Dr Renée Hoenderkamp explains how the patient consultation has evolved in recent years and why this is working to improve aesthetic practice
Running an aesthetic clinic is an all consuming and ever-evolving process. Never has this been truer than over the past five to ten years where we have seen an evolution of the non-surgical consultation. Many things have contributed to this change, ranging from informed consent, increasing treatment solutions and products, and new technology. An understanding of these developments and the desire to constantly grow, adapt and learn, make the challenge of running or owning a clinic exciting and fulfilling; even though sometimes challenging. We must all strive to have an efficient, informative and legally satisfying consultation process for the safety of our patients and longevity of the industry.
With the non-surgical market remaining largely unregulated, those practitioners who aim to run ethical clinics have learnt from other areas of medicine how important consent is. A major change in the consent process has seen the patient become an active and equal partner alongside the practitioner. This ‘duality’ of consent empowers the patient with full, understandable and digestible information, thus allowing them to adequately weigh-up the risks and benefits of the treatment they are considering. The decision to embark upon a particular treatment is made by the patient once in complete knowledge of the facts. There should be no question unanswered, and recent litigation indicates that however rare, all possible complications should be discussed.1 Only with such thoroughness can the patient make a fully informed decision.
It is considered good practice to have clear consent pathways within the clinic environment that satisfy basic levels of good practice, as identified in the ‘Review of the Regulations of Cosmetic Interventions’, which was published in April 2013 and led by Sir Bruce Keogh.2 Aimed at anyone delivering non-surgical treatments, practitioners and nurses now have guidance from their registration bodies, all of which focus on the consent process. The general tenet of all of this guidance is summarised in the ‘Professional Standards for Cosmetic Practice’.3 The Keogh Report garnered much publicity with the often quoted catch phrase, “You have more protection when buying a ball point pen than when having fillers.”2
So what has happened over the past five to ten years to attract such attention to the aesthetics industry, encouraging the government to create guidelines aiming to grow public awareness of good practice? Although a relatively young area of medicine, nonsurgical treatments have grown exponentially over the past five years, worth an estimated £2.3bn in the UK alone in 2010 and predicted to reach £3.6bn by 2015.2
By the very nature of an industry that has seen such rapid growth, both in terms of the number of practitioners, clinics and patient numbers; the consultation has naturally evolved. All of the enquiry recommendations and professional guidance accepts and encourages the need for informed consent with a move towards duality of consent.
A critical part of the consultation process is the discussion of the possible risks involved. A clear explanation of any inherent treatment risks must be fully explained. How many practitioners include ‘blindness’ as part of their filler risk profile? I am sure my colleagues, as do I, see patients who’ve had fillers in the past but were never told of the risks. In my opinion, the decision to undergo a non-surgical treatment is a journey that the patient is embarking on with the practitioner. The decision must be in line with the recommendations and the patient needs to understand the risks involved. The practitioner is also expected to explain that other treatments are available from other practitioners, if it is in the patient’s best interests. For example, Roaccutane for acne could work as well, or even better than a skin peel, and tear trough surgery may be more beneficial for some patients than fillers.
All professional bodies, such as the General Medical Council (GMC) and the Royal College of Surgeons (RCS), recommend that the person conducting the treatment must carry out the consent process.3 This has therefore seen clinics, which have traditionally used different practitioners to consent the patient and carry out the procedure, having to consider and change their consultation process.
Finally, as the main consent method previously detailed is a one-off process, unless a new treatment is added, it is now becoming more common to have an ongoing consent card that the patient signs at each visit to confirm that nothing has changed in their medical history, no new medications are being taken and that they’re not pregnant.4 Clearly, if there were new medical issues to consider, the consent process would need to be revisited and documented accordingly. Crucially, once all of the above has been discussed and a treatment plan agreed, there must be a written record and a form signed for consent. The patient should also take away with them written aftercare instructions.
A major change in the consent process has seen the patient become an active and equal partner alongside the practitioner
Another recommendation from the Keogh report, which is supported by the main professional bodies, such as the GMC and the RCS, is for consent and treatment to be a two-stage process to give the patient time to consider the treatment fully.2 A ‘cooling-off’ period before treatment is also becoming more commonplace. For example, I consult and consent for thread lifts at the initial appointment and carry out the procedure at a future date. Clearly, this changes the timing and planning of appointments and could potentially result in cancellations or no-shows, but follows good practice guidelines. If this isn’t your practice, be satisfied that the patient fully understands the risks and benefits and feels able to ask informed questions or say no to going through with the procedure. A possible method, which can be worthwhile, is allowing patients 30 minutes back in the waiting room to consider whether they would like to go through with treatment.
It is clear that the consent process has altered the consultation dramatically, and, in addition, has added more time and paperwork to the process. There are, however, technologies which may help streamline the process, and others that give you time back as they aid the decision making process. For example, over the past three years, there have been mobile phone/tablet apps, which replicate the entire consultation process and serve to securely store the medical questionnaire, consent and photos together. These apps can negate the need for paper records and the associated risks of storing and accessing confidential patient records. They could also solve the issue of uploading photos from a camera and either printing or collating with the patient record. Currently still relatively early in their uptake, they hold the promise of streamlining the consultation.
There is also the use of 3D simulation to demonstrate the effects of non-surgical treatments. Already being used in the USA5 and Australia,6,7 the simulation works as an addition to the consultation that will allow both patient and practitioner to have a realistic idea of treatment results before committing – if the technology lives up to its promise. Such an advance may limit patient dissatisfaction or manage unrealistic expectations, but will inevitably add more time to the consultation process.
Having said this, many clinics have started to use Computerised Photo Imaging Skin Analysis8 in the consultation process. This is another addition over the past 10 years and the 3D technology would be used in a similar way.
The variety and depth of non-surgical treatments on the market has increased. The treatment list no longer contains just fillers and botulinum toxin for anti-ageing. The solutions now include lasers, sculpting, radiofrequency, cryoneuromodulation, hydradermabrasion, PRP, collagen stimulators, hyaluronic acids and micro-needling, to name a few.9 Within each treatment type, there are multiple choices of products from a range of manufacturers. In regards to different filler treatments, the choice for the patient and practitioner depends on; the area being treated, desired effect, product structure and composition, longevity, and patient preference. Each product type requires specialist training by the practitioner and often a different consent form. Such complexity and more demanding consent makes for a more time consuming consultation, with a detailed explanation covering which treatment of many might be most suitable, what it involves and the risks.
The other transformation affecting products over the past five years has been the addition of lidocaine in fillers. This has changed the requirement for topical anaesthetic prior to treatment, which ultimately speeds up the process.
The internet, social media and growing interest in the market has educated patients as to what is available and what to ask. Social media has allowed engagement in a way never seen before and the sources of information are vast. It not only highlights new treatments and technology quickly, it also addresses bad practice and enables bad news to spread quickly and prompt questions. The engaged patient searches and follows practitioners and is able to ask questions and retrieve answers quickly. Social media empowers the patient: they use it to gather information, research practitioners and interact purposefully. The more the patient knows, the more understanding they bring to the consultation and the more questions they want answered to clarify areas of concern.
There is no doubt that the non-surgical consultation has changed radically over recent times and will continually evolve. Change can be difficult to process, but when changes are in place for improvement, adaptation produces a superior experience for everyone involved. The changing consultation has become more complex and somewhat crowded, but the options are vast, the tools ever expanding and the results that can be achieved keep on improving. The outcome should see happier patients, achieve better patient safety and a more skilled and regulated industry.
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