Resident Corner

Q & A Recap with Dr. Jeremy Brauer

Our Next Steps readers had the opportunity to ask Dr. Jeremy Brauer questions on new technologies, emerging therapies, and the art of communicating complex medical procedure to patients. See all his insightful answers below.

I’m a recently graduated dermatology resident who just joined a private practice group where the majority of the procedures I perform are cosmetic. What is your advice for dealing with difficult patients who expect “miracles” or want a cosmetic procedure they don’t really need?

Congratulations on completing your residency and on your new position!  Your question is an important one, especially as the number of elective cosmetic procedures available to patients continues to expand.  The answer to this question begins with your consultation. As with all patients, an honest and thorough review of the risks, benefits, alternatives and expectations is imperative in establishing a good doctor-patient relationship.  Make sure to ask if they understand, and invite questions about everything you have discussed. Setting realistic expectations – and as you importantly mentioned identifying when they are not – will help make the decision of whether or not to proceed with treatment less of a challenge.  As physicians, “do no harm” should always significantly factor into this decision making process. Stay true to yourself, your expertise and to your patient. Explain to the patient why you believe their goals are unrealistic, or the procedure is not appropriate for them. While this may not always make your patient happy, it is far better to establish this upfront prior to treatment, rather than upon their return when they are likely to be dissatisfied with the results.

How do you handle patients who see no improvement after a cosmetic procedure?

The short answer is – photographs, photographs, photographs.  My staff will sometimes joke with me about my routine requests for pre-operative/treatment photographs, but I insist on them for nearly everything I do – surgical and cosmetic.  It is equally important to establish appropriate follow up times and assess whether or not it may be too soon to appreciate the full benefit of the procedure. If after comparison of the “before and afters” a difference can be appreciated and the patient still believes they do not see improvement, it’s time to explore what else might be behind this entrenched belief.  Always attempt to have an honest and open dialogue with your patients. Most will appreciate this honesty and your desire to assuage any concerns. Those that do not, may never be satisfied with the answer you provide (which is a whole other topic for discussion). Hopefully, as mentioned above, realistic expectations were discussed at the time of consultation, and the appropriate treatment was performed.  If so, this is a perfect place to start. What were the patient’s initial goals for the treatment? Have they changed since the treatment?

Could you please share if you have dealt with patients with conditions that are really beyond the scope of the non-invasive therapies being sought? What’s the best way of communicating this to patients?

I’m noticing a trend with these questions!  Yes, I have dealt with patients who have expressed a desire to achieve surgical results with non-invasive means.  While this may be an oversimplification (there are many invasive and non-invasive procedures and therapies to which this question can be applied), there are generally two types of patients that fit this description.  Those with realistic expectations, and who express a desire to do everything they can to improve their appearance short of having surgery and knowing that they are not likely to get the result they might with surgery, and others that expect to replicate surgical results with non-invasive procedures.

It comes back to the initial consultation, and having an honest and thorough discussion of what the procedures are intended and not intended to achieve.   If there is no benefit to be had, this must be stated outright, and your recommendation should be a surgical consultation. It is a good idea to develop, and readily have available,  a list of colleagues to whom you can refer these patients. How the patient responds to this will dictate your next steps. Some will appreciate your honesty and your expert advice and move on, others will believe you’ve wasted their time and move on after making a scene, and others will want to continue the conversation.  Be prepared for all scenarios. The last group is where the two types of patients I’ve mentioned above come in. The first patient will acknowledge and accept what you’ve shared, and subsequently modify their expectations to be more in line with the possible results of a non-invasive treatment, knowing that they will not pursue surgery.  If you feel you can provide them with meaningful benefit I think it’s reasonable to proceed (don’t forget the photos!). The second patient requires you to stand firm, and perhaps explain your reasoning in greater detail, outlining why you believe it would be a misappropriation of their time, money and efforts, and likely only leave them dissatisfied.  This may take you more time than you want to spend upfront, but it will save you far more time than if you hadn’t later on.

What are your guiding principles in discussing procedure-associated issues/adverse events with patients?

The most likely risks associated with procedures should always be reviewed at time of consultation, and if on a different day, at the time of treatment when obtaining informed consent, and where relevant, upon completion of the treatment prior to their departure.  As importantly, always understand and be prepared for the risks associated with the procedure, do everything possible to minimize them, and have a plan in place to address any that may arise. If you do find yourself dealing with an adverse event, continue to practice as you always have and should – honestly and with the patient’s best interests and one goal in mind – helping them get through it to the best of your abilities.

What do you think is one question dermatology residents should ask themselves before pursuing cosmetic and laser dermatology?

An important question, regardless of specialty or sub-specialty, is will this pursuit provide the personal and professional satisfaction you are hoping to achieve – what does “success” mean to you?  Additionally, residents should ask themselves, if upon graduation they prefer to “learn on the job” or pursue a fellowship allowing for a more supervised environment and opportunity to obtain and refine skills prior to treating your “own patients.”

With so many options in the market, dermatologists wanting to incorporate lasers into their practice are faced with a challenge. Can you share how you went about choosing lasers for your own practice and what you recommend we avoid?

This may be the most common question I am asked.  It’s best answered by sitting down and asking several questions of yourself.  First, what kind of practice do you currently have or want to have? What procedures/devices are you already comfortable with or do you want to learn and how to use?  Assess the demographics of your existing patient population to see which of the procedures you want to perform might make the most sense for their needs. If what you want to do is not suitable to your existing practice, then how likely is it for you to attract those new patients? What kind of budget and space are you working with? If both are limited, you may want to invest in more of a platform-type of device that allows add-ons as your practice grows. Conversely, if you want to start out as a “pre-eminent laser center”with the ability to offer a wide range of treatment options to your patients, then you may need to invest in multiple devices up front.   My suggestion is that if you are building a new laser practice, start with a laser or device that has a proven track record and that you feel will best suit your and your patients’ needs in the present as well as the future, not necessarily something that may have the latest buzz. Do your homework, evaluate the return on investment, and be aware of all associated costs including consumables and maintenance.

Looking back at this past year, which are the most promising emerging therapies in aesthetic dermatology that you can think of and why?

As the shift in aesthetic dermatology continues towards minimally and non-invasive, as well as combination procedures, I am excited by the growing interest in, and number of well designed studies exploring this area.

The number of available injectables – fillers and botulinum toxins – continues to increase, as do the ways in which we use them.  I anticipate greater use of fillers off of the face for volume correction/augmentation and improvement of contour, as well as use of botulinum toxin in varying quantities for treatment of acne, rosacea, skin texture and scarring – not to mention the availability of longer lasting products.  In late 2018, a non-filler non-botulinum toxin made big news in the treatment of cellulite, with Phase 3 study results demonstrating statistically significant improvement in the appearance of cellulite after treatment with collagenase clostridium histolyticum.  In the realm of regenerative medicine, I think we’ll see greater understanding and optimized utilization of platelet-rich plasma and adipose derived stem cells for an expanding list of potential indications (and while not an injectable, one can’t ignore the continued progress reported in three-dimensional printing of human skin).

Regarding lasers and energy devices, body contouring remains the IT thing, with lasers, cryolipolysis, radiofrequency, and ultrasound devices all currently commercially available to reduce fat, while a device utilizing HIFEM (high intensity focused electromagnetic) energy helps build muscle.

What are your thoughts on dermatologists practicing micrographic surgery without fellowship training? Is a fellowship truly necessary?

This practice exists throughout the country, and I am sure there are excellent surgeons that have not completed a fellowship providing excellent care.  As a disclosure, I am a fellowship trained Mohs micrographic surgeon, and this question is very timely, as the American Board of Medical Specialties recently approved the board certification examination for Mohs micrographic surgery.  While there is currently more than one pathway to sit for this eventual board, it is my understanding that at some point in the future only those that complete fellowship training will be able to take the exam and be “Board Certified.”  If having the additional training and credentials are not something you value personally and/or professionally, this will likely not factor into your decision to pursue a fellowship. However, with a constantly evolving medical landscape – including insurance, reimbursements, scope of practice, and an increasing number of non-physicians in the mix, I believe it will be more important than ever to find ways to maintain your ability to provide unparalleled, quality care while in the process make yourself and what you bring to the table stand out.

What’s the one book you think all dermatologists should read (no textbooks!) and why?

One book I think everyone – dermatologist or otherwise – should read is Ikigai, by Hector Garcia and Francesc Miralles.  The closest translation of this Japanese word in English is a sense of purpose or reason for being. It was a quick and enjoyable read that made me both appreciate and question how I have chosen to live my life, focus on family and develop my career.  I can definitely see myself reading it again in the future and gleaning additional life lessons from it.

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