't do unnecessary stuff on people". Most often they listen but sometimes they don't and find someone who will do surgery. They often return after an unnecessary procedure asking how to reverse it.

My recommendation to patients are as follows. If a surgeon tells you that you shouldn't have surgery or you don't need a procedure to be done, think carefully when a second surgeon offers something. If I sent Kate Upton to enough plastic surgeons, eventually someone will offer a procedure or surgery to her. As a patient it is your responsibility to think for yourself what it means if other surgeons say to leave things alone.