The Psycology of Lasers with Dr. James Wang

[Intro] Hey, everyone. Welcome to Facially Conscious. I'm Trina Renea, a medically-trained Master Esthetician here in Los Angeles, and I'm sitting with my rockstar co-host, Dr. Vicki Rapaport, a board-certified dermatologist with practices in Beverly Hills and Culver City, Rebecca Gadberry, our resident skincare scientist and regulatory and marketing expert, and Julie Falls, our educated consumer who is here to represent you. 

We are here to help you navigate the sometimes confusing and competitive world of skincare. Our mission is to provide you with insider knowledge on everything from product ingredients to medical procedures, lasers, fillers, and ever-changing trends.

With our expert interviews with chemists, doctors, laser reps and estheticians, you'll be equipped to make informative decisions before investing in potentially expensive treatments. 

It's the Wild West out there, so let's make it easier for you one episode at a time. 

Are you ready to discover the latest and greatest skincare secrets? Tune in and let us be your go-to girls for all things facially conscious. Let's dive in.

01:31 Dr. Vicki Rapaport: Good morning, everybody, and welcome to Facially Conscious. We have an excellent episode for you today. 

01:36 Trina Renea: Good morning.

01:38 Rebecca Gadberry: Are you Trina?

01:40 Dr. Vicki Rapaport: Oh, yes. I'm Trina. 

01:41 Trina Renea: Good morning. I'm Trina, esthetician.

01:45 Rebecca Gadberry: And I'm Rebecca and it's wonderful here. We're recording this on the first day of fall and it is so lovely out. It's just beautiful. Of course, we want to remember to wear our sunscreen.

01:59 Trina Renea: Always.

02:00 Rebecca Gadberry: Yes. Absolutely.

02:02 Trina Renea: So who do we have with us today Dr. Vicki?

02:05 Dr. Vicki Rapaport: I'm happy to introduce our favorite Dr. Wang.

02:07 Trina Renea: Hi, Dr. Wang.

02:09 Dr. Vicki Rapaport: So, I'm going to just remind everybody of your amazing accolades and remind people that we're going to talk about the psychology of lasers this morning.

02:18 Dr. James Wang: Oh, fun.

02:19 Dr. Vicki Rapaport: Dr. Wang is a Harvard and UCLA-trained, board-certified dermatologist and dermatopathologist, meaning he reads slides or has been trained to read slides. And, of course, he's our cherished laser expert.

He earned his MD from the Harvard Medical School and his MBA in Healthcare Policy also from Harvard, but that was at the Harvard Business School. He's joining us this morning to talk about the psychology of lasers, expectations, realities, disappointments and the recovery process.

Welcome, Dr. Wang.

02:55 Dr. James Wang: Happy to be here again. Great to see you, everyone.

02:57 Trina Renea: Hi.

02:59 Dr. Vicki Rapaport: I want to just remind people that trying to get into the psychology of patients when we do procedures is tricky, whether it's laser treatments, that we're going to talk about today, or plastic surgery and how to best serve our patients. So can you briefly explain how do the psychologic expectations influence a patient's experience when they come and see you for laser treatments and maybe talk about some of the downfalls to laser treatments when they don't get what they want.

03:36 Dr. James Wang: Yeah. I think this is a very complex subject that has been discussed before, but I think in many different ways this is a very personalized experience for people, I think even not just on the patient side but even the provider side, because we all come to our patient consultations with our own set of experiences, our own positives and negatives of what we've dealt with before.

But I think many patients do come to us dermatologists or plastic surgeons kind of with a history. A lot of people come in. They've kind of gone to different places. They're trying to figure out online who is the best person to go to for them. They read reviews. So people come into a consultation not fresh but also already with their own conceptions of what's going to happen. 

I think that makes it really challenging because we spend almost half of the consultation on just figuring out where has the patient been, like psychologically. Have you had things done before? Have you had negative experiences in the past with consultations? Did you feel rushed? What were the things that really you felt were helpful in a consultation? What are the things that you felt you really didn't get what you needed from that?

Sometimes it's hard to place that particular point of what is that person really looking to get out of that consultation, because it's not always clear, and people don't always make it clear what they're expecting from it. Some people are kind of still far from the decision-making process so they're just there to gather information. Some people have already gathered their own information and are trying to figure out which particular procedures are correct for them. Some people are just, “Hey, we trust you. Just tell me what I need to do to make it happen.”

And so there's really a wide range of what people are expecting when they first come to the door. It may be our first time seeing that patient but that patient may have been already thinking about this process for the last year, two years or may have been to other providers. So all these are really important factors that determine whether someone has a successful consultation or not.

05:45 Dr. Vicki Rapaport: I have a question about when you show somebody befores and afters. I tend to show amazing befores and afters but I also like to show somebody who just got a minimal improvement so that they can remember that visual. Do you always give these homerun befores and afters to try and convince patients to do things or are you really reasonable when you show different op, you know, different potential outcomes?

06:13 Dr. James Wang: I'm not a big before-and-afters kind of person. It's probably surprising in a very visual field like ours not to have a lot of before-and-afters. We do have before-and-afters that we take for medical documentation purposes but I rarely show them because it does put in people people's minds an expectation that may not be realistic for them.

So when I do lecture on lasers, I do give before-and-afters, but what I really like is the chronological process. This is what your treatment looks like after one or two sessions. This is what your treatment looks like after four or five sessions. So they know that it's more of a journey than a destination when it comes to results. 

And the more I do lasers, the more I realize that the results truly are variable. I mean, it is so different. Someone who comes in who looks exactly the same as someone else in terms of the spots we're trying to get rid of or the tightening that we want to achieve, you can show someone, someone who looks just like them on the outside, but because everyone has such different capacity to heal and to create collagen that the results are very different. And I think it's a disappointment when people don't see the before-and-after.

I think I agree with you on the sense that if you do show before-and-afters, you don't always just want to show your best work. You want to show probably your most representative work. But in my mind, a lot of our patients come to us trusting the process, because we do guide people through all the pros and cons and everything. We do let the people know, like, it doesn't work for everyone. We don't have necessarily like a magic bullet for everything that's out there. 

A lot of it's just the technology. We're advancing a ton but we don't have the perfect device. No such device exists yet, at least that I'm aware of. And then also depends on just their body as well for the results. 

The before-and-afters that you do show, I do agree you' be kind of cautious about it. This is why we don't do too many before-and-afters online as well because it's really easy for before-and-afters to be faked. So if you go on Google and you look at everyone's before-and-afters, everyone looks amazing. But when everything looks amazing it means nothing is amazing. It means that none of it is real.

08:29 Trina Renea: It's tricky because if you show that then the person is going to expect that. And then if that doesn't happen for them, then they're mad. What happens when they go get mad? They're like, “I just paid $2,000 for this laser,” and then what do you guys do to help them with what they do next? Do they ask for their money back? Do you tell them you have to do three more? How does that process happen?

09:05 Dr. James Wang: Yeah, I think tricky. I think that's just something in cosmetics and esthetics that we deal with all the time, because the amount people pay is based on a couple different things. The quality of the device, the effort that's gone into the consultation and also the expertise that goes into it. 

Nowhere in any of the consultations do people guarantee results, or they shouldn't be guaranteeing results. It's not that we can say in 80% of our patients we're seeing a general 25% to 30% improvement in this particular thing, and I think that's a really important part of the consultation, but I do think it's tricky. 

I think every place struggles with this and I think people go online they read reviews that say, “Oh, I had one thing done and everything's suddenly gone. Everything's perfect.” I think you do have to take those with a grain of salt because some things go away on their own even without treatment. 

Certain people have incentives to believe reviews that are glowing. So I just have to tell my patients, especially our younger patients, and we have a lot of Millennial and Gen Z patients, that what you see and read online isn't necessarily what the expectation is, because I've been doing this long enough where I know there's not a single treatment that works 100% at a time. There's nothing like that. 

It's just more of an educational component of the consultation that resets people's minds like, “Oh, yeah, that makes sense.” I want to make sure people understand before delving into specific treatments that, in general, esthetics works this way because no one knows 100%.

10:44 Dr. Vicki Rapaport: Yeah, and Rebecca mentioned something on a Tip of the Day on our Instagram a while back, saying that patients should take ownership for their own expectations, which I loved because we as patients cannot expect, even after a facelift you cannot expect perfection. You're going to have scarring. You might have a little bulge. You might be a little less tight than you think.

I realize that's not what we're talking about. We're talking about dermatological procedures and laser procedures but I think that doctors also pick the right patients to do the right procedures on them. 

The careful consultation, I love that you mentioned that, Dr. Wang, because I think it is true. In that consultation, not only are we seeing what they want, really listening to the patient, trying to give them some options to help the issues that they want to address, but we also give them really realistic expectations.

And we're also seeing how they're responding to us and sort of watching them psychologically. I remember this story years ago. I had a friend who was a plastic surgeon and did this hour-long consultation for the facelift and getting them prepped and prepared and they were all ready to kind of sign on the dotted line and pay their down payment. The plastic surgeon had mentioned all the things that they wanted the patient to stop doing, i.e. not smoke, maybe not be on any blood thinners, all the things that you prep. 

And the patient clearly said, “Oh, I'm not a smoker. I don't do any of that,” blah, blah, blah.

The patient gets up, cigarettes fall out of the patient's purse.

12:07 Rebecca Gadberry: Oh, my goodness.

12:07 Trina Renea: Oh, my God.

12:09 Dr. Vicki Rapaport: Basically, the doctor said, “Well, I'm not going to be able to perform your procedure because I feel like you weren't as forthcoming and honest with me and I feel worried about your healing if you're really going to smoke and we talked about it.”

So I think that we also are evaluating patients when they come in to make sure it's the right thing for them and that we're not going to have problems and we're going to make them happy and not have trouble with them after.

12:29 Dr. James Wang: I think the consultation is a lost art. I do think that people in esthetics oftentimes downplay the consultation. I think the consultation is probably 70% of the success of a treatment.

Look, people can fire lasers. People can memorize where to inject this or inject that, but the hardest part is that assessment. And so we don't do free consultations because we feel like people who don't value consultations don't value the process. People have to understand that that consultation with a provider that they trust and has educated them on the process is the most important thing that we do in esthetics. 

Yes, it's important to have really great devices and it's really important to get the right settings and it's really important to have those things, but lasers are dangerous things. It's really easy to injure people with lasers. With an incorrect evaluation, a great laser can be a weapon. 

So that consultation is the most important thing. I think that's the most valuable part and this is why people pay for it, because you want to pay for expertise and time and thoughtfulness. Those are all the initial components of a successful treatment, in my opinion.

13:45 Trina Renea: I agree. And we estheticians also have to give very thorough consultations. And, often, in consultations, I talk to them about lasers and procedures and plastic surgery options and stuff like that, but I let them know don't go in there expecting for your one laser that you're going to spend all this money for is going to fix your skin. Like, your products matter, what you're doing before and after, how you're eating, if your body's going to heal properly, if it's going to hold, you can't go in the sun. Like, there's so many things that I tell them before they even go in and then hope that they go to somebody… 

I recommend, obviously, Dr. Wang’s office and Dr. Vicki's office, but if they go somewhere and get something and they don't give them a proper consultation, they are often disappointed with the result. So I try to do that as an esthetician as well, try and kind of prep them for that, because you don't know where they're going to go.

14:47 Rebecca Gadberry: I think consultation is important regardless of who you're seeing or where you're going for treatments at any time.

14:55 Trina Renea: Yeah. Somebody's not giving you a consultation, you should probably not go there.

14:55 Rebecca Gadberry: Absolutely. I love what you’re saying. 

15:03 Dr. James Wang: Packages are important, but packages given out to everyone without any kind of valuation whether that treatment is actually the correct one I think is not ideal.

15:15 Trina Renea: Yes. Another thing that I notice, and Dr. Wang, you don't have this problem because you have all kinds of lasers, but, often, a doctor's office will have one laser that they have in their office. Basically, they're trying to sell it to their patient and they're saying that whatever this patient's problem is, this laser is going to fix it. I see that a lot as well.

So with my clients, they'll ask me, “Oh, my doctor says I should get this laser.” 

And I'm like, “Which laser?” And then I tell them whether that laser is correct for them or not, because sometimes people are just trying to sell their lasers as well.

15:57 Rebecca Gadberry: Oh, yeah. 

15:58 Trina Renea: And they're giving deals on packages. I mean, they're all over the place, these little shops that are trying to do that.

15:58 Rebecca Gadberry: So I have a question. We're talking about packages. We all know what packages are but some of our listeners may not know what we're talking about. I know Dr. Wang said sometimes you have to be cautious of packages. Can we elaborate a little bit about what we're talking about?

16:25 Dr. James Wang: Sure. We actually don't do packages at our practice. But the way packages are is it's really a discussion of how many sessions one thinks is needed for an outcome. Therefore, for example, laser hair removal, right? So we know that it takes multiple sessions to get a result. And so instead of purchasing them one by one, practices will bundle, say, eight or 10 or 12 sessions into ones you pay upfront and then you kind of use your sessions as you go along.

I think pros and cons to packages, I think most places do offer packages for a variety of reasons. One is it signals to people that, hey, this is not a one-time thing. I think that's a very powerful kind of message.

The second thing is people have already paid out of pocket upfront and so they're incentivized to come back and finish the treatment to get the result that they want. I think those are the pros of packages.

In my experience, which is why we don't do it, is that packages, because they are a set number, also sets expectation that when the package is done that you should already see the resolution of an issue. It can be problematic for people where maybe they've seen already great results. They say they're 70% of the way there after eight sessions, but then what they'll wonder is why was their package of 8 instead of 12 and should have been completely clear by that time. So for me, I think about that messaging and how it gets across to our customers and our patients. 

But people have done it very successfully. People definitely do like packages. We've just made a conscious decision at our place not to have them. For now, we have a few very limited ones.

With things like LED light where we people can use it as they go along, that doesn't have a specific end point. But for most other things, we like to evaluate the patient each time they come in in case that particular treatment that that package would have been is no longer appropriate based off of the response of their skin.

18:37 Dr. Vicki Rapaport: Another way to look at packages, because we do packages in the office. We don't have a lot of lasers, but the ones that we do, we'll do a treatment package and then a maintenance recommendation.

18:50 Rebecca Gadberry: That’s an idea.

18:51 Dr. Vicki Rapaport: Not really a package. So, let's say with Morpheus, for instance, we'll do three to six treatments and then we'll recommend one a year. Some people need more than one a year, but it does set up that expectation that they are going to need a maintenance version, whether it's that laser or a different laser.

I think the other lovely thing that you said, Trina, was doctors do purchase these lasers for hundreds of thousands of dollars and so they obviously want to get a return on their investment. So somebody like Dr. Wang who has multiple lasers, he is really going to choose the right one for your skin or for what you're coming in for. Not a lot of doctors do that.

I refer out all the time for lasers. Sometimes, that's how I decide to purchase my own laser when I'm realizing I'm sending all these people out for this one particular laser, because I know the lasers that work the best. I'm not going to push them into using something that I have that doesn't do what they are looking for just because I want to pay off my laser. That is not the case at all with our office.

And when I realize I'm referring out these patients ten times a day, I'm like, “I need to consider purchasing this laser.” I like that as a tool for myself, but, yes, if your doctor says— and some places are a one-stop shop. They really do have every technology and everything to satisfy, but it should be different modalities. There isn't just one device for everything.

20:12 Rebecca Gadberry: Yeah. Are packages cheaper than like one-time-only treatments?

20:17 Dr. Vicki Rapaport: Yes. Usually, you save a little bit of money if you're buying a package. And it is true you do like to set up that expectation that's going to take multiple treatments to get to a certain place and they're saving $100 or $200. I don't really know, like depending on what laser they are wanting or what peel or what facial package, but, yes, of course when they buy more they're saving money.

20:40 Trina Renea: So do you find that, like, if they buy a package of three, let's say, do you say the results might not be complete at three?

20:51 Dr. Vicki Rapaport: Yes. Absolutely. It's all in the consult. Again, back to the consult. We're going to explain to them they're going to have some tightening, some pore reduction, some improvement of skin texture, but it's not like they're going to look 20 if they're 50 years old. 

21:02 Trina Renea: Like they have a facelift.

21:04 Dr. Vicki Rapaport: No. Never. 

21:04 Rebecca Gadberry: Right. So it's all in the consult.

21:06 Dr. Vicki Rapaport: Yes.

21:06 Trina Renea: It's all in the consult, I really think. It's so important.

21:10 Dr. James Wang: Yeah.

21:11 Trina Renea: Also, I think with the consult, you guys as doctors learn more about the patient, whether this patient is the right person for this laser anyway. And without doing the consult, you could have a problem on your hands when the person comes back with expectations. 

21:11 Rebecca Gadberry: Right. So it's beneficial for everybody involved.

21:34 Trina Renea: I also find like the downtime varies on people. Sometimes, for instance I'll just say myself. I went and got some kind of a laser-ish thing. I went to a person who was wanting to show it to me and my face blew up like a balloon. She didn’t tell me that could happen. And maybe it doesn't happen, but it happened, and I couldn't get a hold of the office and I was panicking and freaking out. I had to call Dr. Vicki to get me some prednisone. 

But it was like, “Oh, my God, my face feels like a balloon that's going to pop.” It was like very big.”

22:16 Dr. Vicki Rapaport: Swollen.

22:19 Trina Renea: And so that was not an expectation.

22:22 Rebecca Gadberry: That should be mentioned in the consult.

22:23 Trina Renea: I also couldn’t get a hold of the office. Like, I do also find that doctors these days are giving their cell phone numbers to people. Do you guys do that?

22:32 Dr. Vicki Rapaport: I just gave my cell phone to somebody yesterday. I did a little surgery on her, a lovely lady, and it's the weekend. I'd rather give it to her and have no problems than for her to suffer and get so upset, go to Urgent Care. They're not going to know what to do.

22:46 Rebecca Gadberry: They can mess things up horribly.

22:48 Trina Renea: Do you, Dr. Wang?

22:51 Dr. James Wang: We don't give personal emails or cell phone numbers. I do this intentionally. I think it depends on the practice. We're growing really fast. And one thing I do want to make really clear, and our patients understand this, is that my role as the head of this organization is to not just only to protect patients. It's also to protect my providers. 

Doctors are humans. Doctors deserve to have a weekend. Doctors deserve to have evenings. I want to be really clear that my role is to make sure that my doctors are happy, they have good quality of life, my patients can get access to us. We have a centralized system with which our patients can reach us, but it is filtered so there is an ability for a frontline person to help the patient at the point of contact. And anything that really does need to be funneled to a certain person, we have a process for that.

But I do tell my providers, “You can give your cell phone numbers. You can give your email if you want.” We have a specific email that is work-related so it doesn't get messed into or kind of like melded into their personal lives. So I'm a big proponent of work-life balance and I think it leads to healthier and happier doctors, which leads to healthier and happier patients. But we do have a system for that kind of stuff so people don't have to feel like the emergency room is the only way they can get air after treatment. 

Now, that being said, most of the treatments that we do are non-invasive or minimally invasive, and so we're not doing any major surgery. Certainly, if we're doing things like most surgery and things that are a bit more there's like bleeding risk and other kinds of risk, absolutely, there is a specific responsibility for the surgeon to be on call for those surgeries. But most of what we do, we give really good pre- and post-care instructions.

We're also open on Saturdays and so we actually do answer phone calls and messages on Saturdays. For us, that is also our additional timeline. So it's really only on one day of the week where you can't get that direct access to the clinic, but we have a whole system set up to accommodate emergencies and urgent questions.

That is maybe a slightly different way that deal with it, but I do feel very strongly that my job is to protect patients but also to protect our providers so they actually can have personal lives and family life and those things on the evenings and weekends.

25:21 Rebecca Gadberry: So you don't abandon the patient? They still have a way to communicate and get help.

25:24 Dr. James Wang: No. Absolutely . So we have not only phones but we actually have a direct HIPPA-compliant messaging system that they can message us directly. It's where they can send photos, they can send those things in real time. We basically intercept those and make sure that people are doing okay.

25:47 Dr. Vicki Rapaport: We have the HIPAA-compliant texting system too and it's great because although it's not in the chart, it basically is interrelated, in a sense. We go back and forth. We use Klara. What do you guys use?

25:59 Dr. James Wang: We use Klara as well, yeah. It integrates with our electronic medical record. And so it pulls the information in two directions so we don't do too many manual type of things. But it pulls that up, their phone numbers as well as we can look at, it links directly to the electronic medical record. It's really nice to have that integration happen.

26:23 Dr. Vicki Rapaport: And what's your electronic medical record? Do you guys use EMA?

26:25 Dr. James Wang: We use EMA.

26:26 Dr. Vicki Rapaport: Amazing. So do we.

26:28 Dr. James Wang: Yeah. They integrate.

26:30 Rebecca Gadberry: State of the art.

26:31 Dr. Vicki Rapaport: State of the art.

26:32 Trina Renea: So, I have a question. Do you find that different age groups react differently to their expectations of lasers, the younger 20, 30-year-olds compared to the 50, 60-year-olds? Also gender, does that make a difference? Do men tend to be more, like, fine with it than women or… that's two questions.

27:03 Dr. James Wang: I think there's a very big difference generationally. I think patients who are in their 50s and 60s have seen the evolution of esthetics over time. They’ve seen all the trends and the fads come and go. They're aware that there's no magic bullet.

While sometimes our younger patients, the information is only filtered through TikTok, which is a couple seconds of really, really distilled, oversimplified thing.

And so I think part of when we bring new providers, we have a sit-down orientation. The orientation is how do we position things in a way where people know what is information and what is for entertainment. TikTok is for entertainment.

And there are some snippets of educational value but most people on TikTok are not experts in this. Like, tell me you're an expert once you fired the laser. Don't tell me you're an expert if you have not done anything but you're just making a commentary. A commentary is a commentary. It's an opinion piece. It is not an absolute fact.

And so part of it is just discussing the modes at which information is bombarding people every single day and figuring out, hey, like if you want… 

I don't believe I'm the arbiter of the truth, because I really don't believe that anyone has the answer, but there's something to be said about education, training, experience together that gives us a really three-dimensional view of a treatment process. And people can then decide on their own what they want to do.

I do think generationally, there is more of a discussion on that front when the people are younger. People who are a little bit older tend to be like, “Look, I understand that this is not going to solve all my problems.” Oftentimes, they've already done some of the noninvasive things and they've seen those results, and some are very pleased with the results but they know that new things come out. That there are side effects to everything. 

I'm a firm believer that there is no perfect solution to anything. I think everything that has a pro has a con, whether that's skincare, whether that's Ozempic, whatever it is there's always something on the backend. Whether you know that exists or not does not make it go away.

Skincare is the same way. Lasers are fantastic in some contexts, but then in other ways they are not. They have kind of hidden side effects that are oftentimes ignored, especially in a short 30-second or 60-second snippet of a discussion.

Podcasts like this are helpful because they are a bit longer. They allow us to discuss things in-depth versus just a quick, like, how many seconds can they get an eyeball to look at this particular video post. And that gives the algorithm, I guess, time to move it up to the top of people's feeds.

30:07 Trina Renea: With lasers, do you find that you have a younger patient or an older patient?

30:13 Dr. James Wang: Our patients are really young, surprisingly so. I think when I first started my practice not that long ago, honestly, I was expecting the older population where people are actually trying to fix things that they see in the mirror, like deeper lines and wrinkles or kind of like blemishes that happened over decades from sun damage. But our patients are really at that cusp of, “I see my parents looking this way. I want to prevent that from happening.”

So we have a lot of people who are in this pre-juvenation stage, which is why I think our consultations are so critical because we can tell people this is the treatment and this is pre-juvenation. And when you’re doing pre-juvenation, do no harm is always the first mantra. You already have good skin. How do we keep it this way versus taking a risk and getting your skin to have some side effect that then requires us to fix something?

And so this is kind of a different way to— it's not guaranteeing the result but it's also discussion about how the skin will naturally mature over time. If you want to slow that down, these are the lowkey options we have to get you there while minimizing any risk to you throughout this journey.

31:30 Trina Renea: Interesting. Okay. How about men to women? Do you find— I mean, you probably have more women, but like do men react differently to their expectations than women?

31:41 Dr. James Wang: We have a surprisingly even number of men and women at our practice. I don't know what it is about our practice but we have a 50/50 split.

31:49 Trina Renea: Really? So guys are getting a lot of lasers too?

31:52 Dr. James Wang: Absolutely. The guys don't talk about it as much in their friendship circles, and I think the biggest concern that guys have when they come in is like, “Is anyone going to know?” I think that's like the first question. 

I think in LA most women are like, “Eh. Like we talk about it. My friend told me about the treatment she had with you and she loved it, and so all of us are coming in.” Like that happens a lot with women. 

I think guys are more like, “I don't want my guy friends to know.” And so we're just very— it helps us select the right treatment for them where, yeah, you're right, there's no downtime.

Now, again, that tradeoff. Without downtime, it may take more sessions to get to the end point, but people can make that choice for themselves. I'm not here to dictate what someone should feel or something. We don't judge. Our big thing is like here are the pros and cons of these various treatments that we have. And, from that, they can choose what they want to do.

Men also run the gamut of how they feel. I think it's more of a personality profile of high anxiety versus low anxiety. I think that helps us also choose what it is. And people come and they know. Like, people with high anxiety come in. They come in like, “I have high anxiety. I have a lot of questions.”

And we're like, “That's fine. Our goal is so we give you the information and you can decide whether it's the right thing for you.” 

We don't make anyone do the treatment that day, although we oftentimes can, but that anxiety level will dictate what we start off with first. And that is a non-gendered personality trait, in my experience.

33:27 Dr. Vicki Rapaport: A couple of things you said made me really understand that it's so important when the patient is a really good communicator. My day would be perfect if my patient said, “I know this won't solve all my problems. I know there are some downsides. I know there are side effects, but can we do this?” That would be awesome. They don't say that.

And then also what you said, when the patient comes in like, “I'm high anxiety. I have lots of questions.” Great. Like, “Yes, give me your questions. I'm happy that you know you are a high anxiety. I'm happy you understand that. Now I can treat you in a different… maybe a little kid glove more than the other one before you who was a little more laissez-faire.”

So I think as a patient, being a really clear communicator is so important. Talk to your doctor. We have heard it all. Nothing will surprise us. Don't be ashamed of anything. Give it to us straight.

34:16 Dr. James Wang: Agreed. If you hide information like that, you mentioned that plastic surgeon, if you know you’re a certain way but you're hiding it in that consultation, it will lead to mistrust. It will lead to dissatisfaction. 

And so what happens is if you're not forthcoming in the very beginning but, say, two treatments later you feel like you should have gotten something else but you never voiced it, we're not mind readers. We don't know. We're doing what we think is the best for you based off of what you tell us. And so two sessions later, if you're not specific, “Oh, I thought I was going to treat this but not that.” 

Number one, it's not great for yourself but also it really breaks the bond of trust between the provider and the patient. I think at that point sometimes it's irreparable. Then they have to move on to someone else. That cycle can continue happening.

So I agree that communication is really important. Part of it is that providers communicate and we try to elicit as much as we can through that trusting relationship out of the patient in that limited amount of time that we have, but it's also the patient's responsibility to be willing to open up to discuss these things and to be aware of the insecurities that we all have inside about why we're doing what we're doing. 

Esthetics is a complicated thing. People are using esthetics to treat different types of things. I think, oftentimes, the superficial masks the deep. I think it's really important for people to realize that superficial changes don't alter the deep in a material way, so it's also important to understand why you're doing something and what it means to you. A really, really deep and fruitful relationship between provider and a patient, that does come out. And that can be discussed without any kind of judgment. That's a really important relationship to have.

36:09 Trina Renea: I think that's super important and that's a great takeaway for this episode for sure, because it is deep. And the reason you are going in is a feeling you're having about yourself. To manage that with your doctor I think is a key important thing. 

I think that being said, you should really be careful about the doctor you're trusting. If you don't get a good feeling, like that you guys are having that good communication, maybe it's just not the right provider for you and you can step away and choose somebody else even in the same practice, if you like to go there. I don't know who you would tell that to but, like, you don't have to make that decision right then and there. You can step back a second if you feel that something's not matching. 

37:05 Dr. James Wang: We always tell patients that they should. They should talk to different providers to figure out who's the right fit for them. I think a red flag for a provider is someone who gets defensive about someone potentially getting a second opinion. I think people have the right to have a second opinion. 

Certainly, I do it when I search for doctors or whoever else I'm going to. I don't need someone to make a snide comment about me wanting to make an important consumer choice. I think we live in a world where we do have a lot of choices. There are places where there's only one dermatologist in 100 square miles where you don't have a choice, but in Los Angeles we have so many dermatologists and there is the right person for every person. So I think it's really important to be educated with the kind of provider that fits your personality the best.

37:54 Trina Renea: Yeah, and who's going to understand you. Just like picking relationships. You have to pick the right person.

38:02 Dr. James Wang: Different podcast.

38:04 Trina Renea: Yeah. Well, that was awesome. I think we're good. I think we got the point across and I think that was perfect. You're awesome. We love you.

38:14 Dr. James Wang: Fantastic. This is fun. It's always fun.

38:18 Trina Renea: We have a question. Do you want to…

38:21 Dr. Vicki Rapaport: We have a listener question.

38:23 Rebecca Gadberry: This question actually comes from a listener in Alabama and it's an interesting comment about what we've been focusing on here at Facially Conscious because, as our listeners know, we come at everything. We cover everything from procedures to skincare to ingredients. If it has to do with skin, we talk about it.

But this person, who's a man, said a lot of people don't have the money and are not going to be doing all of these procedures or they don't have access to them, especially in places like Alabama or some areas that are rural. And I'm not picking on Alabama. I'm quoting this gentleman, so I don't know about all of that but that's what he had said.

And he says, “So you talk about all these procedures but most of us won't get them. If somebody's on a limited budget, what are one or two procedures you recommend that offer the most bang for your buck?”

I think that's a fair question.

39:32 Dr. James Wang: Is this for me?

39:33 Dr. Vicki Rapaport: Yes.

39:35 Dr. James Wang: I actually, one of the things that I think make us unique is that when we bring on new providers, I say there is a traditional way of looking at relationship of patients, doctors, healthcare providers to money. My background is part business, part medical so I have no problems talking to people about money. I think it's super important. I think that question is so important because you can't do a proper consultation without talking about someone's budget. For us, we integrate the discussion of money with the treatment options.

Look, there are different buckets. This is the lowest high-value low-cost option, these are kind of our middle-of-the-road. As you pay more, yes, we're charging things based on the value of things over time. And so, sure, you're not going to get that two-session laser treatment to get rid of all your sunspots in one session without paying much out of pocket. However, there are things that are more economical that exist everywhere. 

And so the discussion about kind of which bucket you want to discuss in entirety, because we don't discuss lasers unless someone brings them up, honestly. We try to always find ways for people to treat what bothers them the most in the most economical way possible. But the truth is, there are certain things that are not possible to treat that way. If there were, we wouldn't even have that entire field exist. Why have lasers if a simple clean can fix all the problems that exist on the skin?

But people know that from the consultation, like we discuss there are things that we can prescribe you, because as dermatologists, Dr. Vicki and myself, we can prescribe medications while there may be some, like, medi-spas or various places that don't have the ability to prescribe so they may not have the full arsenal at their disposal. 

But, for us, we always put things into— we look at people's insurance. We look at people's ability to pay. We look at people's expectations. And, from those, we'll figure out is an over-the-counter skincare product enough? Will that do more harm than good? Are there prescriptions we can send over that will help over longer period of time knowing that that patient also knows that it does take more time to get to a certain end point? If someone can't get to that particular end point, then do we discuss procedures or options that may work better for the future?

I tell people, look, people waste a lot of money. People come in and say, “Oh, the co-pay is so much. It's $70.” That's their co-pay from insurance. And you think about all the things that people spend money on, whether it's a face wash, whether it's a subscription to Netflix, whether it's a dinner that cost $80 in LA these days for a standard dinner, which is so crazy. People can choose how they spend the money but people have to know that they're getting something out of giving up something for another goal. 

And so I think it's really important to talk about how people save, how people disperse their money, how people view the importance of their skin relative to other facets of their life. And, again, it depends on people's priorities. I like to go through that with people when they come in and say, “That's expensive.” I was like, “What do you mean by expensive? What does that word mean?” 

Because things that have high value actually are not expensive. They're actually investments into a result. And there are many things in the world that are expensive that don't give results and so people have to understand that. That's how I would approach that question. I think it is a good question without a one-word answer, but I do think it's really evaluating all the things that we're spending in our lives and figure out what are the things that are worth it, if that's really going to help you get to your final goal.

43:39 Rebecca Gadberry: So from what I'm hearing, it kind of depends upon what the person wants to work on and how much they're able or willing to invest in it?

43:53 Dr. James Wang: Yes. It is very specific, because there are certain things that are not treatable with topical things. 

44:00 Trina Renea: Well, I also don't think there's a one-size-fits-all type of a laser or a procedure. It really depends on the person and what their issue is on their skin and how they live their life and where they live. You can't really say, like, “This is good for everybody. If you want to get one laser, get the IPL.” I think it's not as specific. You can't really say that.

But also, in his area, what he needs might not be offered there. So I think, like take a vacation and go to Los Angeles and see a doctor that can offer you something. I don't know.

44:44 Rebecca Gadberry: Most people won't do that, though.

44:45 Trina Renea: I know, so maybe don't do it.

44:48 Rebecca Gadberry: I think that the question was more aimed not at whether I should do a product or a procedure but only procedures. And are fillers better than lasers as far as more bang for your buck? And that's what I'm hearing. 

I thought the same thing when I was asked, but I wanted to pose it here because I think a lot of people do think, “Well, gosh, I'm not going to afford $80,000 for this.”

45:19 Trina Renea: I think a little Botox goes a long way.

45:20 Dr. Vicki Rapaport: Honestly, when I first heard you say the question, I obviously wanted to give James an option to answer first. But my kneejerk reaction to that question is Botox, because it…

45:33 Rebecca Gadberry: Or the other one that we've been talking about.

45:34 Dr. Vicki Rapaport: But again, he might not care about a wrinkle in between his eyebrows or he might not care about his forehead or his crow’s feet, so it wouldn't be appropriate for him. But that is my kneejerk reaction and that it is almost impossible to mess up Botox. Almost impossible. You can almost guarantee people will be quite pleased with the results and it's minimally expensive.

45:55 Rebecca Gadberry: What about the other one that came out that we talked to Dr. Day about?

46:01 Trina Renea: That's the same type of thing.

46:02 Rebecca Gadberry: That lasts longer.

46:03 Dr. Vicki Rapaport: Oh, the Daxxify.

46:04 Rebecca Gadberry: Daxxify, because I know Botox is a registered trademark. So Daxxify is the same concept.

46:11 Dr. Vicki Rapaport: Yeah.

46:12 Trina Renea: There's a few options that do the same thing to numb out a muscle.

46:15 Dr. Vicki Rapaport: So the neuromodulator option to me is the fast answer. But, again, if he cares about his pores or if he has acne, then maybe at-home peels. 

I had this a lovely, lovely patient who had terrible sun damage on her chest, didn't want to spend any money. She really did need an IPL. It would have been a one- or two-and-done and her chest— she was very light-skinned, we could have really amped up that laser. She would have had a beautiful result, but she didn't want to spend the $350.

So what she ended up doing was getting an $11 product at Sephora and she used it for a year. And I'm telling you, she repeatedly refilled this. So she probably got 10 of them. Maybe she spent $100. Her chest looked much better.

She was super motivated. She used it for a year. She needed to use it for a year. It did work. It wouldn't have worked if she used one bottle. So I think it all boils down to, again, having that man go and get a consult. Go to the dermatologist. Get a skin exam and, at the same time, ask the question about what should he do for the biggest bang for his buck, because they should be able to help him.

47:19 Rebecca Gadberry: I think that's probably the bottom line with what's available in your area. Go to the providers. Interview them. Do the consult and ask them their opinion as it applies to you. I don't think us sitting here can make any real recommendations, unless we can see the person, because everybody's different.

47:41 Trina Renea: For sure. 

47:42 Dr. James Wang: Yeah, for sure. I think the theme of this is the consultation. I mean, really, that is money well spent, especially locally because your local provider should also know what's available to you locally too.

47:56 Dr. Vicki Rapaport: And you say money well spent. There are sneaky consultations that patients sneak in on me. Of course, I give them a full consultation, but they come in for their skin exam and then I'm about to walk out the door because I think I've given them the best skin exam ever…

48:08 Rebecca Gadberry: They do the Columbo, “Oh, one more thing…”

48:10 Dr. Vicki Rapaport: And then they're like, “Oh, I don't want to talk to you about my pores.” 

I'm like, “(inhales deeply) Okay.” And so they sneak it in and it's totally fine. Now, whether it's absolutely thorough or not depending on how much time I have, but I don't charge them for that. So it is a way to get a quick consultation.

48:27 Dr. James Wang: There you have it. That's the back door to see Dr. Vicki.

48:31 Dr. Vicki Rapaport: Oh, no, no, no, no, no. Oh, no. I'm doomed. 

48:37 Trina Renea: Look what you just did. 

48:41 Rebecca Gadberry: Well, we have, I've learned so much in this. I really have. This has been great.

48:46 Dr. Vicki Rapaport: Yes, Dr. Wang, excellent. I love everything that you said. I feel like you're so thoughtful. You're so kind. You're so caring. You obviously have a thriving, fascinating, fabulous office business.

And also, how do you get all your providers? Do you guys use Indeed or do you have like some kind of— because I feel like you have wonderful… I mean, obviously, I'm not expanding the way you are. I know you have a goal of lots and lots of locations, but how do you get your providers?

49:15 Dr. James Wang: You know, I think about this but I don't know if I have the answer to that either. I feel like people approach us because I think they're excited about what we do. 

I think as Dermatology as a field gets consolidated, they feel a lot more corporate in many cases, and people are still looking for that creative outlet where they can grow and learn and have colleagues that are of the same mindset. 

I think that it's all word-of-mouth, because we don't really post or list any provider positions that are open but we get approached a lot, because our providers, actually, they have their own work as well and they did training with this person and that person. When they're having a really good time when they go to meetings and meet each other, the people are like, “Oh, wow, that sounds great. I would love to see if there's any opening.”

So we don't post very much. For us, it really is an organic kind of thing. I like to think that's because we value our providers a lot and we want to make sure everyone's getting properly trained but will also have a lot of fun toys to play with. We have a lot of lasers. But we also really value our providers as human beings, as people not just workhorses. 

I think it's so important for people to not to get burnt out, to really love what they're doing, and that translates to patient care. I really do believe in that emotional investment into our entire team and our leadership as well.

50:47 Trina Renea: I love that. Thank you so much for sharing it all with us today.

50:50 Dr. Vicki Rapaport: Thank you, and we'll have you back again.

50:53 Dr. James Wang: Until next time, right?

50:54 Dr. Vicki Rapaport: Yes.

50:54 Trina Renea: We'll have you back again soon.

50:54 Rebecca Gadberry: Until next time.

50:56 Trina Renea: Have a good rest of your Saturday.

50:59 Dr. James Wang: Thank you so much. Great to see you. 

51:01 Dr. Vicki Rapaport: Okay, everybody. Bye-bye now.

51:02 Trina Renea: Bye.

51:02 Rebecca Gadberry: Bye.

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