Commentary

We can learn a lot from a car rentals. Like medicine, they are a service industry. And all service industries have the same problem: Service is delivered in real time, and the quality of that service depends on variables that may or may not be in the company’s control.

Even so, one bad experience can result in termination of a life-long customer, or in our case, patient. Worse, the patient can now go online and write a scathing review, criticizing everything from your bedside manner to the artwork in your waiting room.

What can you do when a visit goes wrong? Employ service-recovery techniques. Service recovery is the act of trying to resuscitate an encounter once things have gone badly. It happens to physicians and to restaurants and to car rentals.

While on vacation with my wife in Salt Lake City, we rented a car from a company (let’s call them “Discount Cars”). We don’t usually book with them; however, we got double airline points for choosing them, so we bit.

At the airport rental terminal, we waited for 15 minutes before being helped. When we reached the counter, we were told that our reserved car was not ready yet. (I immediately thought of the Seinfeld episode when Jerry says: “So you can take a reservation, but you can’t keep a reservation?!”) We were advised that our car was being washed and would be ready in 15 minutes “tops.” Thirty minutes later, my miffed wife pushed through the line to the counter. “It’s still being washed,” she was told. So she asked for another car and was offered a full-size pickup truck. My wife, who drives a teeny Honda Fit at home, said no thanks. Another 30 minutes passed and my incensed wife returned to the counter. “It’s been over an hour! This is unacceptable!” A different representative replied it was our fault for declining the pickup truck. There would be more cars soon, so they promised.

We were too far to walk to any airport bars, and the situation was rapidly deteriorating. I decided to take action. I fired up Twitter and let her rip:

“Closing in on 1 hr for a car promised in 15 min. Which we reserved ahead. This isn’t the first time, @DiscountCars #operations #fail.”

Within minutes, they replied by Twitter:

Them: @Dermdoc We are so sorry for the wait! What location are you at?

My wife, along with five other equally incensed wives, continued to wait for a response (and a car) from the live representatives at the counter.

Nearly 1 hour and 20 minutes later, we got a car. It was much larger than we wanted, but we were done waiting. After signing the papers, we got inside – it reeked of smoke. Oh, this is no bueno, I thought. We requested a different car. Twenty more minutes passed before our smoke-free vehicle arrived. The gas tank was 7/8’s full. And the carpets were littered with twigs and leaves.

Now I’m thinking, this is so bad, I should write an article about it. From the front seat of our faulty but moving vehicle, I fired again: “Dear @DiscountCars we waited 1+ hrs. Not the car we wanted. Then tank not full. Yet, not a single apology from anyone. Really?”

Them: @Dermdoc, we are sorry.

Them: @Dermdoc Please e-mail us the details and your RA# to [email protected] so we can look into this for you!

Me: @Discount Thank you! Will do.

I sent a list of grievances to the e-mail as they requested. Within an hour they offered us a $50 credit on a future rental.

What’s remarkable about this story is that not a single live person was able to assuage us, but their digital team managed to apologize and save us as customers. There might have been legitimate reasons for their service failure, but it didn’t matter. What mattered was that they responded to me personally, apologized, and made amends. This is an important lesson for us physicians. Patients will expect that your digital channels are legitimate ways to express their level of satisfaction with your practice. The stakes are higher for us in health care in particular because of the risks of violating patients’ privacy. However, as you can see from the rental car example, it can effectively be done without revealing any information about the customer or the experience. The goal is to recover the service publicly and take all of the information offline and manage it in a secure, private fashion.

The formula is simple: Believe the customer. Listen. Apologize for not satisfying the customer. Even if you’ve done nothing wrong, you have in some way failed to satisfy the customer’s needs. Ask for more information in a secure, private manner, never on a public platform. Do what you can reasonably do to remedy the problem and remediate the situation.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.

We can learn a lot from a car rentals. Like medicine, they are a service industry. And all service industries have the same problem: Service is delivered in real time, and the quality of that service depends on variables that may or may not be in the company’s control.

Even so, one bad experience can result in termination of a life-long customer, or in our case, patient. Worse, the patient can now go online and write a scathing review, criticizing everything from your bedside manner to the artwork in your waiting room.

What can you do when a visit goes wrong? Employ service-recovery techniques. Service recovery is the act of trying to resuscitate an encounter once things have gone badly. It happens to physicians and to restaurants and to car rentals.

While on vacation with my wife in Salt Lake City, we rented a car from a company (let’s call them “Discount Cars”). We don’t usually book with them; however, we got double airline points for choosing them, so we bit.

At the airport rental terminal, we waited for 15 minutes before being helped. When we reached the counter, we were told that our reserved car was not ready yet. (I immediately thought of the Seinfeld episode when Jerry says: “So you can take a reservation, but you can’t keep a reservation?!”) We were advised that our car was being washed and would be ready in 15 minutes “tops.” Thirty minutes later, my miffed wife pushed through the line to the counter. “It’s still being washed,” she was told. So she asked for another car and was offered a full-size pickup truck. My wife, who drives a teeny Honda Fit at home, said no thanks. Another 30 minutes passed and my incensed wife returned to the counter. “It’s been over an hour! This is unacceptable!” A different representative replied it was our fault for declining the pickup truck. There would be more cars soon, so they promised.

We were too far to walk to any airport bars, and the situation was rapidly deteriorating. I decided to take action. I fired up Twitter and let her rip:

“Closing in on 1 hr for a car promised in 15 min. Which we reserved ahead. This isn’t the first time, @DiscountCars #operations #fail.”

Within minutes, they replied by Twitter:

Them: @Dermdoc We are so sorry for the wait! What location are you at?

My wife, along with five other equally incensed wives, continued to wait for a response (and a car) from the live representatives at the counter.

Nearly 1 hour and 20 minutes later, we got a car. It was much larger than we wanted, but we were done waiting. After signing the papers, we got inside – it reeked of smoke. Oh, this is no bueno, I thought. We requested a different car. Twenty more minutes passed before our smoke-free vehicle arrived. The gas tank was 7/8’s full. And the carpets were littered with twigs and leaves.

Now I’m thinking, this is so bad, I should write an article about it. From the front seat of our faulty but moving vehicle, I fired again: “Dear @DiscountCars we waited 1+ hrs. Not the car we wanted. Then tank not full. Yet, not a single apology from anyone. Really?”

Them: @Dermdoc, we are sorry.

Them: @Dermdoc Please e-mail us the details and your RA# to [email protected] so we can look into this for you!

Me: @Discount Thank you! Will do.

I sent a list of grievances to the e-mail as they requested. Within an hour they offered us a $50 credit on a future rental.

What’s remarkable about this story is that not a single live person was able to assuage us, but their digital team managed to apologize and save us as customers. There might have been legitimate reasons for their service failure, but it didn’t matter. What mattered was that they responded to me personally, apologized, and made amends. This is an important lesson for us physicians. Patients will expect that your digital channels are legitimate ways to express their level of satisfaction with your practice. The stakes are higher for us in health care in particular because of the risks of violating patients’ privacy. However, as you can see from the rental car example, it can effectively be done without revealing any information about the customer or the experience. The goal is to recover the service publicly and take all of the information offline and manage it in a secure, private fashion.

The formula is simple: Believe the customer. Listen. Apologize for not satisfying the customer. Even if you’ve done nothing wrong, you have in some way failed to satisfy the customer’s needs. Ask for more information in a secure, private manner, never on a public platform. Do what you can reasonably do to remedy the problem and remediate the situation.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.

We can learn a lot from a car rentals. Like medicine, they are a service industry. And all service industries have the same problem: Service is delivered in real time, and the quality of that service depends on variables that may or may not be in the company’s control.

Even so, one bad experience can result in termination of a life-long customer, or in our case, patient. Worse, the patient can now go online and write a scathing review, criticizing everything from your bedside manner to the artwork in your waiting room.

What can you do when a visit goes wrong? Employ service-recovery techniques. Service recovery is the act of trying to resuscitate an encounter once things have gone badly. It happens to physicians and to restaurants and to car rentals.

While on vacation with my wife in Salt Lake City, we rented a car from a company (let’s call them “Discount Cars”). We don’t usually book with them; however, we got double airline points for choosing them, so we bit.

At the airport rental terminal, we waited for 15 minutes before being helped. When we reached the counter, we were told that our reserved car was not ready yet. (I immediately thought of the Seinfeld episode when Jerry says: “So you can take a reservation, but you can’t keep a reservation?!”) We were advised that our car was being washed and would be ready in 15 minutes “tops.” Thirty minutes later, my miffed wife pushed through the line to the counter. “It’s still being washed,” she was told. So she asked for another car and was offered a full-size pickup truck. My wife, who drives a teeny Honda Fit at home, said no thanks. Another 30 minutes passed and my incensed wife returned to the counter. “It’s been over an hour! This is unacceptable!” A different representative replied it was our fault for declining the pickup truck. There would be more cars soon, so they promised.

We were too far to walk to any airport bars, and the situation was rapidly deteriorating. I decided to take action. I fired up Twitter and let her rip:

“Closing in on 1 hr for a car promised in 15 min. Which we reserved ahead. This isn’t the first time, @DiscountCars #operations #fail.”

Within minutes, they replied by Twitter:

Them: @Dermdoc We are so sorry for the wait! What location are you at?

My wife, along with five other equally incensed wives, continued to wait for a response (and a car) from the live representatives at the counter.

Nearly 1 hour and 20 minutes later, we got a car. It was much larger than we wanted, but we were done waiting. After signing the papers, we got inside – it reeked of smoke. Oh, this is no bueno, I thought. We requested a different car. Twenty more minutes passed before our smoke-free vehicle arrived. The gas tank was 7/8’s full. And the carpets were littered with twigs and leaves.

Now I’m thinking, this is so bad, I should write an article about it. From the front seat of our faulty but moving vehicle, I fired again: “Dear @DiscountCars we waited 1+ hrs. Not the car we wanted. Then tank not full. Yet, not a single apology from anyone. Really?”

Them: @Dermdoc, we are sorry.

Them: @Dermdoc Please e-mail us the details and your RA# to [email protected] so we can look into this for you!

Me: @Discount Thank you! Will do.

I sent a list of grievances to the e-mail as they requested. Within an hour they offered us a $50 credit on a future rental.

What’s remarkable about this story is that not a single live person was able to assuage us, but their digital team managed to apologize and save us as customers. There might have been legitimate reasons for their service failure, but it didn’t matter. What mattered was that they responded to me personally, apologized, and made amends. This is an important lesson for us physicians. Patients will expect that your digital channels are legitimate ways to express their level of satisfaction with your practice. The stakes are higher for us in health care in particular because of the risks of violating patients’ privacy. However, as you can see from the rental car example, it can effectively be done without revealing any information about the customer or the experience. The goal is to recover the service publicly and take all of the information offline and manage it in a secure, private fashion.

The formula is simple: Believe the customer. Listen. Apologize for not satisfying the customer. Even if you’ve done nothing wrong, you have in some way failed to satisfy the customer’s needs. Ask for more information in a secure, private manner, never on a public platform. Do what you can reasonably do to remedy the problem and remediate the situation.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.

 Do you remember the discussion of the ethical dilemma of Huntington’s disease you probably participated in during medical school? The question was whether you would want to know that you were at risk for a chronic debilitating condition that would develop at some later age if there was nothing that could be done about it. In that discussion, you also may have heard about individuals who, after hearing about their risk status, become depressed or suicidal, depending on the story line.

Some pediatricians seem to have taken this example too far in arguing that there is no point in screening for issues of development, autism, maternal depression, or child mental health because “there are no services” available to treat them.

Despair is understandable. Physicians’ lack of knowledge about resources in the community is often a sore point among local agencies, parents, and even pediatricians themselves. In spite of United Way, state 3-1-1 programs ,and the occasionally available social worker, the resources with which we are familiar sometimes come from hard-working parents telling us about a program they found on their own. It also seems that, just when we hit upon a valuable resource, it runs out of funding, changes eligibility requirements, or loses key staff. Worse yet, we may rely on resources we know about because of our own children’s problems, activities, or friends. While the Internet is an increasingly valuable method of finding resources, there is no filter of the evidence-basis of the care provided, and the process of searching, vetting, and informing your patients is extremely time consuming, and often the patient is not eligible or has a long waiting period after all that.

There are important reasons not to succumb to throwing up one’s hands about service availability. And more important reasons to still screen even if you do not know where to refer.

Screening using validated tools is recommended by the American Academy of Pediatrics because parent concern and even clinical observation are not adequately sensitive to detect significant problems of development and mental health, even when done by experienced physicians who know families well. The process of screening sends an important message to the parents – that you care about the child’s progress and are using proven methods to ensure that it is going well and consider it part of complete medical care.

And families often already think that their child may have a problem, even when they don’t bring it up. Perhaps deep down they are afraid that somehow raising the question of autism will make it true. They may be in denial, are feeling guilty, or are under pressure from their spouse, relatives, or friends not to worry, that “he will grow out” of it, that better discipline will fix the problem, etc. They may even care so much about your positive regard that they do not want to seem overly anxious, obsessive, or be regarded as a failure for having a “defective” child. They, like you, also may be in despair about finding effective help.

But there can be serious consequences to not screening, even when you are not sure what you will do with the results. The family may push the child with delays or mental health problems beyond his abilities, and even become negative and punitive in trying to make him succeed, in the process promoting unnecessary behavior problems, discouragement, and even defiance in the child. Failure to detect also means failure to list the child on a registry for follow-up to determine progress or refer when resources become available. Some problems of development or mental health that are detected by screening may have medical causes that you can treat, even though counseling or therapy interventions are not available. Examples include hearing or vision deficits causing delays or anemia, sleep apnea, or hypothyroidism or maternal depression or attention-deficit/hyperactivity disorder (ADHD). For issues with a genetic basis, siblings may be born with same problem during the period of delay in making a diagnosis, a prime example being Fragile X. In untold cases, the family loses trust in you and in the medical system for not acknowledging a problem.

In many cases, your acknowledgment, explanation, sympathy, and advice can help enormously. Families can cope better, garner support from family or friends, deal with the child’s behavior better, and find steps to take to help their child in their own ways, even without formal services, once told that their child has a specific problem.

On a system level, it is important to realize that how services are established and maintained is far less rational than might be imagined. State programs, schools, hospitals, and insurers all have legal requirements to provide services within a certain time frame once referred. Even if the services are not there to help a your child or family right now, the referral itself adds to the data used to determine if services are adequate and to plan for additional service types or capacity. The Autism Waiver is one such example where waits are years long, but getting on the list is crucial to the future of the program.

Until you screen and give parents information – especially middle-class parents – we will never have the resources. As it was for lead paint, until we identified prevalence of elevated lead levels and the harm associated, we got no action on lead paint removal policies. Another example where complaints about access made a difference, is the relatively new Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 that requires health insurers and health plans to guarantee that financial requirements on benefits for mental health, such as copays, deductibles, and limitations on treatment benefits, are not more restrictive than those that are for medical benefits. This does not guarantee that services will be available or of high quality, but is a step toward accessibility.

You may be one of the many pediatricians who consider advocacy a basic component of your professional responsibilities. If you cannot advocate for services that you see your patients in need of, you can pass your concerns onto a group that does. Many American Academy of Pediatrics state chapters have so-called Pediatric Councils that receive ideas about system problems and put group pressure on leaders in the state to address them.

As in the historic painting of the physician leaning over the ill child whom he could not cure, after detection through screening our thoughtful evaluation, explanations, shared concern, and our patients’ advocacy have great value even when specific services are not yet available.

Dr. Howard is an assistant professor of pediatrics at the Johns Hopkins University, Baltimore, and creator of CHADIS (www.chadis.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. E-mail her at [email protected].

 Do you remember the discussion of the ethical dilemma of Huntington’s disease you probably participated in during medical school? The question was whether you would want to know that you were at risk for a chronic debilitating condition that would develop at some later age if there was nothing that could be done about it. In that discussion, you also may have heard about individuals who, after hearing about their risk status, become depressed or suicidal, depending on the story line.

Some pediatricians seem to have taken this example too far in arguing that there is no point in screening for issues of development, autism, maternal depression, or child mental health because “there are no services” available to treat them.

Despair is understandable. Physicians’ lack of knowledge about resources in the community is often a sore point among local agencies, parents, and even pediatricians themselves. In spite of United Way, state 3-1-1 programs ,and the occasionally available social worker, the resources with which we are familiar sometimes come from hard-working parents telling us about a program they found on their own. It also seems that, just when we hit upon a valuable resource, it runs out of funding, changes eligibility requirements, or loses key staff. Worse yet, we may rely on resources we know about because of our own children’s problems, activities, or friends. While the Internet is an increasingly valuable method of finding resources, there is no filter of the evidence-basis of the care provided, and the process of searching, vetting, and informing your patients is extremely time consuming, and often the patient is not eligible or has a long waiting period after all that.

There are important reasons not to succumb to throwing up one’s hands about service availability. And more important reasons to still screen even if you do not know where to refer.

Screening using validated tools is recommended by the American Academy of Pediatrics because parent concern and even clinical observation are not adequately sensitive to detect significant problems of development and mental health, even when done by experienced physicians who know families well. The process of screening sends an important message to the parents – that you care about the child’s progress and are using proven methods to ensure that it is going well and consider it part of complete medical care.

And families often already think that their child may have a problem, even when they don’t bring it up. Perhaps deep down they are afraid that somehow raising the question of autism will make it true. They may be in denial, are feeling guilty, or are under pressure from their spouse, relatives, or friends not to worry, that “he will grow out” of it, that better discipline will fix the problem, etc. They may even care so much about your positive regard that they do not want to seem overly anxious, obsessive, or be regarded as a failure for having a “defective” child. They, like you, also may be in despair about finding effective help.

But there can be serious consequences to not screening, even when you are not sure what you will do with the results. The family may push the child with delays or mental health problems beyond his abilities, and even become negative and punitive in trying to make him succeed, in the process promoting unnecessary behavior problems, discouragement, and even defiance in the child. Failure to detect also means failure to list the child on a registry for follow-up to determine progress or refer when resources become available. Some problems of development or mental health that are detected by screening may have medical causes that you can treat, even though counseling or therapy interventions are not available. Examples include hearing or vision deficits causing delays or anemia, sleep apnea, or hypothyroidism or maternal depression or attention-deficit/hyperactivity disorder (ADHD). For issues with a genetic basis, siblings may be born with same problem during the period of delay in making a diagnosis, a prime example being Fragile X. In untold cases, the family loses trust in you and in the medical system for not acknowledging a problem.

In many cases, your acknowledgment, explanation, sympathy, and advice can help enormously. Families can cope better, garner support from family or friends, deal with the child’s behavior better, and find steps to take to help their child in their own ways, even without formal services, once told that their child has a specific problem.

On a system level, it is important to realize that how services are established and maintained is far less rational than might be imagined. State programs, schools, hospitals, and insurers all have legal requirements to provide services within a certain time frame once referred. Even if the services are not there to help a your child or family right now, the referral itself adds to the data used to determine if services are adequate and to plan for additional service types or capacity. The Autism Waiver is one such example where waits are years long, but getting on the list is crucial to the future of the program.

Until you screen and give parents information – especially middle-class parents – we will never have the resources. As it was for lead paint, until we identified prevalence of elevated lead levels and the harm associated, we got no action on lead paint removal policies. Another example where complaints about access made a difference, is the relatively new Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 that requires health insurers and health plans to guarantee that financial requirements on benefits for mental health, such as copays, deductibles, and limitations on treatment benefits, are not more restrictive than those that are for medical benefits. This does not guarantee that services will be available or of high quality, but is a step toward accessibility.

You may be one of the many pediatricians who consider advocacy a basic component of your professional responsibilities. If you cannot advocate for services that you see your patients in need of, you can pass your concerns onto a group that does. Many American Academy of Pediatrics state chapters have so-called Pediatric Councils that receive ideas about system problems and put group pressure on leaders in the state to address them.

As in the historic painting of the physician leaning over the ill child whom he could not cure, after detection through screening our thoughtful evaluation, explanations, shared concern, and our patients’ advocacy have great value even when specific services are not yet available.

Dr. Howard is an assistant professor of pediatrics at the Johns Hopkins University, Baltimore, and creator of CHADIS (www.chadis.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. E-mail her at [email protected].

 Do you remember the discussion of the ethical dilemma of Huntington’s disease you probably participated in during medical school? The question was whether you would want to know that you were at risk for a chronic debilitating condition that would develop at some later age if there was nothing that could be done about it. In that discussion, you also may have heard about individuals who, after hearing about their risk status, become depressed or suicidal, depending on the story line.

Some pediatricians seem to have taken this example too far in arguing that there is no point in screening for issues of development, autism, maternal depression, or child mental health because “there are no services” available to treat them.

Despair is understandable. Physicians’ lack of knowledge about resources in the community is often a sore point among local agencies, parents, and even pediatricians themselves. In spite of United Way, state 3-1-1 programs ,and the occasionally available social worker, the resources with which we are familiar sometimes come from hard-working parents telling us about a program they found on their own. It also seems that, just when we hit upon a valuable resource, it runs out of funding, changes eligibility requirements, or loses key staff. Worse yet, we may rely on resources we know about because of our own children’s problems, activities, or friends. While the Internet is an increasingly valuable method of finding resources, there is no filter of the evidence-basis of the care provided, and the process of searching, vetting, and informing your patients is extremely time consuming, and often the patient is not eligible or has a long waiting period after all that.

There are important reasons not to succumb to throwing up one’s hands about service availability. And more important reasons to still screen even if you do not know where to refer.

Screening using validated tools is recommended by the American Academy of Pediatrics because parent concern and even clinical observation are not adequately sensitive to detect significant problems of development and mental health, even when done by experienced physicians who know families well. The process of screening sends an important message to the parents – that you care about the child’s progress and are using proven methods to ensure that it is going well and consider it part of complete medical care.

And families often already think that their child may have a problem, even when they don’t bring it up. Perhaps deep down they are afraid that somehow raising the question of autism will make it true. They may be in denial, are feeling guilty, or are under pressure from their spouse, relatives, or friends not to worry, that “he will grow out” of it, that better discipline will fix the problem, etc. They may even care so much about your positive regard that they do not want to seem overly anxious, obsessive, or be regarded as a failure for having a “defective” child. They, like you, also may be in despair about finding effective help.

But there can be serious consequences to not screening, even when you are not sure what you will do with the results. The family may push the child with delays or mental health problems beyond his abilities, and even become negative and punitive in trying to make him succeed, in the process promoting unnecessary behavior problems, discouragement, and even defiance in the child. Failure to detect also means failure to list the child on a registry for follow-up to determine progress or refer when resources become available. Some problems of development or mental health that are detected by screening may have medical causes that you can treat, even though counseling or therapy interventions are not available. Examples include hearing or vision deficits causing delays or anemia, sleep apnea, or hypothyroidism or maternal depression or attention-deficit/hyperactivity disorder (ADHD). For issues with a genetic basis, siblings may be born with same problem during the period of delay in making a diagnosis, a prime example being Fragile X. In untold cases, the family loses trust in you and in the medical system for not acknowledging a problem.

In many cases, your acknowledgment, explanation, sympathy, and advice can help enormously. Families can cope better, garner support from family or friends, deal with the child’s behavior better, and find steps to take to help their child in their own ways, even without formal services, once told that their child has a specific problem.

On a system level, it is important to realize that how services are established and maintained is far less rational than might be imagined. State programs, schools, hospitals, and insurers all have legal requirements to provide services within a certain time frame once referred. Even if the services are not there to help a your child or family right now, the referral itself adds to the data used to determine if services are adequate and to plan for additional service types or capacity. The Autism Waiver is one such example where waits are years long, but getting on the list is crucial to the future of the program.

Until you screen and give parents information – especially middle-class parents – we will never have the resources. As it was for lead paint, until we identified prevalence of elevated lead levels and the harm associated, we got no action on lead paint removal policies. Another example where complaints about access made a difference, is the relatively new Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 that requires health insurers and health plans to guarantee that financial requirements on benefits for mental health, such as copays, deductibles, and limitations on treatment benefits, are not more restrictive than those that are for medical benefits. This does not guarantee that services will be available or of high quality, but is a step toward accessibility.

You may be one of the many pediatricians who consider advocacy a basic component of your professional responsibilities. If you cannot advocate for services that you see your patients in need of, you can pass your concerns onto a group that does. Many American Academy of Pediatrics state chapters have so-called Pediatric Councils that receive ideas about system problems and put group pressure on leaders in the state to address them.

As in the historic painting of the physician leaning over the ill child whom he could not cure, after detection through screening our thoughtful evaluation, explanations, shared concern, and our patients’ advocacy have great value even when specific services are not yet available.

Dr. Howard is an assistant professor of pediatrics at the Johns Hopkins University, Baltimore, and creator of CHADIS (www.chadis.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. E-mail her at [email protected].

SANTA CLARA, CALIF. – When Dr. Omar Dawood demonstrated the AliveCor Heart Monitor with a new app and algorithm for detecting atrial fibrillation on stage at the Health 2.0 fall conference 2014, it showed that his heart was in normal sinus rhythm – but he had a heart rate of 135 beats per minute.

Chalk it up to the excitement of speaking before an audience of physicians and technologists about this new mobile ECG tool, Dr. Dawood said. “I’m not always that anxious.”

The AliveCor device attaches to the back of iPhones or Android-based smartphones and sells for $60-$199, depending on the model of smartphone. The Food and Drug Administration approved it in 2013, and patients have used it since March 2014. The device sends an ECG reading to a cardiologist or cardiac technician, who sends a reply within 24 hours.

With the new, free app, however, patients get an immediate result from the device showing whether or not they are likely to have atrial fibrillation. The FDA cleared the algorithm for the app in August 2014, and the company launched it on the marketplace at the Health 2.0 conference.

Validation studies have shown that the AliveCor system performs comparably to a traditional 12-lead ECG, Dr. Dawood said in a video interview.

For other recent news on studies of AliveCor in clinical settings, see our Evidence-Based Apps column.

Dr. Dawood, a surgeon by training, is a clinical adviser at AliveCor and also works for a separate technology company.

[email protected]


On Twitter @sherryboschert

SANTA CLARA, CALIF. – When Dr. Omar Dawood demonstrated the AliveCor Heart Monitor with a new app and algorithm for detecting atrial fibrillation on stage at the Health 2.0 fall conference 2014, it showed that his heart was in normal sinus rhythm – but he had a heart rate of 135 beats per minute.

Chalk it up to the excitement of speaking before an audience of physicians and technologists about this new mobile ECG tool, Dr. Dawood said. “I’m not always that anxious.”

The AliveCor device attaches to the back of iPhones or Android-based smartphones and sells for $60-$199, depending on the model of smartphone. The Food and Drug Administration approved it in 2013, and patients have used it since March 2014. The device sends an ECG reading to a cardiologist or cardiac technician, who sends a reply within 24 hours.

With the new, free app, however, patients get an immediate result from the device showing whether or not they are likely to have atrial fibrillation. The FDA cleared the algorithm for the app in August 2014, and the company launched it on the marketplace at the Health 2.0 conference.

Validation studies have shown that the AliveCor system performs comparably to a traditional 12-lead ECG, Dr. Dawood said in a video interview.

For other recent news on studies of AliveCor in clinical settings, see our Evidence-Based Apps column.

Dr. Dawood, a surgeon by training, is a clinical adviser at AliveCor and also works for a separate technology company.

[email protected]


On Twitter @sherryboschert

SANTA CLARA, CALIF. – When Dr. Omar Dawood demonstrated the AliveCor Heart Monitor with a new app and algorithm for detecting atrial fibrillation on stage at the Health 2.0 fall conference 2014, it showed that his heart was in normal sinus rhythm – but he had a heart rate of 135 beats per minute.

Chalk it up to the excitement of speaking before an audience of physicians and technologists about this new mobile ECG tool, Dr. Dawood said. “I’m not always that anxious.”

The AliveCor device attaches to the back of iPhones or Android-based smartphones and sells for $60-$199, depending on the model of smartphone. The Food and Drug Administration approved it in 2013, and patients have used it since March 2014. The device sends an ECG reading to a cardiologist or cardiac technician, who sends a reply within 24 hours.

With the new, free app, however, patients get an immediate result from the device showing whether or not they are likely to have atrial fibrillation. The FDA cleared the algorithm for the app in August 2014, and the company launched it on the marketplace at the Health 2.0 conference.

Validation studies have shown that the AliveCor system performs comparably to a traditional 12-lead ECG, Dr. Dawood said in a video interview.

For other recent news on studies of AliveCor in clinical settings, see our Evidence-Based Apps column.

Dr. Dawood, a surgeon by training, is a clinical adviser at AliveCor and also works for a separate technology company.

[email protected]


On Twitter @sherryboschert

Dermatology has yet to conquer the cosmetic corner of the specialty. That’s according to Dr. Leslie S. Baumann, of the Miami-based, Skin Type Solutions, who explains a new franchise model she says will help “put dermatology back in the hands of dermatologists.”

In this interview, Dr. Baumann, who writes the Cosmeceutical Critique column for Skin & Allergy News, explains her new franchise method for selling skin care products in the dermatologist’s office, and why she thinks it will “disrupt” business as usual in the retail skin care marketplace, including for online retailers.

The following is an edited transcript of the interview, which you can hear in its entirety here.

SAN: Welcome, Dr. Baumann. You recently wrote that you were helping to “put dermatology back in the hands of dermatologists.” Can you expand on that?

Dr. Baumann: I find that most patients really don’t buy their products from dermatologists. They buy them from Sephora, CVS, or the department store, but it’s dermatologists who have years of training about skin, and consumers don’t realize that the dermatologist’s office is the natural choice for where to buy their skin care products. I know that in some parts of the country, access to dermatologists is limited. I think that if a person can see a dermatologist, then that should be where they go for products as well, but that’s not happening. I think dermatologists have done a poor job in getting the word out that we’re the complete skin care experts.

SAN: So, you’ve created a business model to help with this. Please explain how it works.

Dr. Baumann: I love the science of skin care ingredients, and I want to prescribe the right skin care products to my patients. I was at the University of Miami for about 15 years. We didn’t have a huge staff, and I went through the whole skin care evaluation process and created the correct regimen myself. The original evaluation regimen took about 45 minutes, and I realized that patients would probably purchase products from me at first, but the next time, they would buy them somewhere else.

So, I streamlined my approach to make it faster and not require a lot of staff. I determined that I needed to divide patients into skin types. I came up with 16 main skin types, based on four issues: oily vs. dry; sensitive vs. resistant; pigmented vs. unpigmented; and whether the skin is wrinkle-prone. This was the basis of my book, “The Skin Type Solution,” which was a New York Times Bestseller. This showed me that consumers really care about skin products.

The biggest challenge was to get my staff to be able to correctly diagnose the skin type. It took me years to develop my questionnaire, and we have done all kinds of clinical trials to validate it. Now my staff can administer that questionnaire on an iPad, and it automatically calculates the skin type.

The next step was figuring out which products work for each skin type, and then presetting regimens. I found the best products from the companies that had the best technology, and then I tested those on different skin types. I might have five or six products from four or five different brands for one skin type.

SAN: And you are confident that mixing products from the different brands and all the different ingredients won’t somehow irritate the patient’s skin?

Dr. Baumann: I have done a lot of research on cosmetic ingredients; that’s really my core competency. One company might have the best sunscreen technology, but that doesn’t mean they have the best retinol technology, yet every brand feels that pressure to have lots of different products. However, because I do the research trials for the companies, I know each one’s best technology. So, I find the best technology and apply it like a Rubik’s Cube to each skin type’s need, so they always get the best product, and then I test the product. I have been testing this method since 2005.

SAN: What about eponymous skin care lines?

Dr. Baumann: When you go private label, you hire a formulator the way you’d hire a personal chef. That person may not be the scientist who invented that technology. When you have a private label, there is no way you can achieve the same results as you can when you are sourcing products from the best scientists in the world. I know who these people are because I do the research trials. I also know the ingredient supply companies who have the basic scientists in the lab, tinkering with the cell cultures and looking at the mitochondria, so I know where those basic ingredients go. Because I have a large following after the sale of my book and my online blog, I can get volume discounts from the companies. I created a store in the office, and each shelf is color-coded by skin type so it’s easy to know what products to buy,

My friend, who franchised Blimpie’s sandwich shops, was in my office one day watching customers take everything off the shelf and purchase all of it, and he convinced me to franchise it.

It’s important to understand why we chose this model. If you are a cosmetics company, you are not allowed to tell doctors how much to charge for the products because it violates antitrust laws. This allows some people to buy products and then dump them cheaply on the Internet. We control that by having the doctors sign an agreement that they will not sell the products online, and if they do, we cut them off.

SAN: How do you ensure that the products in your franchises aren’t elsewhere on the Internet?

Dr. Baumann: The plan is that once we have enough doctors in the program, we will negotiate with the manufacturers to create products that are exclusive to us.

SAN: Is this a revolution?

Dr. Baumann: That’s the point. It’s putting the power back in the hands of the dermatologist because we are the authorities on skin care. We need to be the ones that people get all the best news and products from first. Just imagine a world where a great new skin care technology comes out, and the only place you can get it is from the dermatologists. That’s going to drive so much business into the dermatologist’s office, and will help dermatologists build their general and cosmetic practice. The beauty of my system is that it trains your staff to identify the most appropriate products for each patient, but I have selected those products. I tested this method in six dermatologists’ offices, and we found that the product exchange rate went from about 35% to 3%. So, when your patient has a better outcome, they are more likely to trust you, and more likely to refer friends to you.

SAN: But what if a patient doesn’t have access to a dermatologist and the model for purchasing skin care products does change? It sounds like it will be harder for them to get the skin care they need.

Dr. Baumann: That is a great question. It’s a problem I have to figure out how to solve. Right now we’re considering Skype consults. This is not considered practicing medicine, so you can do it across state lines.

SAN: Do you plan to franchise dermatologists only or would you also sell the franchise rights to medical spas and physicians other than dermatologists?

Dr. Baumann: That’s really against my philosophy. I want to bring skin care back to the dermatologist. Did you know that only 15 percent of dermatologists sell skin care products in their practice? It’s difficult for them to set the system up and buy products from the different companies. My company streamlines that process. Another reason many dermatologists don’t sell products is because of ethical concerns. I believe if you are offering patients the best products for their skin types, products they can’t get somewhere else, and at the best price, then that is ethical. When you’re just selling things to make money by taking advantage of the patient-doctor relationship, then I am absolutely against it.

SAN: Why might a dermatologist turn away from this franchise model?

Dr. Baumann: There is no reason not to do it, because the startup costs are minimal. The only reason they might not want to do it is if they have their own skin care brand. A doctor could still sell his or her own brand, but they wouldn’t be able to have it on the Skin Type Solutions shelves, and that gets complicated. Based on patient surveys I’ve done, people don’t really want private skin care labels. I think they feel very suspicious of them. My system solves that problem by helping consumers realize the doctor isn’t pretending they invented these products. This is a more honest approach, in my opinion. That might be controversial, but that’s how I feel.

SAN: It sounds like the cosmetic manufacturers would favor this if you like their line.

Dr. Baumann: My system favors good technology. So the charlatans who are trying to sell stem cell therapies or peptides that don’t work aren’t going to like my system. My system favors the geniuses in the lab who don’t know how to get their technology out there, and I know a lot of them. We’ll be able to find that technology and then launch it through dermatology practices. This helps the genius underdogs who don’t know what to do with what they’ve discovered.

Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in the Design District in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote the textbook “Cosmetic Dermatology: Principles and Practice” (McGraw-Hill, New York 2002) , and a book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). She has contributed to the Cosmeceutical Critique column in Skin & Allergy News since January 2001. Her latest book, “Cosmeceuticals and Cosmetic Ingredients,” will be published in November 2014. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Evolus, Galderma, GlaxoSmithKline, Kythera, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy,Topix Pharmaceuticals, and Unilever.

[email protected]

On Twitter @whitneymcknight

Dermatology has yet to conquer the cosmetic corner of the specialty. That’s according to Dr. Leslie S. Baumann, of the Miami-based, Skin Type Solutions, who explains a new franchise model she says will help “put dermatology back in the hands of dermatologists.”

In this interview, Dr. Baumann, who writes the Cosmeceutical Critique column for Skin & Allergy News, explains her new franchise method for selling skin care products in the dermatologist’s office, and why she thinks it will “disrupt” business as usual in the retail skin care marketplace, including for online retailers.

The following is an edited transcript of the interview, which you can hear in its entirety here.

SAN: Welcome, Dr. Baumann. You recently wrote that you were helping to “put dermatology back in the hands of dermatologists.” Can you expand on that?

Dr. Baumann: I find that most patients really don’t buy their products from dermatologists. They buy them from Sephora, CVS, or the department store, but it’s dermatologists who have years of training about skin, and consumers don’t realize that the dermatologist’s office is the natural choice for where to buy their skin care products. I know that in some parts of the country, access to dermatologists is limited. I think that if a person can see a dermatologist, then that should be where they go for products as well, but that’s not happening. I think dermatologists have done a poor job in getting the word out that we’re the complete skin care experts.

SAN: So, you’ve created a business model to help with this. Please explain how it works.

Dr. Baumann: I love the science of skin care ingredients, and I want to prescribe the right skin care products to my patients. I was at the University of Miami for about 15 years. We didn’t have a huge staff, and I went through the whole skin care evaluation process and created the correct regimen myself. The original evaluation regimen took about 45 minutes, and I realized that patients would probably purchase products from me at first, but the next time, they would buy them somewhere else.

So, I streamlined my approach to make it faster and not require a lot of staff. I determined that I needed to divide patients into skin types. I came up with 16 main skin types, based on four issues: oily vs. dry; sensitive vs. resistant; pigmented vs. unpigmented; and whether the skin is wrinkle-prone. This was the basis of my book, “The Skin Type Solution,” which was a New York Times Bestseller. This showed me that consumers really care about skin products.

The biggest challenge was to get my staff to be able to correctly diagnose the skin type. It took me years to develop my questionnaire, and we have done all kinds of clinical trials to validate it. Now my staff can administer that questionnaire on an iPad, and it automatically calculates the skin type.

The next step was figuring out which products work for each skin type, and then presetting regimens. I found the best products from the companies that had the best technology, and then I tested those on different skin types. I might have five or six products from four or five different brands for one skin type.

SAN: And you are confident that mixing products from the different brands and all the different ingredients won’t somehow irritate the patient’s skin?

Dr. Baumann: I have done a lot of research on cosmetic ingredients; that’s really my core competency. One company might have the best sunscreen technology, but that doesn’t mean they have the best retinol technology, yet every brand feels that pressure to have lots of different products. However, because I do the research trials for the companies, I know each one’s best technology. So, I find the best technology and apply it like a Rubik’s Cube to each skin type’s need, so they always get the best product, and then I test the product. I have been testing this method since 2005.

SAN: What about eponymous skin care lines?

Dr. Baumann: When you go private label, you hire a formulator the way you’d hire a personal chef. That person may not be the scientist who invented that technology. When you have a private label, there is no way you can achieve the same results as you can when you are sourcing products from the best scientists in the world. I know who these people are because I do the research trials. I also know the ingredient supply companies who have the basic scientists in the lab, tinkering with the cell cultures and looking at the mitochondria, so I know where those basic ingredients go. Because I have a large following after the sale of my book and my online blog, I can get volume discounts from the companies. I created a store in the office, and each shelf is color-coded by skin type so it’s easy to know what products to buy,

My friend, who franchised Blimpie’s sandwich shops, was in my office one day watching customers take everything off the shelf and purchase all of it, and he convinced me to franchise it.

It’s important to understand why we chose this model. If you are a cosmetics company, you are not allowed to tell doctors how much to charge for the products because it violates antitrust laws. This allows some people to buy products and then dump them cheaply on the Internet. We control that by having the doctors sign an agreement that they will not sell the products online, and if they do, we cut them off.

SAN: How do you ensure that the products in your franchises aren’t elsewhere on the Internet?

Dr. Baumann: The plan is that once we have enough doctors in the program, we will negotiate with the manufacturers to create products that are exclusive to us.

SAN: Is this a revolution?

Dr. Baumann: That’s the point. It’s putting the power back in the hands of the dermatologist because we are the authorities on skin care. We need to be the ones that people get all the best news and products from first. Just imagine a world where a great new skin care technology comes out, and the only place you can get it is from the dermatologists. That’s going to drive so much business into the dermatologist’s office, and will help dermatologists build their general and cosmetic practice. The beauty of my system is that it trains your staff to identify the most appropriate products for each patient, but I have selected those products. I tested this method in six dermatologists’ offices, and we found that the product exchange rate went from about 35% to 3%. So, when your patient has a better outcome, they are more likely to trust you, and more likely to refer friends to you.

SAN: But what if a patient doesn’t have access to a dermatologist and the model for purchasing skin care products does change? It sounds like it will be harder for them to get the skin care they need.

Dr. Baumann: That is a great question. It’s a problem I have to figure out how to solve. Right now we’re considering Skype consults. This is not considered practicing medicine, so you can do it across state lines.

SAN: Do you plan to franchise dermatologists only or would you also sell the franchise rights to medical spas and physicians other than dermatologists?

Dr. Baumann: That’s really against my philosophy. I want to bring skin care back to the dermatologist. Did you know that only 15 percent of dermatologists sell skin care products in their practice? It’s difficult for them to set the system up and buy products from the different companies. My company streamlines that process. Another reason many dermatologists don’t sell products is because of ethical concerns. I believe if you are offering patients the best products for their skin types, products they can’t get somewhere else, and at the best price, then that is ethical. When you’re just selling things to make money by taking advantage of the patient-doctor relationship, then I am absolutely against it.

SAN: Why might a dermatologist turn away from this franchise model?

Dr. Baumann: There is no reason not to do it, because the startup costs are minimal. The only reason they might not want to do it is if they have their own skin care brand. A doctor could still sell his or her own brand, but they wouldn’t be able to have it on the Skin Type Solutions shelves, and that gets complicated. Based on patient surveys I’ve done, people don’t really want private skin care labels. I think they feel very suspicious of them. My system solves that problem by helping consumers realize the doctor isn’t pretending they invented these products. This is a more honest approach, in my opinion. That might be controversial, but that’s how I feel.

SAN: It sounds like the cosmetic manufacturers would favor this if you like their line.

Dr. Baumann: My system favors good technology. So the charlatans who are trying to sell stem cell therapies or peptides that don’t work aren’t going to like my system. My system favors the geniuses in the lab who don’t know how to get their technology out there, and I know a lot of them. We’ll be able to find that technology and then launch it through dermatology practices. This helps the genius underdogs who don’t know what to do with what they’ve discovered.

Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in the Design District in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote the textbook “Cosmetic Dermatology: Principles and Practice” (McGraw-Hill, New York 2002) , and a book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). She has contributed to the Cosmeceutical Critique column in Skin & Allergy News since January 2001. Her latest book, “Cosmeceuticals and Cosmetic Ingredients,” will be published in November 2014. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Evolus, Galderma, GlaxoSmithKline, Kythera, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy,Topix Pharmaceuticals, and Unilever.

[email protected]

On Twitter @whitneymcknight

Dermatology has yet to conquer the cosmetic corner of the specialty. That’s according to Dr. Leslie S. Baumann, of the Miami-based, Skin Type Solutions, who explains a new franchise model she says will help “put dermatology back in the hands of dermatologists.”

In this interview, Dr. Baumann, who writes the Cosmeceutical Critique column for Skin & Allergy News, explains her new franchise method for selling skin care products in the dermatologist’s office, and why she thinks it will “disrupt” business as usual in the retail skin care marketplace, including for online retailers.

The following is an edited transcript of the interview, which you can hear in its entirety here.

SAN: Welcome, Dr. Baumann. You recently wrote that you were helping to “put dermatology back in the hands of dermatologists.” Can you expand on that?

Dr. Baumann: I find that most patients really don’t buy their products from dermatologists. They buy them from Sephora, CVS, or the department store, but it’s dermatologists who have years of training about skin, and consumers don’t realize that the dermatologist’s office is the natural choice for where to buy their skin care products. I know that in some parts of the country, access to dermatologists is limited. I think that if a person can see a dermatologist, then that should be where they go for products as well, but that’s not happening. I think dermatologists have done a poor job in getting the word out that we’re the complete skin care experts.

SAN: So, you’ve created a business model to help with this. Please explain how it works.

Dr. Baumann: I love the science of skin care ingredients, and I want to prescribe the right skin care products to my patients. I was at the University of Miami for about 15 years. We didn’t have a huge staff, and I went through the whole skin care evaluation process and created the correct regimen myself. The original evaluation regimen took about 45 minutes, and I realized that patients would probably purchase products from me at first, but the next time, they would buy them somewhere else.

So, I streamlined my approach to make it faster and not require a lot of staff. I determined that I needed to divide patients into skin types. I came up with 16 main skin types, based on four issues: oily vs. dry; sensitive vs. resistant; pigmented vs. unpigmented; and whether the skin is wrinkle-prone. This was the basis of my book, “The Skin Type Solution,” which was a New York Times Bestseller. This showed me that consumers really care about skin products.

The biggest challenge was to get my staff to be able to correctly diagnose the skin type. It took me years to develop my questionnaire, and we have done all kinds of clinical trials to validate it. Now my staff can administer that questionnaire on an iPad, and it automatically calculates the skin type.

The next step was figuring out which products work for each skin type, and then presetting regimens. I found the best products from the companies that had the best technology, and then I tested those on different skin types. I might have five or six products from four or five different brands for one skin type.

SAN: And you are confident that mixing products from the different brands and all the different ingredients won’t somehow irritate the patient’s skin?

Dr. Baumann: I have done a lot of research on cosmetic ingredients; that’s really my core competency. One company might have the best sunscreen technology, but that doesn’t mean they have the best retinol technology, yet every brand feels that pressure to have lots of different products. However, because I do the research trials for the companies, I know each one’s best technology. So, I find the best technology and apply it like a Rubik’s Cube to each skin type’s need, so they always get the best product, and then I test the product. I have been testing this method since 2005.

SAN: What about eponymous skin care lines?

Dr. Baumann: When you go private label, you hire a formulator the way you’d hire a personal chef. That person may not be the scientist who invented that technology. When you have a private label, there is no way you can achieve the same results as you can when you are sourcing products from the best scientists in the world. I know who these people are because I do the research trials. I also know the ingredient supply companies who have the basic scientists in the lab, tinkering with the cell cultures and looking at the mitochondria, so I know where those basic ingredients go. Because I have a large following after the sale of my book and my online blog, I can get volume discounts from the companies. I created a store in the office, and each shelf is color-coded by skin type so it’s easy to know what products to buy,

My friend, who franchised Blimpie’s sandwich shops, was in my office one day watching customers take everything off the shelf and purchase all of it, and he convinced me to franchise it.

It’s important to understand why we chose this model. If you are a cosmetics company, you are not allowed to tell doctors how much to charge for the products because it violates antitrust laws. This allows some people to buy products and then dump them cheaply on the Internet. We control that by having the doctors sign an agreement that they will not sell the products online, and if they do, we cut them off.

SAN: How do you ensure that the products in your franchises aren’t elsewhere on the Internet?

Dr. Baumann: The plan is that once we have enough doctors in the program, we will negotiate with the manufacturers to create products that are exclusive to us.

SAN: Is this a revolution?

Dr. Baumann: That’s the point. It’s putting the power back in the hands of the dermatologist because we are the authorities on skin care. We need to be the ones that people get all the best news and products from first. Just imagine a world where a great new skin care technology comes out, and the only place you can get it is from the dermatologists. That’s going to drive so much business into the dermatologist’s office, and will help dermatologists build their general and cosmetic practice. The beauty of my system is that it trains your staff to identify the most appropriate products for each patient, but I have selected those products. I tested this method in six dermatologists’ offices, and we found that the product exchange rate went from about 35% to 3%. So, when your patient has a better outcome, they are more likely to trust you, and more likely to refer friends to you.

SAN: But what if a patient doesn’t have access to a dermatologist and the model for purchasing skin care products does change? It sounds like it will be harder for them to get the skin care they need.

Dr. Baumann: That is a great question. It’s a problem I have to figure out how to solve. Right now we’re considering Skype consults. This is not considered practicing medicine, so you can do it across state lines.

SAN: Do you plan to franchise dermatologists only or would you also sell the franchise rights to medical spas and physicians other than dermatologists?

Dr. Baumann: That’s really against my philosophy. I want to bring skin care back to the dermatologist. Did you know that only 15 percent of dermatologists sell skin care products in their practice? It’s difficult for them to set the system up and buy products from the different companies. My company streamlines that process. Another reason many dermatologists don’t sell products is because of ethical concerns. I believe if you are offering patients the best products for their skin types, products they can’t get somewhere else, and at the best price, then that is ethical. When you’re just selling things to make money by taking advantage of the patient-doctor relationship, then I am absolutely against it.

SAN: Why might a dermatologist turn away from this franchise model?

Dr. Baumann: There is no reason not to do it, because the startup costs are minimal. The only reason they might not want to do it is if they have their own skin care brand. A doctor could still sell his or her own brand, but they wouldn’t be able to have it on the Skin Type Solutions shelves, and that gets complicated. Based on patient surveys I’ve done, people don’t really want private skin care labels. I think they feel very suspicious of them. My system solves that problem by helping consumers realize the doctor isn’t pretending they invented these products. This is a more honest approach, in my opinion. That might be controversial, but that’s how I feel.

SAN: It sounds like the cosmetic manufacturers would favor this if you like their line.

Dr. Baumann: My system favors good technology. So the charlatans who are trying to sell stem cell therapies or peptides that don’t work aren’t going to like my system. My system favors the geniuses in the lab who don’t know how to get their technology out there, and I know a lot of them. We’ll be able to find that technology and then launch it through dermatology practices. This helps the genius underdogs who don’t know what to do with what they’ve discovered.

Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in the Design District in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote the textbook “Cosmetic Dermatology: Principles and Practice” (McGraw-Hill, New York 2002) , and a book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). She has contributed to the Cosmeceutical Critique column in Skin & Allergy News since January 2001. Her latest book, “Cosmeceuticals and Cosmetic Ingredients,” will be published in November 2014. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Evolus, Galderma, GlaxoSmithKline, Kythera, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy,Topix Pharmaceuticals, and Unilever.

[email protected]

On Twitter @whitneymcknight

Thursday was a rough day. Not for me, but for my front-desk personnel. I wouldn’t even have known about it, if Nilda hadn’t clued me in.

“I’m a preschool teacher,” she said, after asking about Botox for underarm sweating. “So I have a lot of patience. But your front-desk people are amazing.”

“What do you mean?” I asked her.

“This lady walks in without an appointment,” she said. “Several people are trying to check in, and she just waltzes over and says, ‘The doctor said I could come in whenever I wanted.’”

I smiled. “That’s Harriet. She’s worried that she has an infection. We make allowances for people over 90.”

“And then there was a woman who didn’t even want to be seen,” Nilda went on. “She’d gotten a bill she didn’t approve of, and she kept going on and on.

“Your secretary said she would call the insurance company to look into it, but the woman kept saying, ‘I’ve been a patient here for 20 years, and there’s never been a problem with the insurance.’

“It would have been fine for your secretary to politely tell the woman she’d take care of it, but now she had to get back to patients trying to register. But she didn’t lose her cool, just kept repeating that she would call the patient’s insurer and let her know.”

I thanked Nilda very much for the feedback. “Most people don’t bother to comment unless they have a complaint,” I said, “so I appreciate your taking the time to say something positive. I’ll be sure to pass it on.”

“And I thought preschool children were tough,” said Nilda.

At lunch, I asked the staff what had been going on.

“Must be a full moon,” said Irma, her eyes twinkling. “The registration desk was like a zoo, what with all the new patients and the old ones who hadn’t been here in years re-registering. And in the middle of it all, a lady whose husband had already checked in and sat down kept calling out, ‘Is Gustav next’?”

“The man sitting next to her – must have been Gustav himself – grumbled at her to please keep quiet, but she kept calling out, ‘Is Gustav next?’ 

“Then Dorit comes in, complaining about her bill. It turns out that her insurance changed in May, but she had forgotten about it, and she didn’t understand what the change would mean for payment. I told her I would call her insurer and find out.

“ ‘I’ve been a patient here for 20 years,’ she kept saying. ‘So don’t overcharge me!’

“I told her I would let her know what her insurer said and promised that we wouldn’t overcharge her on the copay.

“In the meantime, Harriet, the walk-in, kept standing in front of the window saying, ‘Doctor Rockoff said I could come in whenever I want, and my son-in-law took off work to bring me in and he’s waiting outside.’

“And while Harriet was saying that, the lady in the chair kept calling out, ‘Is Gustav next? Is Gustav next?’ ”

I smiled to myself, trying to think of which absurdist playwright could do justice to what went on that morning in my waiting room, and maybe on lots of mornings and afternoons in waiting rooms everywhere.

“You should know,” I told Irma and the rest of the staff, “that one of the patients commented on how well you all did. You handled all that insanity while staying cool and polite. Great job!”

Of course, we have to stay vigilant for rude or discourteous behavior on the part of our staff. But that same staff often protects us from some pretty unreasonable behavior that patients sometimes can throw at them. It makes sense to make a point of telling our front-desk representatives from time to time how much we appreciate the graceful way they handle the guff and allow us to focus on each patient in the exam room.

Meantime, I am working on my new drama, a sequel to Waiting for Godot. I will call it, Is Gustav Next?

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Skin & Allergy News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

Thursday was a rough day. Not for me, but for my front-desk personnel. I wouldn’t even have known about it, if Nilda hadn’t clued me in.

“I’m a preschool teacher,” she said, after asking about Botox for underarm sweating. “So I have a lot of patience. But your front-desk people are amazing.”

“What do you mean?” I asked her.

“This lady walks in without an appointment,” she said. “Several people are trying to check in, and she just waltzes over and says, ‘The doctor said I could come in whenever I wanted.’”

I smiled. “That’s Harriet. She’s worried that she has an infection. We make allowances for people over 90.”

“And then there was a woman who didn’t even want to be seen,” Nilda went on. “She’d gotten a bill she didn’t approve of, and she kept going on and on.

“Your secretary said she would call the insurance company to look into it, but the woman kept saying, ‘I’ve been a patient here for 20 years, and there’s never been a problem with the insurance.’

“It would have been fine for your secretary to politely tell the woman she’d take care of it, but now she had to get back to patients trying to register. But she didn’t lose her cool, just kept repeating that she would call the patient’s insurer and let her know.”

I thanked Nilda very much for the feedback. “Most people don’t bother to comment unless they have a complaint,” I said, “so I appreciate your taking the time to say something positive. I’ll be sure to pass it on.”

“And I thought preschool children were tough,” said Nilda.

At lunch, I asked the staff what had been going on.

“Must be a full moon,” said Irma, her eyes twinkling. “The registration desk was like a zoo, what with all the new patients and the old ones who hadn’t been here in years re-registering. And in the middle of it all, a lady whose husband had already checked in and sat down kept calling out, ‘Is Gustav next’?”

“The man sitting next to her – must have been Gustav himself – grumbled at her to please keep quiet, but she kept calling out, ‘Is Gustav next?’ 

“Then Dorit comes in, complaining about her bill. It turns out that her insurance changed in May, but she had forgotten about it, and she didn’t understand what the change would mean for payment. I told her I would call her insurer and find out.

“ ‘I’ve been a patient here for 20 years,’ she kept saying. ‘So don’t overcharge me!’

“I told her I would let her know what her insurer said and promised that we wouldn’t overcharge her on the copay.

“In the meantime, Harriet, the walk-in, kept standing in front of the window saying, ‘Doctor Rockoff said I could come in whenever I want, and my son-in-law took off work to bring me in and he’s waiting outside.’

“And while Harriet was saying that, the lady in the chair kept calling out, ‘Is Gustav next? Is Gustav next?’ ”

I smiled to myself, trying to think of which absurdist playwright could do justice to what went on that morning in my waiting room, and maybe on lots of mornings and afternoons in waiting rooms everywhere.

“You should know,” I told Irma and the rest of the staff, “that one of the patients commented on how well you all did. You handled all that insanity while staying cool and polite. Great job!”

Of course, we have to stay vigilant for rude or discourteous behavior on the part of our staff. But that same staff often protects us from some pretty unreasonable behavior that patients sometimes can throw at them. It makes sense to make a point of telling our front-desk representatives from time to time how much we appreciate the graceful way they handle the guff and allow us to focus on each patient in the exam room.

Meantime, I am working on my new drama, a sequel to Waiting for Godot. I will call it, Is Gustav Next?

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Skin & Allergy News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

Thursday was a rough day. Not for me, but for my front-desk personnel. I wouldn’t even have known about it, if Nilda hadn’t clued me in.

“I’m a preschool teacher,” she said, after asking about Botox for underarm sweating. “So I have a lot of patience. But your front-desk people are amazing.”

“What do you mean?” I asked her.

“This lady walks in without an appointment,” she said. “Several people are trying to check in, and she just waltzes over and says, ‘The doctor said I could come in whenever I wanted.’”

I smiled. “That’s Harriet. She’s worried that she has an infection. We make allowances for people over 90.”

“And then there was a woman who didn’t even want to be seen,” Nilda went on. “She’d gotten a bill she didn’t approve of, and she kept going on and on.

“Your secretary said she would call the insurance company to look into it, but the woman kept saying, ‘I’ve been a patient here for 20 years, and there’s never been a problem with the insurance.’

“It would have been fine for your secretary to politely tell the woman she’d take care of it, but now she had to get back to patients trying to register. But she didn’t lose her cool, just kept repeating that she would call the patient’s insurer and let her know.”

I thanked Nilda very much for the feedback. “Most people don’t bother to comment unless they have a complaint,” I said, “so I appreciate your taking the time to say something positive. I’ll be sure to pass it on.”

“And I thought preschool children were tough,” said Nilda.

At lunch, I asked the staff what had been going on.

“Must be a full moon,” said Irma, her eyes twinkling. “The registration desk was like a zoo, what with all the new patients and the old ones who hadn’t been here in years re-registering. And in the middle of it all, a lady whose husband had already checked in and sat down kept calling out, ‘Is Gustav next’?”

“The man sitting next to her – must have been Gustav himself – grumbled at her to please keep quiet, but she kept calling out, ‘Is Gustav next?’ 

“Then Dorit comes in, complaining about her bill. It turns out that her insurance changed in May, but she had forgotten about it, and she didn’t understand what the change would mean for payment. I told her I would call her insurer and find out.

“ ‘I’ve been a patient here for 20 years,’ she kept saying. ‘So don’t overcharge me!’

“I told her I would let her know what her insurer said and promised that we wouldn’t overcharge her on the copay.

“In the meantime, Harriet, the walk-in, kept standing in front of the window saying, ‘Doctor Rockoff said I could come in whenever I want, and my son-in-law took off work to bring me in and he’s waiting outside.’

“And while Harriet was saying that, the lady in the chair kept calling out, ‘Is Gustav next? Is Gustav next?’ ”

I smiled to myself, trying to think of which absurdist playwright could do justice to what went on that morning in my waiting room, and maybe on lots of mornings and afternoons in waiting rooms everywhere.

“You should know,” I told Irma and the rest of the staff, “that one of the patients commented on how well you all did. You handled all that insanity while staying cool and polite. Great job!”

Of course, we have to stay vigilant for rude or discourteous behavior on the part of our staff. But that same staff often protects us from some pretty unreasonable behavior that patients sometimes can throw at them. It makes sense to make a point of telling our front-desk representatives from time to time how much we appreciate the graceful way they handle the guff and allow us to focus on each patient in the exam room.

Meantime, I am working on my new drama, a sequel to Waiting for Godot. I will call it, Is Gustav Next?

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Skin & Allergy News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

Urinary incontinence is a major health care concern, both in terms of the numbers of women who are suffering and with respect to societal costs and the impact on health care spending. Approximately 15 years ago, an international group reported in the Journal of the American Medical Association that 200 million people worldwide – 75%-80% of them women – were suffering from urinary incontinence (JAMA 1998;280:951-3).

Since then, a high prevalence of urinary incontinence has been documented in various studies and reports. Experts have estimated, for instance, that between 13 million and 25 million adult Americans experience transient or chronic symptoms, and that approximately half of these patients suffer from severe or bothersome symptoms. Again, the majority of these individuals are women.

Consumer-based research suggests that 25% of women over the age of 18 years experience episodes of urinary incontinence, according to prevalence data collected by the National Association for Continence. In 2001, 10% of women under the age of 65 years and 35% of women over 65 had symptoms of involuntary leakage, according to the National Institute of Diabetes and Digestive and Kidney Diseases. Despite this, nearly two-thirds of patients never discussed bladder health with their health care provider and on average, women wait over 6 years from symptom onset before a diagnosis is established. Moreover, the costs are significant; in 2001, the cost for urinary incontinence in the United States was $16.3 billion (Obstet. Gynecol. 2001;98:398-406).

There are four types of urinary incontinence – urge, stress, mixed, and overflow. Urge incontinence typically is accompanied by urgency. Stress incontinence occurs with the increased abdominal pressure that accompanies effort, exertion, laughing, coughing, and sneezing. Overflow incontinence generally involves continuous urinary loss and incomplete bladder emptying.

Over the next four installments of Master Class in Gynecologic Surgery, I have chosen to feature the workup and treatment of urinary incontinence. For our first installment, I have asked my former resident Dr. Sandra Culbertson, who is now a professor in the department of obstetrics and gynecology at the University of Chicago, to share her knowledge of the optimal approach for evaluating urinary incontinence in the office. As she explains, it is critical to discern the uncomplicated cases of stress urinary incontinence from possibly complicated cases that require more assessment.

Dr. Miller is clinical associate professor at the University of Illinois at Chicago, immediate past president of the International Society for Gynecologic Endoscopy (ISGE), and a past president of the AAGL. He is a reproductive endocrinologist and minimally invasive gynecologic surgeon in private practice in Naperville, Ill., and Schaumburg, Ill.; the director of minimally invasive gynecologic surgery and the director of the AAGL/SRS fellowship in minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill.; and the medical editor of this column, Master Class. Dr. Miller had no relevant financial disclosures.

Urinary incontinence is a major health care concern, both in terms of the numbers of women who are suffering and with respect to societal costs and the impact on health care spending. Approximately 15 years ago, an international group reported in the Journal of the American Medical Association that 200 million people worldwide – 75%-80% of them women – were suffering from urinary incontinence (JAMA 1998;280:951-3).

Since then, a high prevalence of urinary incontinence has been documented in various studies and reports. Experts have estimated, for instance, that between 13 million and 25 million adult Americans experience transient or chronic symptoms, and that approximately half of these patients suffer from severe or bothersome symptoms. Again, the majority of these individuals are women.

Consumer-based research suggests that 25% of women over the age of 18 years experience episodes of urinary incontinence, according to prevalence data collected by the National Association for Continence. In 2001, 10% of women under the age of 65 years and 35% of women over 65 had symptoms of involuntary leakage, according to the National Institute of Diabetes and Digestive and Kidney Diseases. Despite this, nearly two-thirds of patients never discussed bladder health with their health care provider and on average, women wait over 6 years from symptom onset before a diagnosis is established. Moreover, the costs are significant; in 2001, the cost for urinary incontinence in the United States was $16.3 billion (Obstet. Gynecol. 2001;98:398-406).

There are four types of urinary incontinence – urge, stress, mixed, and overflow. Urge incontinence typically is accompanied by urgency. Stress incontinence occurs with the increased abdominal pressure that accompanies effort, exertion, laughing, coughing, and sneezing. Overflow incontinence generally involves continuous urinary loss and incomplete bladder emptying.

Over the next four installments of Master Class in Gynecologic Surgery, I have chosen to feature the workup and treatment of urinary incontinence. For our first installment, I have asked my former resident Dr. Sandra Culbertson, who is now a professor in the department of obstetrics and gynecology at the University of Chicago, to share her knowledge of the optimal approach for evaluating urinary incontinence in the office. As she explains, it is critical to discern the uncomplicated cases of stress urinary incontinence from possibly complicated cases that require more assessment.

Dr. Miller is clinical associate professor at the University of Illinois at Chicago, immediate past president of the International Society for Gynecologic Endoscopy (ISGE), and a past president of the AAGL. He is a reproductive endocrinologist and minimally invasive gynecologic surgeon in private practice in Naperville, Ill., and Schaumburg, Ill.; the director of minimally invasive gynecologic surgery and the director of the AAGL/SRS fellowship in minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill.; and the medical editor of this column, Master Class. Dr. Miller had no relevant financial disclosures.

Urinary incontinence is a major health care concern, both in terms of the numbers of women who are suffering and with respect to societal costs and the impact on health care spending. Approximately 15 years ago, an international group reported in the Journal of the American Medical Association that 200 million people worldwide – 75%-80% of them women – were suffering from urinary incontinence (JAMA 1998;280:951-3).

Since then, a high prevalence of urinary incontinence has been documented in various studies and reports. Experts have estimated, for instance, that between 13 million and 25 million adult Americans experience transient or chronic symptoms, and that approximately half of these patients suffer from severe or bothersome symptoms. Again, the majority of these individuals are women.

Consumer-based research suggests that 25% of women over the age of 18 years experience episodes of urinary incontinence, according to prevalence data collected by the National Association for Continence. In 2001, 10% of women under the age of 65 years and 35% of women over 65 had symptoms of involuntary leakage, according to the National Institute of Diabetes and Digestive and Kidney Diseases. Despite this, nearly two-thirds of patients never discussed bladder health with their health care provider and on average, women wait over 6 years from symptom onset before a diagnosis is established. Moreover, the costs are significant; in 2001, the cost for urinary incontinence in the United States was $16.3 billion (Obstet. Gynecol. 2001;98:398-406).

There are four types of urinary incontinence – urge, stress, mixed, and overflow. Urge incontinence typically is accompanied by urgency. Stress incontinence occurs with the increased abdominal pressure that accompanies effort, exertion, laughing, coughing, and sneezing. Overflow incontinence generally involves continuous urinary loss and incomplete bladder emptying.

Over the next four installments of Master Class in Gynecologic Surgery, I have chosen to feature the workup and treatment of urinary incontinence. For our first installment, I have asked my former resident Dr. Sandra Culbertson, who is now a professor in the department of obstetrics and gynecology at the University of Chicago, to share her knowledge of the optimal approach for evaluating urinary incontinence in the office. As she explains, it is critical to discern the uncomplicated cases of stress urinary incontinence from possibly complicated cases that require more assessment.

Dr. Miller is clinical associate professor at the University of Illinois at Chicago, immediate past president of the International Society for Gynecologic Endoscopy (ISGE), and a past president of the AAGL. He is a reproductive endocrinologist and minimally invasive gynecologic surgeon in private practice in Naperville, Ill., and Schaumburg, Ill.; the director of minimally invasive gynecologic surgery and the director of the AAGL/SRS fellowship in minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill.; and the medical editor of this column, Master Class. Dr. Miller had no relevant financial disclosures.