The culture of entering aesthetic dermatology amongst freshers

INTRODUCTION

About 20 years ago, the path of practicing dermatology was straightforward and simple. After residency, one would join a college as a senior resident, then join a senior dermatologist to learn the nuances of private practice before venturing out into the world. The tools of aesthetics were few and so were the patients. Chemical peels and microdermabrasion were the options available, which neither needed a large investment nor special training.

Since the advent of lasers, energy-based devices, and injectable treatments, the scenario has changed drastically. Though the influence of social media has increased awareness, it has also increased the pressure on the patients to look good, as well as the pressure on the dermatologists to make their patients look good.

As a result, we have seen a recent trend among young dermatologists of shunning clinical dermatology altogether and starting a private practice primarily focused on aesthetics. A practice made primarily of clinical dermatology cannot garner the glamour and money of a cosmetic dermatology practice. Aesthetics have become a part and parcel of dermatology practice, and the patients also expect dermatologists to be well versed with aesthetic procedures and device-based treatments.

PRESENT SCENARIO

Some freshers start with aesthetics as they do not find clinical dermatology engaging and rewarding, because most dermatology conditions are chronic and patients do not get cured, robbing a young dermatologist of the satisfaction of curing the patient that, for example, a surgeon can derive.

Some start with aesthetics as they are not fully confident of their clinical acumen, as some residency programs do not provide enough all-around clinical exposure.

Some have financial needs which force them to join aesthetic centers where the dermatologists are only a cog in the wheel. A number of such centers are driven by investors and businessmen who are less bothered with the standard operating procedures and best medical practices, and rather the focus is solely on the financial top-line and bottom line.

Unfortunately, in our country, there are no laws as to who can and who cannot practice aesthetics. The competition is already huge because dermatologists are not the only doctors practicing aesthetic dermatology. We have to compete with plastic surgeons, dentists, gynecologists, ENT surgeons, and sometimes unqualified quacks too.

For any postgraduate student, the training starts at the time of residency. The structured syllabus does not include much aesthetics. Unlike some other branches like plastic or reconstructive surgery, a dermatology resident must rely on conferences and workshops for learning aesthetics, where hands-on experience is minimal to nil. They need to have self-learned experiences after their postgraduation, which can have many pitfalls. While residency can prepare a fresher with patience and empathy for a clinical dermatology patient, it can never prepare for an unreasonable and tough-to-satisfy patient that comes with aesthetic dermatology. That can be learned only with time and experience. So, someone who starts with aesthetics as a fresher will find it difficult to handle such situations.

There is a basic rule of a well-rounded dermatology practice: clinical dermatology feeds aesthetic dermatology. If one practices only aesthetics, it may take longer to break even and get a steady footfall of patients. A fresher should advertise himself as a dermatologist first. A patient who trusts his dermatologist can eventually be converted into a candidate for aesthetic dermatology.

As patients expect a pure aesthetics clinic to look fancy with artwork, plush interiors, and at a high street location, in order to invite more footfall, one has to invest heavily into the location of the space and interiors, which puts additional stress on an aesthetic dermatologist.

There are some positives to a purely aesthetic practice as well. While most dermatology diseases are chronic and relapsing, aesthetic procedures often have quick and gratifying results. A patient with a chronic disease will most likely indulge in jumping from one doctor to another out of frustration. With just one satisfactory outcome of aesthetic treatment, some patients become ‘bhakts’ for life and would trust only you when it comes to an aesthetic procedure. The downside of a hurried aesthetic establishment is improper training and skill because it may lead to suboptimal results and the patient will leave you to look for another aesthetic doctor.

As there are many new doctors entering the field of aesthetics with each passing day, and the competition for survival is increasing, time is a commodity that has to be respected. In a practice that concentrates on aesthetic dermatology, the focus group is small. Hence, there is enough time to excel and innovate in this field. This is something that might not be possible if one does a mixed aesthetic and clinical practice. Making this choice early in the career saves time in trying hands in different subspecialties. It is not necessary to start big and with a huge investment, but some forms of aesthetic procedures like chemical peels, microneedling pens, dermabrasion, etc. can be started early. Before making a substantial investment in aesthetic dermatology, it is important to gauge the potential market and the number of suitable patients one has. The machinery needed for an aesthetic practice is a big investment even if only basic devices and procedures are selected initially. Aesthetic procedures demand time and patience, and the economic return of this investment can be slow. The investment should not cloud a fresher’s judgment as it can lead to overcharging and suggesting unnecessary procedures. While we have a responsibility for what is best for our patients, we also have a responsibility for what is best for our practice. A fresher has to learn to never indulge a patient who has unrealistic expectations. One should be very transparent about what a procedure has to offer and its limitations of the procedure. Always give an estimated range of the improvement and change that can be achieved. Make sure the patient fully understands the procedure and has realistic expectations of it. Transparency and patience are what create harmony between a doctor and the patient.

While energy-based devices demand investment, procedures like botulinum toxin injections, hyaluronic acid fillers, threads, etc. are charged as per the retail price of the product plus the procedure charges. Now, this is something that does not need a specialized setup and machinery, but it does need a fair amount of practice to perfect. The lure of easy money without investment and profit should not cloud one’s judgment to oversell and overuse. Another issue that has arisen in the race of learning aesthetic procedures is freshers joining aesthetic clinics and trainers that are not qualified but are providing training in such procedures. The existence of such establishments is in bounty but not legitimate.

EPILOGUE

The choice of either switching over to or practicing aesthetic dermatology gradually can be made when the time, circumstance, and confidence are right. It is a decision that should be made according to one’s interests, economical situation, and risk-taking capabilities. If this is done under the influence of what others are doing or how much money the peers are making, not only will it cause a burnout soon, but it can also be unsatisfactory for the doctor as well as the patients. Even if the choice is made to follow aesthetic dermatology, one should keep in touch with the updates of clinical dermatology and keep on brushing up the knowledge by attending Continuing Medical Education and seminars. Yes, it is true that in today’s day, clinical dermatology-based practice is not enough to flourish. Start slow with aesthetic practice, but start from day one and build from there. Rather than jumping into the rat race of minting money, build a holistic practice that caters to all kinds of patients. We should listen to and know how to solve the clinical queries of an aesthetic patient as well. This will help to find gratification in practice and help win the trust of the patient. Divide and fix the number of slots as per interest between aesthetic, clinical consultations, dermatosurgery, lasers, and aesthetic procedures. Keep 2-3 emergency slots vacant to accommodate dermatology emergencies. The timely help of the people in need from the community will build a strong doctor-patient relationship.

Grow organically instead of being in a hurry to achieve all the goals in a short duration. Do not compromise your self-esteem by stooping down and becoming a “dermatology service provider.” Give yourself time to innovate, not just follow what is going around. Be respectful and earn the respect of your colleagues.