I recently did a  live on Instagram with Clinical Psychologist Dr Toni Pikoos, in which we discussed the intersection of medical aesthetics and psychology as I have been reflecting on the type of patients who are less likely to have success with aesthetic treatments.

As a doctor, I cannot overestimate the importance of the initial consultation in assessing patient concerns, their understanding of what is possible as well as their expectations of how aesthetic treatments will help them, whether they are willing to stick to the suggested timeframe and budget for the best possible outcomes.

As such we simply will not engage with anyone who refuses to begin with an initial consultation or believes they can simply order a treatment as there is a chance they may be wrong, and feel they’ve wasted their time in attending the appointment.

Perhaps especially because non-surgical treatments are largely elective from a medical point of view, I believe that practitioners have an ethical responsibility to select patients carefully, including screening for certain red flags and having protocols in place before treatment even begins.

Related to this, it is imperative to look out for signs of body dysmorphic disorder (BDD) during the initial consultation and early stages of treatment as this is a contraindication to aesthetic treatment. The mental health of patients and the responsibility to protect the vulnerable ultimately lies with us so we have a duty of care to assess this before we inject or to press pause if we recognise it after starting if we can’t educate our patients. 

Social media contributes to the disconnect between what is physically possible and what is best left to photoshop and filters, and marketing by big companies further encourages this by disguising medical treatments as just beauty - “lunchtime procedures” etc only serves to perpetuate this myth, so at Skin Essentials we go to some lengths to screen all new patients for potential red flags, but read on to see why this is harder than it seems.

3 key examples we encounter regularly enough:

1. Unrealistic expectations

Often as early as during the consultation, but more commonly during the early treatment stages, it may begin to become apparent that the patient has expectations of aesthetic treatments that are unrealistic -

• for example, they may expect to be frozen with anti wrinkle treatments and to stay that way for the whole 3 months.
• or they may expect that 1ml of filler will replace typical volume loss in a 40 year old face, which might need on average, 4-6mls.
• others may come in with stories of having had treatment elsewhere with impossibly low doses which lasted unreasonably long periods of time. 

At this stage, if it becomes apparent, I try and explore this expectation with them, how likely it is, and whether I can reasonably help them, including suggesting I may not be the right person for them if I am unlikely to be able to meet their expectations with respect to price, dose (and related to this, cost) or timeframe. 

2. Budget vs true cost mismatch

By the time we see people at Skin Essentials, most people have been dissatisfied with the ageing process for some time, usually months to years, and are keen to begin to do something about it. Unfortunately due to social media, as well as well meaning friends and a general sense of secrecy around the true cost of aesthetic treatments  they may severely underestimate the cost in terms of timeframe, frequency of treatments initially and the budget realistically needed to effect significant change in the areas that trouble them, which are usually also multi-factorial:

• skin
• lines, wrinkles and sundamage
• volume loss with hollowing of the face and sagging around the lower face 
• sun damage 
• pigmentation 
• redness/sensitivity etc 

There is no one treatment that will treat all these various concerns; treatment options are usually best combined, and undertaken over multiple sessions over months to begin to see changes. For this reason, I commonly tell patients it is like orthodontic treatment - if it’s going to cost $10,000 and they only have a budget of $2500, they may be better off not beginning as they won’t achieve desired results.

Equally, it is better to start and keep going than to wait because the ageing process will not. 

3. Requesting to look like celebrities

Rarely, patients will present with pictures of celebrities they wish to look like eg JLo, one of the Kardashians or specific attributes - big juicy lips, a non surgical butt lift for example - and it is then up to the practitioner to explain why it may not be a reasonable goal even if they have the money for it, due to limitations of anatomy. 

So when this occurs, how do we deal with it at Skin Essentials? 

1. Consultation 

The fact is, there is never such a thing as “just some anti wrinkle treatment for X or Y” or “just some lip filler”.

It does not matter how simple the prospective patient thinks the issue is, as a medical practitioner it is my responsibility and duty of care to assess each person, including a detailed medical history, assessment if appropriate and their expectations before we proceed to treatment, if it is appropriate to do so. We don’t do treatments made to order. 

At Skin Essentials, you are emailed an intake form as soon as you have booked an appointment and it is in your best interests to fill this out as soon as feasible so we have a clear idea of your concerns as well as what is likely to be the problem. In truth, the consultation begins well before you walk through the door and we have a fairly good idea of what we will see and suggest when we finally meet you. 

2. Education 

We aim to maximise our time in clinic addressing your concerns, educating you on what they mean, and what, if any, the options to help improve them are; additionally, we discuss timeframe to achieve results, frequency of treatments initially and longterm as well as how much you will need to budget initially and ongoing if you decide to proceed. 

There is absolutely no pressure to proceed with any treatment on the day unless you feel ready to. Additionally you will get a written treatment plan outlining short, medium and longterm goals and costs if you decide to commit, and what we expect of you in addition to our clinic promise to you. 

3. Consent 

Consent, both verbal, for the treatment as well as financial, is paramount so as to avoid any unexpected surprises. Consent forms for treatments are emailed to you for your perusal as soon as you book an appointment and treatment so you have plenty of time to read the potential side effects, risks and options, which include not proceeding with suggested treatment at all, and seeking a second opinion. We strongly encourage, and expect that you will read the risks and before and aftercare before signing, and not simply trust that all will go to plan. 

Equally important is the financial consent, and an outline of expected costs. We expect that in a competitive field such as aesthetics, people will talk and possibly compare costs, and someone may experience  buyer’s remorse after beginning treatment because they find out someone else got treatment for less elsewhere so it’s important to us that you are aware of our prices before beginning and that it’s based on Dr Joshi’s experience and skillset over 22 years of being a medical practitioner and surgical trainee, which is not comparable to a junior doctor or a nurse in chain clinics. Ultimately, if your needs are price sensitive, we will absolutely not be offended if you go elsewhere and encourage you to do so. 

4. Photographs 

Photographs of our patients are non negotiable for clinical record keeping. While we absolutely respect your right not to allow us to share photos with others or on social media to show others what is possible, aesthetics is a visual industry and it is not unheard of that as we begin treatments, we forget what we used to look like, and may feel that we are not getting our money’s worth. For this reason, we take baseline photos as well as photographs at key points of treatments so we can both monitor your progress over time, especially as medical aesthetics done well, is very very subtle. 

At Skin Essentials, we won’t treat anyone who refuses to allow photos for clinical records. 

5. Refusal to treat 

Finally, while this does not happen often, if, during our initial consultation or in the early stages of treatment, it becomes apparent to us that we are not the best clinic to help address your concerns, then it is our duty of care to communicate this with you and discharge you from our care. If this happens, we will email records of treatment to date including dates and doses as well as photos we have for you on file for you to take to your next practitioner. 

Sometimes it may be because despite careful discussion including projected volumes and units needed

• a patient feels dissatisfied with the rate of progress or feel they aren’t getting enough “bang for their buck” compared to their friend or sister;
• other times it may be that once motivation to budget wears off, they realise they won’t be able to source the money.
• less commonly, we have seen patients for whom we are the 5th or 6th practitioner and they’ve been unhappy with all the previous clinics;
• or rarely, we see someone who,  having had nothing done for decades, are no longer a candidate for non surgical treatments but would benefit most from surgery. 

In these cases, it would be unethical to (continue to) treat them so I usually refuse and explain why. I may suggest they find one practitioner they are happy with and stick to them as it’s in their best interest.

In these cases, agreeing to continuing treatment in my opinion, would risk more harm than good and is not in keeping with good medical care.