Our Dermatology Online

Review Article

Aesthetic practitioner as a physician and

businessperson – Is it achievable?
Elena Thomaidou
Department of Dermatology, Hadassah- Hebrew University Medical Center, Jerusalem, Israel

Corresponding author: Dr. Elena Thomaidou, E-mail: [email protected]

ABSTRACT

Aesthetic medicine subspecialty is no longer limited to the fields of plastic surgery and dermatology, as many specialties
are offering aesthetic medical procedures to better accommodate their patients’ aesthetic needs. During the last decade
there is an enormous increase of cosmetic treatments worldwide and the absence of regulations in aesthetic practice
has become more noticeable. This article illustrates the challenges that every aesthetic physician must overcome daily
to maintain high ethos and make decisions according to patient’s best interest and safety. Aesthetic practitioner should
be more than a businessperson with a medical degree. If they place their integrity and moral standards to the test, then
they will continue to be judged by their colleagues and society. Is it possible to maintain the same moral obligations
during cosmetic procedures as with any other medical treatments?

Key words: Aesthetic dermatology; Cosmetic dermatology; Ethics; Malpractice; Safe practice; Good
clinical practice

INTRODUCTION to rise to £3.6 billion by 2015 as it was reported by

Professor Sir Bruce Keogh KBE [4]. On the other side
“A physician shall be dedicated to provide competent of the Atlantic Ocean, American society for aesthetic
medical service in full professional and moral plastic surgery reported more than $13.5 billion spent
independence, with compassion and respect for human for the first time ever in the year of 2015, with surgical
dignity” as it has been described by Word Medical procedures accounted for 58% of the total expenditures,
Association International Code of Medical Ethics [1]. and nonsurgical procedures accounted for 42% [5]. A
This article will explain the challenges that every aesthetic comprehensive analysis, which was published in USA
physician must overcome daily to maintain high ethos in August 2016, indicated that the current medical
and make decisions according to patient’s best interest aesthetic market was worth $52,405 million for both
and safety. Aesthetic medicine subspecialty is no longer service and product revenue, which over the next five
limited to the fields of plastic surgery and dermatology, as years was expected to grow at 5.5% Compound annual
many specialties are offering aesthetic medical procedures growth rate (CAGR) and to hit $69,786 million in 2021.
to better accommodate their patients’ aesthetic needs [2]. The invasive aesthetic procedures were set to grow at
How difficult is for all the aesthetic practitioners to set a CAGR of 4.3%, while the non-invasive ones were
their priorities straight? People are willing to spend a lot of supposed to reach a CAGR of 4.5% over the coming
money for staying forever young having the perfect facial five-year period [6]. Therefore, due to this increase
skin and body. Therefore, in the western world, financial of cosmetic treatments worldwide, the absence of
incentives for the aesthetic practitioners can be dangerous regulations in aesthetic practice has become more
against ethical practices [3]. noticeable. In fact, in the review document regarding
the regulation of cosmetic interventions in U.K., the
In UK, cosmetic interventions are booming business, committee was surprised to discover that non-surgical
which worth of £2.3 billion in 2010, and it was estimated interventions, which can have major and irreversible

How to cite this article: Thomaidou E. Aesthetic practitioner as a physician and businessperson – Is it achievable?. Our Dermatol Online. 2018;9(2):210-214.
Submission: 24.09.2017; Acceptance: 18.11.2017
DOI: 10.7241/ourd.20182.28

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adverse impacts on health and well-being, are almost intervention [12]. If the patients ask for a cosmetic
entirely unregulated [4]. treatment that the physician considers unnecessary
and/or dangerous, then it is physician’s obligation to
discuss the issues and explore the reasons for their
THE ROLE OF AESTHETIC
request [13]. Always, it is important during the first
PRACTITIONER AS A PHYSICIAN
consultation to consider the patients’ psychological
Physicians, who choose to work in aesthetic areas, needs and if necessary to seek expert advice from
should maintain a high standard of safety. Patients are colleagues prior to any intervention [12]. It is extremely
more demanding and treatments are embellishments, challenge for every aesthetic practitioner to go ahead
so there is little tolerance for poor results and with an unnecessary treatment since the financial
complications are less acceptable [7]. Prendergast incentives outweigh his/her decision.
mentioned in his book that there is no “medical”
Aesthetic practitioners should be open and honest
indication for the procedure and the physician is only
about their skills, experience, fees and conflicts
responsible for proposing a method by which the
of interests [12]. Attendance only at a training
patient’s goal should be achieved [1]. Patients must be
course is insufficient to become competent in a
able to trust that their physicians are always acting in
procedure, whether this is a surgical or a non-surgical
the patients’ best interests [7]. The Council of Medical
procedure. As it is mentioned in the Professional
Speciality in U.K. states that “physicians should treat
standards for cosmetic practice, direct practice is also
each patient with honesty, compassion, dignity, respect
necessary. Therefore, it is highly recommended that all
for individual autonomy and educate them about health
practitioners undertake a period of formal or informal
issues” [8].
mentorship and they must keep their skills up to
The role of physician demands on their cautious date by undertaking relevant continuing professional
judgment guide about the different aesthetic treatments development [13].
that can be provided to patients, rather than simply
yielding to patients’ demands [7]. Unfortunately, the THE ROLE OF AESTHETIC
patient’s conception depends to media advertising PRACTITIONER AS A BUSINESSPERSON
resulting to exaggeration of patient’s expectations on
aesthetic results of procedures. Therefore, legal claims A businessperson’s main objective is to maximize profit
are higher than other surgical operations, especially by increasing productivity and minimizing costs, but an
if physicians do not respect patient’s autonomy by aesthetic practitioner must not follow this goal, as this
not explaining treatment process and outcomes [9]. would have negative implication on the quality of the
The initial consultation must not serve the purpose service offer [14,15]. The role of the dermatologist, for
of “selling” an aesthetic procedure, but placing the example, is transforming from a traditional healer into
interests of patients above those of the physician is one one of a businessperson, who will promote “big ideas”.
of the fundamental principles of professionalism [1,10]. “Bluffing, puffing, and spinning”, which were described
by Illingworth [16], are acceptable marketing practices
The principle of informed consent tends to for businesses but are those behaviours acceptable for
reflect the concept of autonomy of the person physicians as well?
requiring and requesting medical and/or surgical
interventions [11]. Seven criteria relate to an informed In microeconomics, the profit maximization rule states
consent: (i) competence to understand and to decide, that if a company chooses to maximize its profits, it
(ii) voluntary decision making, (iii) disclosure of must choose that level of output where marginal cost
material information, (iv) recommendation of a (MC) is equal to marginal revenue (MR) [14]. In more
plan, (v) comprehension of terms and (vi) decision simple terms, profit maximization is an advantage for
in favour of a plan, and (vii) authorization of the a company, but it can be a disadvantage for consumers
plan [9]. A person, who is a candidate for an aesthetic if the company starts to use cheaper products/services
procedure, must complete all the criteria in order to or decides to raise prices especially when the firm has a
give an informed consent, and every aesthetic physician monopoly power in the market [17]. If this concept is
must make sure patients are given enough time and applied in the health care sector then the outcome can
information before they decide whether to have an be dangerous and unethical for the patients. According

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to Sidorsky, it may be argued, that healthcare providers sometimes devoid of evidence based support. Cantor
should not function merely as profit-maximizing entities mentioned in her article that every product should be
since they principally promote patient health [7]. evaluated by randomized, double-blinded and placebo
Unfortunately, in the free market economy due to the controlled trials regardless the overall cost burden for
minimum government interference through insufficient the physicians [20].
laws and regulations, this might not always be achievable.
Furthermore, information asymmetry, one type of
Firstly, most aesthetic practitioners want to maximize market failure in the free market, is a challenging
their profit by increasing provision of services in their issue in aesthetic practice. According to definition,
clinics. Recently, this has been achieved by hiring an asymmetric information is a situation in which one
aesthetician to perform a variety of skin-care procedures party in a transaction has more or superior information
like mild chemical peels, microdermabrasion etc. compared to another [21]. In aesthetic practice, this
However, it is important to remember that aestheticians often happens when the doctor knows more than the
treat “clients,” not “patients” [18]. In the USA, there patient. Potentially, this could be a risky situation
are many aesthetic practices, where “dermatology because one party can take advantage of the other
physician assistant (PA)” assists during the cosmetic party’s lack of knowledge [21]. Information must be
procedure and “physician extenders” (PE) are communicated clearly and respectfully to the patient
employed for basic dermatological evaluation and and a shared understanding of expectations and
treatments [19]. Therefore, as correctly stated by Slade limitations that consent to intervention is sought by
and Grant-Kels [18], it would be appropriate only if the doctor [12]. However, few practitioners’ desire to
the aesthetician, PA or PE are employed in a cosmetic make profit might carry on unnecessary treatments
practice to receive only patients, who are first evaluated hiding important information.
by a physician and are referred to them for specific
treatment part of the medical plan of care. In addition, Aesthetic physicians, who want to be good
they recommended that aesthetic practitioners need to businesspersons, need to apply a business plan consisting
monitor the scope of practice, delegate appropriately, of their financial, marketing, and operational strategies
and manage patient expectations [18]. Secondly, and actions of their practice. It is a demanding, time-
aesthetic practitioners in order to maximize their profit consuming process to apply a business plan as it requires
they might try to minimize their costs by cheaper setting accountable, realistic and measurable objectives
unauthorized products for their treatments. that should be achieved in the future. These would be
even more difficult for a practitioner of no business
Recently, aesthetic physicians have achieved profit background. The purpose of advertising is to increase
maximization by allying with some major cosmetic the demand of services and products and building
companies [15]. However, as it was mentioned in brand loyalties to make their demand more inelastic.
the editorial note of Kassirer and Angell [3] “it is one This would allow practitioners to charge higher prices
thing to recommend health-related products based on for their services without considerable fault in their
careful scientific scrutiny; it is another to enter into an quantity demanded raising their total revenues and
exclusive marketing arrangement with a single company enhance their profits [22]. However, spending on
in which royalties are linked to sales”. In addition, some advertising is highly expensive to carry out and in many
physicians become a paid spokesperson at scientific and cases, it might be misleading to the consumers due to
professional meetings, for off-label cosmetic products false claims regarding the advertising product or service.
or aesthetic uses of products and procedures, without If aesthetic practitioners, for example, market their
any mention of the risks or actual approved indications services irresponsibly by making unjustifiable claims
in order to promote them [15]. Are these ethical about interventions, trivialising the risks involved, or
behaviours? The statement of American Academy using promotional tactics might encourage people to
of Dermatology’s on office dispensing, for example, make “ill-considered” decisions [12]. Ethical dilemmas
emphasises that “Dermatologists should not dispense related to the commercialization of medicine have
or supply drugs, remedies or appliances unless it is been a challenging matter in the western world [23].
manifestly in the best interest of their patients” [7]. White –coat endorsement is a marketing tool that
Often dermatologists do not only sell cosmetic products has been used in aesthetic medicine for promotion
in their practices, but in order to maximize their profits cosmetic products as Cantor said “Great products need
they have produced their own skincare products, no MD endorsement, the market will find them” [20].
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DISCUSSION subject would be supported by the following example.

The scope of dermatologic practice is broadening owing
Aesthetic medicine makes profit from the ideology to recent advances in cosmetic services; these services
of a society that serves only vanity, youthfulness and reduce the dermatologic workforce resources that can
personal success, and one which is losing sight of be devoted to medical dermatologic patients [27]. It is
the real values [24]. In fact, “a person having a non- not illegal or unethical when aesthetic practitioners, like
surgical cosmetic intervention has no more protection dermatologists, decide to restrict their everyday practice
and redress than someone buying a ballpoint pen or to only cosmetic or procedural dermatology [19].
a toothbrush”, as it was mentioned by Professor Sir However, what will it happen if most dermatologists
Bruce Keogh KBE [4]. The tricky question is “How have no available time to treat complex dermatological
do we approach this issue?” Actions should be taken conditions or follow up suspicion malignant skin
for enhancing patients’ safety. The first step in every lesions? Tsang and Resneck [28] stated in their article
solution and decision-making process is to identify and that even for patients willing to pay for face dermatology
define the problem [25]. In this situation, a worldwide appointment due to changing pigmented lesions, the
concern must be confronted. mean wait-time was 38 days (median, 26 days) in the
metropolitan areas in the United States. However,
An informed and empowered public is crucial to Meffert and Villegas mentioned that the waiting time
driving up the standards of aesthetic practice and the for a botulinum toxin injection appointment also varied
quality of care provided [14]. Today, it is believed that widely with geographic location (6–32.5 days) but had
the public is more informed through social media and a relatively short median wait of 8 days [19]. Therefore,
advertisements, but they are not better or correctly this argument raised an important issue that there is
informed. Therefore, aesthetic practitioners have an increase shift from classical medical dermatology
an obligation to educate their patients using up to to the more cash–driven cosmetic procedure and
date evidence that will favour patient’s best interest sometimes due to shortage of dermatologists in
reducing asymmetry information. certain areas several dermatological conditions remain
underdiagnosed
In addition, a certification system should be introduced
or a governmental body should be assigned to monitor In conclusion, I agree with the statement first
the quality and safety of products that are used by the mentioned by Cantor in one of her articles “Ethics
practitioners [12]. Dermal fillers, for example, are used requires doctors to be more than just salespeople
by healthcare and non-healthcare practitioners with no with an M.D” [20] I strongly believe that aesthetic
requirement for previous experience, training or even practitioners, especially physicians, must set their
basic knowledge of the product. For example, the scope priorities straight. If they decide to practice aesthetic
of the EU Medical Devices Directive, in the European medicine, they need to appreciate that they have the
Union, should be extended to include all cosmetic same moral obligations to the cosmetic patients as with
implants including dermal fillers, and legislation should any other patients. Cosmetic dermatologist should
be introduced to classify fillers as a prescription-only follow the good medical practice guidance as General
medical device [12]. All practitioners must be registered Medical Council in U.K. states: ‘Good doctors make
and the register should be independent of professional the care of their patients their first concern: (i) they are
groups or commercial bodies. Entry to the register, competent, keep their knowledge and skills up to date,
for example, should be subject to: (i) achievement of establish and maintain good relationships with patients
accredited qualification; (ii) premises meeting certain and colleagues, they are honest and trustworthy, and
requirements; (iii) adherence to a code of practice act with integrity and within the law’ [29]. If they
that covers handling complaints and redress, insurance continue to place their integrity and moral standards
requirements, responsible advertising practice and to the test, they will continue to be judged by their
consent practices; and (iii) continued demonstration colleagues, society [30].
of competence through an annual appraisal [26].
Finally, every aesthetic practitioner should remember
The initial question of this article was whether that pull of profit cannot be a primary motivation like
an aesthetic practitioner can be a physician and a in the case of businessperson. Instead, they should
businessperson at the same time. Both of their roles remember what Sir William Osler advised the ‘Students
are discussed above, but my own opinion regarding the of Medicine’ : “Seek your own interests, make of a high
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Copyright by Elena Thomaidou. This is an open-access article distributed
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under the terms of the Creative Commons Attribution License, which
cosmetic interventions: a public consultation on our draft guidance
permits unrestricted use, distribution, and reproduction in any medium,
2015. provided the original author and source are credited.
13. Rcsengacuk: Royal College of Surgeons, Rcsengacuk. 2016. Source of Support: Nil, Conflict of Interest: None declared.
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