Harley Street Secrets

A recent comment from DrX reminded me of an old topic I wanted to discuss: the famous five-minute consultations served by some commercial cosmetic surgeons. I am aware that GPs can do a consultation in five minutes, but even GPs, and their patients, get more stressed when the time is so tight, according to the BMJ. Nevertheless, some commercial cosmetic surgeons would easily and routinely see ten or more patients per hour.

Being honest, I am probably talking about this because speed has never been my best quality. No matter how hard I tried, I never managed to go under 20 minutes for a single consultation, which can best be described like running with Usain Bolt and finishing in 38.74 seconds, if my calculation is right. By the time I had seen my first couple of patients, the Usain Bolts of cosmetic surgery were normally already sitting in front of their dinner with the family, out for a drink with a new lover, shopping at Selfridges, flying abroad to their own country or doing whatever they liked, while I was still in the office with three quarters of the distance to run.

I spent years trying to figure out the magic trick. I tried to talk as fast as possible, and I almost managed to beat the guy that on Youtube can recite the books of the Bible (Old and New Testaments) the Book of Mormon, the 50 US States, the alphabet backwards, the United States Presidents and the Academy Award Best Picture winners all in 1’59″. I can tell you, patients didn’t like it. I didn’t like it myself and I wondered why they didn’t teach speed talking at medical schools, since it was such an essential skill in modern medicine. At the end, doctors had terrible handwriting since humans can remember, so making their speech unintelligible could also be seen as a sign of progress.

The BMJ proved me wrong again, with an article stating that the handwriting of doctors was no less legible than that of non-doctors, and yes, that very fast surgeon was really writing nicely during his five-minute consultation, and I could read he discussed everything. In the time I could cook an egg, a barely soft-cooked runny yolk, that surgeon could examine the patient, discuss the procedure, the alternatives, the implants and their positions, the risks and the postoperative instructions. All was written down, and the only thing I could not understand was: how.

I discovered the secret of the five-minute consultation much later, after I even managed to convince myself that some surgeons could really be superior human beings, with almost supernatural skills, and after accepting that I was never going to compete with them, because of my serious handicap with consultations. The revelation arrived when I became a more popular surgeon, and patients started coming for a second opinion, after seeing some of the speed monsters out there. I quickly realised, when talking to them, that they were behaving like they had no consultation at all. One very nice woman was even embarrassed when I asked what she knew about the possible complications of her procedure, since, she said, ‘we didn’t really discuss complications with the other doctor‘. All of a sudden, it was looking like I had been running with Usain Bolt, only I was doing the full 400 m while he was stopping at the 100 m mark.

In few cases I have been able to see the notes from the surgeon that did the first, five-minute consultation, and every time every single aspect of the procedure, particularly risks, was neatly written. Still, the patient didn’t have a clue. There was even a surgeon that was regularly writing he recommended to come for a second consultation before the procedure, but I have never seen a single one of his patients that confirmed listening to such a recommendation. I will never know why that was written, but I believe it was there to help in case the occasional unhappy patient managed to prove that the preoperative consultation only lasted five minutes (something that may not look great in court…).

So, MrX, the secret is out. Some surgeons do write things in their notes that are not actually said during the consultation. The problem is that, if surgeons write too much, patients do not quite read enough. They countersign the consultation form at the end of their five minutes, and so they state that they really understood everything written in there. Some companies have an extremely well structured process for this. To give a simple example, patients coordinators in some companies routinely tell their ‘customers’ that breast implants are guaranteed for life (without explaining that they will need replacement anyway) while the surgeons write down in their notes that ‘lifespan of implants’ has been discussed, without actually doing that. There is no proof of what those patients coordinators said, and no proof of what those surgeons didn’t say. If it is a joke, it is a clever one.

I am going back to speed talking, anyway. I figured out a new product that will greatly improve the consulation process for companies. I am making a video of my painfully slow, almost one-hour long consultation, and then I will record a faster version, that runs in five minutes. Everything will be in there. When patients come for a consultation, I will play the video while sitting in front of them, with my nicely written notes. At the end, I will ask if they have any questions. In case they have any, I will replay the relevant part of the video, I would assume not more than 15 seconds of it. After patients had an answer to all their questions, I will ask them to sign and go. Legally, I cannot see where the problem can be.

Technology is changing the way doctors consult their patients (telemedicine is a good example) but some clever cosmetic surgeons apparently went further and just figured out how to avoid consulting patients altogether, using already available, simple pieces of hardware (their own smartphones).

The problem that till now couldn’t be solved is rather simple: if you want to operate on ten or more patients a day, every day, you will end up with no time for consultations, which in turn will leave you with no patients to operate on. Some of the ‘stars’ of commercial cosmetic surgery have been struggling with this dilemma for years, no matter how hard companies have been trying to help. In fact, the simple strategy that companies have been using involves booking patients for consultations with surgeons that, without knowing, will never do the the operations (a particularly disappointing arrangement when your contract states that you are not paid for consultations). After they have their consultation with the ‘dummy’ surgeon, patients are normally told that unfortunately that very surgeon has no available operating space, and so they are quickly and efficiently diverted toward the operating list of the ‘preferred’ surgeon, who almost always happens to have free operating spaces during the following week.

Moving patients from one surgeon to the other is a fine art and, at least according to some managers, it may also solve another embarrassing problem for surgeons and companies that are too busy to wait: it may help to waive the so-called cooling-off period. If you see a surgeon today, some companies would claim, your reflection period also starts now, no matter who is the actual surgeon that will operate on you, and so you can see a new, unknown surgeon on the morning of your procedure, and that surgeon can operate on you without breaking any rules. A very bold statement, that has never been proved true, but that some companies love. The ‘trick’ has been working well, except for the fact that, with companies becoming more greedy and pushy, even the preferred surgeons got worried when their lists started including patients with very poor indications or even serious medical problems. There was an obvious need for accurate screening of the patients that were sent as last minute ‘list fillers‘ (I am sorry if you are, or have been one of these patients: that’s exactly how you have been treated and considered by your company and your surgeon).

I’ve been recently shown the system now used by one of the busiest surgeons around, and I have been seriously surprised, if not shocked. This particular surgeon would get the pictures of the prospective last-minute patients together with the notes written by the poor surgeon that consulted them,  all neatly scanned,  emailed and available on his smartphone for a quick evaluation. The surgeon would read the notes (which says a lot about the confidentiality of the first consultation), look at the pictures (again, very confidential…) and decide if the patient can be accepted for a re-consultation on the day of the procedure or if he/she is best left to the poor surgeon that did the first consultation. I suppose it will not surprise anybody that the surgeon doing the original consultations will only get the leftovers (i.e. the patients with the poorest indications). The reputation of the ‘preferred’ surgeon will grow, while the other surgeon will struggle with problems, complaints and very little money, eventually leaving the country altogether. There is actually a great turnover of relatively young surgeons coming from foreign countries, especially in some companies, and this aggressive ‘patients management‘ is one of the main reasons. Is this fair? You are the judge. Would you be happy meeting your surgeon on the day of your operation? Whatever the answer, at least I can assure you that you would never meet me that way…

Many years ago, when surgeons couldn’t advertise on the web or in magazines, the only way to build a good practice was through referrals, and I can tell you, it used to take both a long time and a good, clever surgeon to reach the top. While the web (or should I say the Web 2.0, with all the forums, the blogs and message boards) and companies changed this business significantly, very famous surgeons still share one very important trait: they all select patients very carefully.

If you are surgeon looking for referrals, your best bet is to be extremely selective with the patients you operate on, rejecting all the cases that will not end up looking stunning. Patients often believe that a great surgeon can bring even the ugliest case to a perfect result, but this is not true and unfortunately there are situations that a great surgeon could improve, but that would still look worse than patients who started with a perfect indication. Just to make a simple example, you can have two surgeons, one operating on a nose with very thick skin and a massive bulbous tip, and the other one only selecting those noses with thin skin, perfect tip and just a bit of dorsal hump. The first surgeon can do the best job in this world, but should you actually meet the two patients, seeing the results without knowing anything else, you would think that the second surgeon was much better. Clever surgeons know this, and would only operate on patients that will turn into good advertisements for their practices.

The biggest marketing advantage of a very famous surgeon is, in fact, the chance to see a very high number of patients and reject those with a less then perfect indication. A less popular surgeon cannot normally afford to reject many patients, and would end up, no matter how skilled, with some results that will look inferior. It is funny, but companies enjoyed this very same marketing advantage at the very beginning, when their ads and the free consultations were bringing in more patients than they could actually operate on. Right now, with their belts tightening more and more every day, companies are hopelessly dreaming of surgeons that would never reject a single patient, and don’t seem able to recognize the severe damage that this approach has been doing to their reputation.

Is there any advantage for a patient in choosing a famous surgeon, who would reject anybody with a less than perfect indication? You bet, and there are at least two good reasons why such a surgeon should be the first one that you see. First, you would immediately know if you are a good candidate, or a less-than-ideal one. Second, you would know that, in case you are accepted as a patient, your chances of coming out with a great result would be much higher than if you saw a less demanding surgeon (don’t forget that fussy surgeons only operate when they are sure to get impressive results). Only after being rejected by a very strict surgeon, you should consider going for a second choice, and accept that your risk of being unhappy with the result  is higher at this point.

Some patients feel deeply hurt after being rejected for a procedure, and fail to see the real practical message linked to that experience. Strict surgeons are normally hated by companies and by some of the patients that were rejected, but nevertheless they manage to keep an outstanding reputation and thriving practices. They may not be technically better than others, but they are miles ahead when it comes to recognizing a proper candidate for cosmetic surgery. It is this very unique ability that makes them worth more for patients and, apparently, less for companies with the ‘supermarket’ mentality.

I have been on holiday for few days, away from the UK and, as much as I could, from cosmetic surgery. I had fun, especially at the airport, trying go past the baggage check carrying a tiny glass snowball. The snowball was actually so small that it could fit easily in my clear plastic bags for the liquids, but still commanded the attention of four different people and had to be inspected by a supervisor. I couldn’t help but notice that in a matter of minutes that little glass ball with about 10 cc. of water went through an x-ray machine, a complete consultation and finally a swab (apparently to check for explosives) before being diagnosed fit for travel. I wish the same level of care could be provided by the NHS and private companies.

Coming back, I have seen a couple of new cases of ruptured breast implants, which would be an ordinary event, except for the fact that the implants were not very old. Still, implants can sometimes rupture quite early for no special reasons, and I am not going to discuss the problem in detail on here. What is interesting is not the scientific, but the commercial side of the problem.

The typical scenario involves a very worried patient, that rushes back to the company where she had her breast enlargement immediately after a GP or a surgeon from the NHS diagnosed her with a ruptured implant. In quite a few cases, the diagnosis of ruptured implant is not unequivocal, and surely the doctors that made it could learn something watching my little snowball going through the baggage check. Almost always there is some degree of ‘competitive behaviour‘, with surgeons from the NHS making naughty comments about their counterparts in private practice, and surgeons working for companies claiming that there is very little knowledge of cosmetic surgery within the NHS. In any case, what the patient understands is that she needs an immediate replacement of implants, and that her surgeon, her brand of implant and the company that she used are the cheapest on the market and not, as she was led to believe, the top of Harley Street.

From there, it only gets worse. I’ve heard that at least one company is now telling patients that their ‘aftercare’ didn’t actually include the replacement of a ruptured implant, unless the rupture happened during the first year. As a consequence many patients will have to pay and turn to their solicitors. I will never stop being amused with the fact that there is at least one manufacturer of implants that is issuing reports about their own ruptured implants, apparently always blaming the surgeons for the rupture. Leaving alone the fact that the manufacturer is directly involved, so the reports are necessarily partial and would never stand a test in a court of law, the pretended reasons for the ruptures are slightly outdated to say the least: I have even been told that the use of povidone-iodine solutions during the procedure is one of the suggested reasons for rupture (not going more into details here, but just for the manufacturers, and the solicitors, I hope they remember a couple of studies that examined peroxide-catalyzed elastomers and platinum-catalyzed ones).

I can see this story snowballing down a perilous path. Patients are unhappy, surgeons are unhappy, companies know no accountability. It could happen that, for the first time, the entire business model of commercial cosmetic surgery companies will end up tested in court, especially if a surgeon knowledgeable enough (and there are a few) will be asked to pay for faults that are not his/hers. Ruptured silicone implants are part of the risks of breast enlargement and quite a simple problem: as far as we know from many studies, they pose no major risks and only need to be replaced. Why this is becoming so difficult, it is one of those commercial mysteries that I don’t really understand.

I didn’t expect the violent reaction that followed my last post about companies posting fake messages on web forums, because I thought that was a quite an obvious and known practice (even if I now understand that the topic was never discussed before anywhere on the web). I like the idea of companies spending their time playing around with innocent pastimes (“In the advanced state of society, therefore, they are all very poor people who follow as a trade what other people pursue as a pastime” – Adam Smith, The Wealth of Nations, 1776), trying to improve the image of improbable cosmetic surgeons or writing nasty comments about each other.
This time, I should talk about mystery shopping, a legitimate business practice that commercial cosmetic surgery companies obviously conduct in their very own rough way. In practice, mystery shopping is about testing the competition with a secret shopper, that will have instructions to investigate the service, the efficiency, the friendliness and the ability to deal with atypical scenarios of a specific business (you can read more about mystery shopping on Wikipedia). There are registered companies providing mystery shopping services, but in general cosmetic surgery companies would avoid them, convinced as they are that they can do better by themselves. As a consequence of this, nurses or ‘friendly’ coordinators would be moved from Watford to Leeds or from Birmingham to London to have a consultation for a breast enlargement that will never happen with another nurse or coordinator they must have never seen before. In the average busy day of any company, the secret shopper will mix with the normal patients, and will get the normal, useless free consultation whose only reason to exist is to find out if a specific patient has really got the money to pay for the operation. It is not unusual for a secret shopper to end up in front of a surgeon, showing her breasts and trying to enter the unusual scenario that was planned in advance, asking, for example, what that surgeon would think of a particular brand/shape of implants that the poor guy could never have available at that specific company he is working with.
I suppose that mystery shopping in cosmetic surgery may account for about 2% of all the free consultations provided (this is based on an article about mystery shopping in healthcare published by the Wall Street Journal), so your chances of being in the same waiting room with a ‘fake’ patient are quite high. In this case, you must remember that, according to the quoted article on the Wall Street Journal “shoppers resort to hiding tape recorders in their bags, jotting details down in appointment books or crosswords, and going to bathrooms to take notes“.
Is this ethical? Probably not. The American Medical Association states in this report that: “Physicians and staff should be informed before a secret shopper program is instituted, and a time frame for when a secret shopper may visit their practice should be given, and physicians should have the opportunity to review the feedback that is generated from an evaluation“, and I’ve never seen any of these measures being taken. Also in the same document: “The confidentiality of the other (bona fide) patients may also be a concern when secret shopper “patients” are employed as these individuals are trained to observe listen to the conversations of medical staff and are thus more likely to overhear confidential information“: is the Healthcare Commission aware of this and of mystery shopping in general?
Mystery shopping is an innocent pastime, but do you really want to have your consultation next to a shopper, or with somebody trained to sell in such a way?