SPEAKER_00: 0:07

You're listening to the Ance Your Practice Podcast Series brought to you by ASPS University. I'm Diana Schwartz, Chair of Practice Management Committee, and I invite you to check out all of our educational offerings from professional surgical videos, courses on practice management, and much more on ASPS Ethnic. Welcome to today's podcast. I'm Diana Ewan Schwartz, and I'm joined today by Dr. Scott Miller, founder of Miller Cosmetic Surgery in La Jolla, California. He's clinical instructor at UCSD and an attending surgeon at Scripps Memorial Hospital. Dr. Miller trained under the legendary Dr. Bruce Connell, and for more than two decades has carried forward that legacy of artistry, safety, and authenticity in aesthetic surgery. So, drawing on more than two decades of experience as a board certified plastic surgeon, Dr. Miller offers an insightful and approachable look at modern aesthetic medicine. With his trademark emphasis on artistry safety and individualized care, his book, Authentic Beauty, guides readers through the world of plastic surgery while highlighting what truly matters, results that look natural, honor individuality, and stand the test of time. So, Dr. Miller, welcome. Oh, thank you very much. It's great to be here. All right, great. So now that we know a little bit about your summary, if you could just take us all the way back, maybe to you know how you trained with Dr. Connell and sort of where your career has led you to date and sort of what you're doing now, your practice, and I can kind of you know guide you through because I think I've asked you like six questions, but if you could kind of take us from the history to current time, um, the floor is yours.

SPEAKER_02: 2:10

So uh, you know, I always had an interest in uh facial rejuvenation, facial aesthetics, uh, but was interested in the breadth of plastic surgery as well, and think there's a lot of overlap. Um and interestingly, just for the residents out there, when I was going through training, I kind of picked people's brain, and I was told that plastic surgeons were the best surgeons, so I decided that's the way I was gonna go because I wanted to be technically as proficient as I could as I went through uh the various steps to sort of take good care of patients down the road. Um, so that's kind of the road I took, and I did general surgery like a lot of us, and then plastic surgery, and um then uh as I was coming to the conclusion of my uh plastic surgery training, uh a friend of mine who I had uh followed and had been very inspirational during my medical school and general surgery. I had spent a lot of time with David Furness and Bruce Ackauer at UC Irvine and worked with um Gars Fisher and Peter Witt and the various other people who were went through the residency and fellowship there at UCI. And um as I was going through that, basically uh Garth had done a fellowship with Dr. Bruce Connell and uh and just said, you know, and Garth was quite a good surgeon and and uh quite a good clinician, and he just said he had never seen anything like that. He said he went over and visited one day and decided I just gotta I just gotta pick that guy's brain and do everything he's doing. And and then he did that and felt like it was worth its weight in gold. And so I was committed to do the same thing. So I spent a year with Dr. Connell and um was also a clinical faculty at UC San Diego at the same time, um kind of running back and forth up and down the coast. And you know, what seemed kind of a little bit crazy at the time, but it turned out to be the best training possible because I was doing fellowship, watching, assisting, and then having my own cases at the same time and putting these things into play. And um also unbeknownst to me, I was developing a practice that was I was just trying to develop my skills and abilities, um, and was developing a practice at the same time just by taking care of people and by uh earning their trust. So over time I ended up uh with a fairly uh healthy um clinical practice uh up and down the coast and decided to settle here at San Diego. Uh looked at every economic factor out there, it all said to go towards LA and Orange County, but followed our heart and lived where we want to live, which is my advice to everyone, um, and um settled here. And uh we found that if you do good work and take good care of patients, I think that that's the the gold in our field is the patients. If you if you take good care of patients, the patients will come. And if you have patients, the rest of the practice, uh as long as you pay a little bit of attention to the paradigm and structure of your practice, takes care of itself. So it allows uh what it's allowed me to do, I should say, is really focus on uh taking good care of patients and uh practicing the way we'd want someone to take care of us, and then the rest of things kind of fall into place. I should mention also that uh uh Steve Miller, no relation, uh who worked at Scripps Clinic had been the chairman at Oregon and um Hershey, Pennsylvania before that. And he was very helpful too in giving me advice, and he said to always control your overhead, not just professional but personal, because that enables you to make better uh clinical and career choices. And so that was very helpful too, as I never uh dug myself in a hole where I felt like I had to do anything I didn't want to do, be it style of practice, type of practice, operating on a patient, specific patient or not. So leaving that flexibility to make wiser choices was very helpful. So over time, uh with a general idea of the goal, uh we I developed uh the practice that I really, really wanted and created. I kind of looked up one day and said, wow, that's sort of exactly how I would have designed it, even though I can't claim to be that um omniscient, um, but I was just sort of had a general idea where I wanted to go and followed that path, trying to take good care of people. And uh that's kind of what I try to go through in this book is how um you know, if you if you set up the right paradigm and practice model and and then you know try to give people the roadmap that we followed to combine artistry experience and ethical care to really uh get them in the best interest of your patients. And uh it's just painful to look out and see uh extremes and and fleeting trends being the identity of plastic surgery. And so part of this book was to kind of reshape the perceptions of what plastic surgery can be and do for people.

SPEAKER_00: 6:55

So um you took us through a nice journey, but would you say your practice as far as types of cases that you're doing or the types of patients that you're engaging with is the same when you started to where it is now?

SPEAKER_02: 7:11

No, I mean I certainly when I started, I you know, I feel like I got a nice broad training in plastic surgery, and I was pretty open-minded. Uh it kind of reminds me of uh the story about um Virgin Airlines, supposedly, when uh Richard Branson started it, but then he leased the planes, you know. So, you know, write things in pencil and have a general idea where you want to go, but be adaptable and flexible. And I I mean I was willing and hopefully able and willing to do anything and go anywhere. I mean, at one point I was working in Orange County, San Diego. I was working at half a day at a wound care center. I was talking to the CEO of the hospital about starting a replant program. So I was open-minded about where things could go, but I did have a direction of what my ideal might be. I would say when I started practice, I did everything for a couple of years and then kind of zoomed in, everything being reconstructive as well as aesthetic. I was fortunate to have a little bit of a healthy flow of aesthetic patients that had resulted from that initial experience and then built on that. And then as that grew more and more, and as I found that I was busy in office number one, there was no point in going to the driving to the womb care center, and then there was no point of going between Orange County and San Diego, and then gradually it narrowed down not only in terms of geography to one office, but also in terms of um case type. So now I do mainly uh face, probably 70%, and then um I do still do uh breast reductions and lifts, and I'll do uh body surgery for patients when it sort of falls. I feel like it falls in my wheelhouse, and when I feel like it's really uh the ideal thing for a patient that's uh a previous patient or somebody I'm doing something else on, but uh revisionary breasts and and uh you know complex uh full-body postbariatric surgery and whatnot, we refer a lot of the stuff within the realm of plastic surgery. We refer to people who do it every day because I think that's a huge factor in whether you uh get the come and stay good at something.

SPEAKER_00: 9:17

So take us through a typical week for Dr. Scott Miller. And again, how many years are we in practice now? Like what year are we in?

SPEAKER_02: 9:28

Uh I guess so. Again, as you heard my story, I kind of ebbed into practice. So I, you know, I'm about 27 or 8 years uh from let's see, from finishing fellowship now, I'm about 27 years. So that's you know, for finishing uh residency, 28 years. So depends where you when when I started counting, because like I said, I kind of I was doing the fellowship and then working at the same time. Um, but yeah, about 27, 28 years. And my practice is is here in La Jolla, uh, I've been since 1999. So uh that's when I really kind of that's when I really kind of put down my footprint for about like there was about a year or two of uh you know multiple offices and settling, but my formal practice I pretty much established in late 98, 1990, 99.

SPEAKER_00: 10:20

And you've been by yourself in solo practice since that time when you settled in Lorraine?

SPEAKER_02: 10:26

Yeah, and I was always in, I was always in pretty much always in solo practice. It's just the first couple years was more sharing spaces, which uh was very helpful to sort of um figure out again, get to see a lot of uh modes of practice and see things that you wanted to emulate and see things that you didn't want to emulate.

SPEAKER_00: 10:46

And and since you've been in practice in Loja, do you uh do any reconstructive still or is it mostly aesthetic now?

SPEAKER_02: 10:55

I still do a fair amount of Moe's reconstruction. Um we're fortunate to have a patient population that that uh can make choices, you know, is fortunate enough to make choices, and so I still have a good relationship with a number of the uh MOES surgeons who like to send their stuff over, especially since we have a surgery center and we can handle it on a save-day basis or a next day basis. So I still do a fair amount of that, and I participate with the interface uh program, and so I do a fair amount of clef lip and pallet and whatnot and various other uh surgeries that are necessary in the third world when we go on those missions, which I do like once a year. But in my practice, it's really MoS reconstruction and then aesthetic surgery with the inclusion of rest reduction, which as you know falls in that spectrum.

SPEAKER_00: 11:45

And so I guess for the more complex cases, you're doing it at uh the uh Scripps Hospital, correct?

SPEAKER_02: 11:54

Yeah. Or we're on the campus of Scripts. We have our surgery center here where we do all the you know appropriate cases that give people kind of the comfort and privacy. Um and then we have uh we're here on the campus of scripts, which is very handy uh for when when that's necessary and appropriate.

SPEAKER_00: 12:13

And do you do uh surgeries in your office as well?

SPEAKER_02: 12:16

Yes, yeah, yeah. So we have a Quad A certified uh surgery center. We've had that since 2002. Um and um we do almost everything there. We have two board certified anesthesiologists that rotate through. They're both fellowship trained, and um and then we mostly uh Tiva uh with regard to anesthesia techniques and stuff. Um so that's what we do here. We have everything, as you know with Quad A, we have everything that you'd have in the hospital. In fact, I always tell patients we're actually closer to all the physicians are on the first floor or the third floor or the fourth floor, so they're all surrounding us. Um so you're we're closer to the various specialties than if we were in the hospital for the most part. But we're on the campus of the hospital and we're actually across the street from UCSD as well. Uh we're online clinical faculty.

SPEAKER_00: 13:08

We would you say that that's been a bonus for you in terms of any kind of referral or relationship with your colleagues, or would it have would it have been sort of a similar situation had your facility been standalone? Like, for example, those who are looking at engaging in a facility that's like multi-specialty but your own, or whether it's uh you know, would have been the same sort of results if you were you know completely out on your own.

SPEAKER_02: 13:41

Yeah, I think um to quote Arthur Ash, you know, you start where you are, use what you have, and do what you can. And I think that um I think that it's manageable either way. For us, it's been a huge advantage. Uh it was particularly early on, being on campus was very, very helpful. I mean, I would I would end each day with, you know, when I early on when you're kind of still uh growing and hungry, I'd end the day with a little walk by the ER to see if my friends in the ER needed any help with anything. And that, you know, it just helps you with uh, you know, being a part of the medical community. It helps you uh probably with referrals, although I never really counted them, um, but it certainly helps you uh maintain a connection to the medical community, you know, which we all evolve from, but then it's really easy to get separated uh from that. It certainly helps when I have patients, you know, we have patients of all ages, but particularly canting middle-aged and older, uh, oftentimes with facial rejuvenation, and they need a lot of uh checked boxes and checked health checks and various studies, and and having that relationship where I can call somebody who's next door across the street, uh, get them in, communicate with them. They're people that I see walking in and out of the office and hospital uh on a regular basis. So from a from a relationship standpoint, from a practice growth standpoint, early on, um I think it was really important. I think it's manageable uh the other way as well. Um, but particularly not being part of a multi-specialty practice or a bigger group, I think maybe it's even all the more important to be uh on or about campus. Otherwise, I think if I wasn't, I would have taken a concerted effort to maintain that connection, uh, which was important to me both in practice and also psychologically.

SPEAKER_00: 15:36

So I'd like to now start getting into the book, but uh hearing your story about your practice and how to set you set things up, you obviously have a wealth of information. So, I mean, for those who are starting out, let's say senior residents or early young physicians, I think that sometimes they sort of see the path that you know you have taken and many others of us in plastic surgery and see it as this sort of daunting task. But I feel like the way you speak, it sounds like a fun adventure. Um, so if you could give some advice, uh would you say that it's different now, or are the I guess landscape have the same sort of opportunities as it did during your time?

SPEAKER_02: 16:26

Yeah, I think it's a different mountain, but it's still a mountain. And I think that I think it it's fun if you keep your you keep your overhead controlled, again, both personal and professional, you keep your mindset on why you chose to do this in the first place. I try to remind myself on a regular basis, you know, when when it gets tedious or when it gets frustrating, you know, you just remember that you craved most of us, we worked really hard to get the privilege of you know taking care of patients in this way and this specialty, and and to remember that you, you know, how important that was to you. I remember the days when I would follow uh Dr. Furnace around on rounds and and how honored I was to be in the presence of Dr. Connell, who was such a genius. And um, I think you keep that top of mind and it really keeps you oriented and grounded. And then if you focus on that, control your overhead, and you know, really take great care of your patients like you would a friend or family member. I that sounds it sounds cliche, but as I heard somebody else say once, uh, you know, that's there's truth in cliches, that's why they're cliches sometimes. And I really think that that's what kept me having fun and enthusiastic. And like I said, I I had a general idea where I wanted to go, but I never got so fixated on it that I started to become exclusionary, particularly early on. So I would say early on, uh, you know, have a plan, write it in pencil, be flexible. Almost everybody I know um didn't end up in the exact practice situation that they started in. You know, we all think we're gonna just sort of finish. We want somebody to give us a job. I had a guy one time I was talking to when I was a senior resident, and he said, you know, if I pay you, I'm gonna think I'm paying you too much, and you're gonna think I'm paying you too little, and a relationship's gonna be shot. And of course, at the time I was like, Yeah, right, you know, I need I need to talk to me about a salary. And I ended up in a situation that didn't have anything like that, and I'm so grateful because I I learned to value everything I had, I worked hard for it, I I appreciated each and every patient. Um, and I think that that's you know, most of the people I know who went into a situation that have have within a year or two, they've switched. Um, so again, nothing wrong with seeking out something that sounds great, but but write in pencil, work on your skills, keep your skill set uh broad early on, even if you want to eventually specialize in narrow. I think having a developing a broad skill set and cultivating and nurturing that early on is advice I would give and do give uh to the senior residents here and to people who come by and and want to pick my brain for some reason. So I'll always kind of suggest uh to kind of you know take good care of patients, get your boards. Um, and then again, nothing wrong with having a general idea, but don't be too aggressive, ambitious. You know, I couldn't handle the practice I have now when I just came out. So you think you know what you want, but you don't always know what you want. You know, you think you'd love to just start and have a booked schedule and be booked out. And trust me, the quality of care would wane, and so would your uh patients' opinions of your skills. And you don't get a ton of shots in a community to make a first impression. So um, you know, know what you do and do what you know uh early on and take call, participate in your medical community, uh, develop your physician identity and play for the long game.

SPEAKER_00: 19:52

Okay. So you mentioned many times about your overhead. Um, if you could sort of for the listeners, maybe the biggest items and how you kept them low, and if you had any uh help, any advisors or a community that helped you keep those things in focus?

SPEAKER_02: 20:15

Um I think that you know, I I like to ask questions, I like to brainstorm. Uh sometimes it drives my wife crazy because I'll just brainstorm ideas, some of which aren't very uh smart, and she's like, Why are you talking about this? But um, but that's how I kind of you know vet things out. Um so you know, they say hire slow and fire fast kind of thing. So I do that with ideas, you know, think them over, roll them over, and then make a decision. But to answer your question directly, I mean I think that I think that people are your biggest expense, they're your biggest asset. So invest in people, uh hire for uh the people they are, not the jobs they've had. Um I always try to hire people who were uh where it was a step ideally up for them, but I thought them fully capable. That way they're very, very, very appreciative of the job and they work hard and do a good job as opposed to lateral or obviously nobody wants to make a downward move, but even lateral moves. I didn't try to uh, you know, I never put my faith. I think there's a the other thing for young surgeons is they're kind of a setup for for an opportunistic manager or or clinician manager to come in and say, I can build this practice, I just need you as the surgeon to put you like a cog uh into the wheel. And I I disagree with that, and I don't think that works out very well. I think you're the man, no matter what you say, this is actually something that was told to me earlier is that you're the manager of your practice no matter how you twist it. You could have a uh somebody assist you in managing, they could be more of they're more of an integrator, but you're the visionary, you're the manager, it's your responsibility, certainly if you're a private practice. But even if you're not, you're still the manager of your career, and you have to you have to take responsibility for that. So, with regard to overhead, though, I mean I do think you should invest in people, but you have to pick those people carefully. With that regard to technology, I think that we uh there's great technology out there. There's also technology that, as you know and everybody here knows, is very fleeting. And so, you know, technology has this nice uh upward sweep that if you catch it early, you you can do really well on that upward sweep, but uh then it usually levels out and then sometimes disappears completely and sometimes sticks around at some uh base level but and plateaus. But um I the other thing is that you don't know really which technology is gonna win out or not. So, you know, I tend to not try to um out technology or out out be on the crest of people and instead kind of focus more on the quality of the results. I I think that if we act as patient advocates, we're not always uh at the tip of the spear, um, and that's okay with me. I'm glad that somebody is. I hope those people are judicious in promoting the things as they come up. I think they should be really studied and vetted and let's see how things come out. So I'm usually not the first in line uh on that stuff because that can be very um costly both for your uh pocketbook and also for your patients. I think you should invest in having a nice office that's uh presents authentically for who you are, but I don't think I think it's a it's a fallacy that patients expect, want, or need to come into the Taj Mahal. I think that's a bit of a uh a fallacy or that they care if you go to the local symphony and opera and all that stuff. I always did things that were things that I enjoyed. I do think you can't hide under a rock. You get out and participate in your community, but you participate in a way that's uh authentic to you and your interests and passions and personality.

SPEAKER_00: 23:47

So, since you mentioned technology, I always love to ask private practitioners this question, but what is something that you've purchased over the last, you know, 20 something years in practice that you wish you didn't buy?

SPEAKER_02: 24:00

Uh that's a good question. Um like I said, I'm usually not the first on the block. Um I can't think of any big purchase mistakes. Um I I really, you know, I think cool sculpting in our practice uh was very useful. We did well with it. It played, but it but it sort of it sort of played out its lifespan for us, and then we sold it. Um but we you know we did fine with it, so that was good. But we were relatively early on that uh could have I saw that as something potentially helpful and kind of uh you know vetted it and thought it fit in nicely. Um we have um the uh microneedling with radio frequency uh and the cool pill and we do that. But other than that, we don't do a lot of I you know I prefer to uh let my uh colleagues in both dermatology and plastic surgery who do a lot of lasers and resurfacing, and I let them do that, and I do what I do. So I realize that's a little different practice paradigm than trying to have the full med spa and have everything under one roof, which uh I don't knock, but I think you're I think one way or another you're either all in on that or you're not. And so uh my my choice was to kind of be not and really zoom in on what I think I do uniquely well and um and let others do the same in their practice and kind of collaborate. So that's worked well for us, and again, it's helped me to keep things kind of simple and never feel obligated. I work because I want to. I operate on patients because I think I can get great results for them. When I don't, I don't. Uh when it's not a good fit. I think surgery is like going on a trip together. If you wouldn't want to go on a cruise with somebody, you probably shouldn't be operating on them. And I realize that can limit clientele. The irony, of course, for young surgeons, it's painful, and it was painful for me too, because the when you early in your practice, when that's probably most important, right? Because if you get a uh a bad result for just a patient who's not uh satisfied early on, that's one out of one, one out of two, one out of five. Later on, when you have more to dilute it with, is actually the time when you're more suited to say thanks but no. But on the other hand, um that's the time when you could tolerate that stuff more. So that's kind of the irony of that. But I would say, even having said that, and I will I certainly violated that principle early on sometimes, but I do think every time I did, I regretted it. So I would really focus on operating on people uh your elective operations, people that you really feel like you can hit it out of the park, both relationship-wise as well as uh result-wise.

SPEAKER_00: 26:44

And uh with the same sort of uh I guess interest, uh, what about any sort of human resource mistakes or have those notes? Yeah, for sure.

SPEAKER_02: 26:59

I for sure made those. No, I for sure made those. And uh and that's again where I think the biggest thing, you know, I mentioned hiring slow and firing fast, and that's really easy to say until your, you know, red desk person is pregnant, you really need somebody to replace them, or somebody moves out of town, and you know, you have a small office and it leans lean staff, and and that's a vital function. So uh so I think I've violated both those principles, particularly at Firefast. I'm not I'm not good at that. And that's when I say that, I have to admit I'm a little more aspirational than reality with that, because you know, I've definitely let people where it's clear, it's clear that you know, we were dealing with a four, five, or six out of ten. And if you asked me, and I would, you know, I'd say, oh my gosh, hire you know, eights and above, and or keep eights and above. But you know, when you have somebody, it it's actually easy when somebody's doing a horrible job. It's not as easy when they're doing an adequate job, even though you know it's not optimal, you know it could be better, it's probably restraining the growth and vitality of the practice, but they're getting the basic functions done. And those are times when I would certainly advise somebody, it'd be a lot easier, you know, if you're sitting upstairs in an office and just I kind of think of all this in private practice where you're a player coach. So it'd be easier if you were just a coach sitting on the bench directing people, but when you're a player coach, it's really hard to kind of get that, keep the perspective. But I think that's the one thing I would do is I would let go of adequate people quicker in my career.

SPEAKER_00: 28:33

All right, so now I'm gonna jump to your books just to make sure I have so many questions to ask you, but I'm gonna jump to the books so that I make sure I want it, um I get all the questions that I had wanted. Sure.

SPEAKER_02: 28:44

And I say that, and I just I say that last comment, I say that because because I now being at a place and you reach these different places until somebody's life and life plans disrupt it and they have to move or go. But like with regard to staff, you know, when you get to a place where everything's kind of functioning on all cylinders, that's when you realize how good it could be, and that's when you look back and say, wow, I can't believe I tolerated that situation as long as I can't. But sorry for those.

SPEAKER_00: 29:08

Meaning you may not know the pain of it when you're there, you're saying.

SPEAKER_02: 29:12

So correct, correct. It's it's it's working, it's working okay.

SPEAKER_00: 29:16

Yeah. Or the loss of opportunity. All right. So your new book is called Authentic Beauty. And first, I want to ask you kind of during what time or period of time you sort of started this book and sort of laid the concept and then kind of the journey for those of us who may be interested in actually writing something on the subject of either plastic surgery, their life, or their practice or their other interests, like take us through the process of like book writing in general.

SPEAKER_02: 29:50

Yeah, so I think that uh just to you know, big picture looking back, I mean, I started this idea conceptually. I probably started this over 10 years ago. And the mistake I made then was looking for, you know, you're always looking for a way to get things done efficiently or for help, or there must be an easier way, and try to kind of figure out. And so originally I kind of looked outside as means of getting it done. Um, and uh none of those were gonna work. They none of them felt like they were working, none of none of the uh some early kind of concepts didn't feel like me, didn't sound like me. Uh, and and so that probably led me to the title of authentic beauty ultimately, but they they just weren't working. So I think my what my advice to somebody would be to kind of get a big picture of what you're trying to say and do, and and then get an outline of that. So that's ultimately what I did after kind of starting and quitting and starting and quitting because I didn't like where it was going and didn't feel right and didn't feel authentic to me. Um so then eventually I had enough stuff that we had written, be it for the website or white papers or editorials or various things. Um, and and again, as you're mature and you're having conversations with patients, you hear patients' concerns on a daily basis. You hear in your head your own responses on a daily basis, you see patients' reactions to them, and you start getting a feeling that there's something that people don't know that they should know, and there's a path that people don't know about that they should know about, and you know, you start becoming convinced that look, if if I'm having this experience where people are really appreciating the value of this information, then there's probably a lot of other people who would as well, and you want to share that on a larger scale, you know, as you get on in your career, and you want to kind of pass that on on a larger basis. So that's kind of what finally kind of what got me to say, you know what, I'm gonna get this done. And I think the way I did it ultimately was uh temporally was to do just blocking it out and kind of you know, for me that would meant working on it for you know, just saying instead of breaking it into chunks and saying, I'm gonna work on this from six to seven. I mean, if you look at my calendar and looked over the years and saw once we've determined the title Authentic Beauty, and you saw the number of times AB was on my schedule from six to seven, you know, it seems like Groundhog Day. But I just decided that, you know, that was the most likely way to get it done, the easiest way to get it done, and that this was something I had to do. And I think you do it because you have to do it. It's not time efficient, it's not some big marketing plan. It's because you have a message that you want to share on a broader uh scale, and it's important enough to you to spend your time and effort uh to get it done. And in the midst of you know, practice and and uh family and and help and everything else, that was the way for me was to make an outline, take the previous stuff that I had written and thought about and figure out where it fits into that outline, and then sort of just start brainstorming the other parts, doing a little bit of, you know, with my uh dictation and just kind of a little bit of a I I talk to book is a little kind of a phrase people use, but basically uh, you know, kind of getting drafts so that I could uh go through my drafts and kind of refine them. Um and that was kind of the tedious process, and again, a lot of fits and starts, but then eventually I would say it's just really the last couple years uh that I got a lot of commitment and momentum to it. And then as it started to take shape, then it starts to you start to feel really good about it, and you start to feel like you're okay, now I've got something that people will find value in. That was always my priority was to produce something that both pay primarily patients, but patients and surgeons alike could find value in. And you know, I would challenge somebody to to not say that they can find, you know, a minimum of three to five pearls in here or at least some sort of reminders uh that that are kind of helpful. I know we do, I do on a daily basis. I we I read my own book, we use it in in the office as a sort of a book club kind of uh and review chapters at office meetings and stuff because um, you know, it while it's descriptive of our practice, it's also aspirational of our practice. So it's kind of like uh reminding yourself of the standard and priorities and initial inspirations for why you're doing this in the first place and what you want to be and do.

SPEAKER_00: 34:37

Yeah, so I mean it sounds like the audience that you're speaking to is the patient, but in speaking to the patient, I mean, for example, when I was in training, I think the part that we lack the most is how to speak to the patients, correct? Absolutely. And and it almost seems like an awesome guide for those in training uh for the part that they're missing is you know, what what language and what words do you speak to the patient during the course of their care?

SPEAKER_02: 35:08

Yeah, I was never the king of like MM, and I think that what tur what was what was challenging in uh practice, in training, was a real asset in practice is that uh I just never really fell into technical speak. Um I mean we all know at our meetings that somebody's describing something, and some people sound so professional and scientific when they're describing something, and other people go, you know, well, you know, here I moved a little bit to the right and I tried to get underneath, and other people use all our proper Latin scientific terms. But I think that was a huge advantage in practice in my ability to communicate with patients. So I think that all of us need to remember patients speak uh English, not medical science, Latin, etc. Um, and so to kind of keep our our our language kind of in that lane. Um and listening, I think that there's a real, not to go on a rant, but I think there's a real lack of uh listening to our patients, do they want uh alteration or do they want rejuvenation? Because patients that want rejuvenation want to restore their useful vitality while honoring their uniqueness. Patients who want alteration want something changed and different. But I think zooming in on that, because I can't tell you the number of patients who come in saying they just want rejuvenation, but if you really dig into it, they might want something a little different, and obviously vice versa. So uh I just think listening, you know, as Stephen Covey says, seek first to understand uh is a huge a huge aspect of a successful practice and a fulfilling practice.

SPEAKER_00: 36:48

All right, so let's go through parts of the book. So I know um one section actually helps people through the process of choosing providers and procedures. Uh, what sort of pearls would you say they could get from that portion of the book?

SPEAKER_02: 37:05

Exactly. Well, I think that I think that I think with regard to providers, you know, I think we all know that they should look for certain academic credentials, but that's just that's entry level, that's like minimum effective dose. That's that's really critical for them to um you know know that um who they're who they're seeking advice from and what their background is. Um and so obviously different for different things, invasive, non-invasive, etc. But with regard to surgery, you know, uh we emphasize the importance of board certification in a American Board of Medical Specialties board, particularly American Board of Plastic Surgery, and um and recognize that there's overlap with other areas as well, but try to everybody staying in their lane. Um so I think that's but that's you know, beyond that, I think people, and we present several checklists in the book, but I think people really need to pay attention to um the external cues that they see in office with regard to the staff, staff longevity, staff communication, staff interaction, the office itself, does it flow, and then their interaction with the surgeon? Is everything is everything primarily geared towards uh the elite and esteemed and you know, king and queen surgeon, or is everything geared towards patient care and patient education with everybody there to assist in that process? You know, as one person put it, you know, if if the whole thing was a Star Wars episode as a surgeon and as a medical professional, we're not supposed to be Luke Skywalker or Yoda. We're the we're the aid, we're the trusted aide, we're the expert helper, and that's the role that to me that we should play. So I think that's with regard to patient selection. And I also think um we talked a little bit about your gut, and you know, when you're 16 years old, I don't know that I would tell somebody to follow their gut. But when we start to be 26, 36, 66, etc., I think your gut is the accumulated uh instinctual knowledge of your lifetime, and your gut is relevant. So I think it's okay for people, and they should uh you know sit back, contemplate, and listen to their gut with regard to this the uh paradigm of the practice and where they're seeking care. I think with regard to what they're seeking care, I think we provide kind of a couple guidelines of and have some uh some tools in the book with regard to um what what their concern is, what the cause of that concern, and what the correction is. So I you know we kind of suggest people take a sheet of paper, draw, draw uh two lines to make three columns, and have you know, concern, cause, and correction. I think people shouldn't be booking surgery unless they understand uh what's the proposed cause of their concern and what the proposed correction is and how it how it addresses that cause and thus that concern. And I think you should be able to draw a straight line between those things. And if you can't, then the question is are you being kind of redirected from something that's going to really address your concern to the favorite uh procedure of the practitioner? So that's kind of a tool for patients that we suggest. We also have uh a decision aid to kind of just help people in sort of clarifying their general thoughts. Um, again, we throw it into numbers because that kind of helps you. Uh, but we have it's it talks about the aggravation factor, uh the improvement potential, and the downside considerations as a tool you rate from one to five. I like to joke, but no three because I think three is a cop out. So you rate these things from one to five and then you put them into a formula, and then it gives you uh a numerical outcome that basically tells you, you know, on the low end of that numerical formula, you know, zero to two, you shouldn't be having surgery. You know, threes, you should be thinking about it and maybe get more information. And fours and fives you should probably push forward because probably right for you. But again, that's just to sort of clarify, crystallize and clarify your thinking and work with that gut that we talked about to help patients to move forward. So that's I think that's a those are both nice tools. One in the consultation to really make sure you're focusing and you don't get lost. Because you know, I've seen patients where they come in for a consult, they come in for one thing, and they start, they're like, you know, maybe they could be like a kidney candy store and they sort of lose sight of their primary concern, and pretty soon they're they're all excited, they're talking about other things, which is great if those things are a concern, but if they're not, then they should reflect on whether that's gonna really make them happy. And I think the one thing in common with surgeons of patients is we all want the patient to be happy and satisfied, and that's not always uh a physical thing, that's that's oftentimes physical as well as well as psychological, and is just really uh satisfying a pain point that the patient has. So um so I think those two tools together, and there's several other in the book that that help people uh in the consultation phase and in the decision phase, that I think is so critical to then carrying out the proper surgery for them, and then of course the vigilant postoperative care uh is you know indispensable.

SPEAKER_00: 42:28

Yeah, I think you've pretty much summarized into words things that probably all of us think about, um, how almost like the psychology of medicine is so integral to how we practice. So it's really nice to hear that uh actually put into words and to some degree. Um tell me a little bit about your P4P paradigm.

SPEAKER_02: 42:52

Yeah, so I mean, I you know, part of it, you know, I have always had a passion for what I do. I'm so lucky that's all I wanted for my kids is to find, you know, something in life that they enjoy doing as much. And obviously, there's that Venn diagram where it's you know, what do you love? What are you good at, what does the world need, and hopefully, obviously, what the world might pay you for too, so you can make the living and move out of the basement. So all those things are taken together, and I feel like I just got so fortunate to have found a field that that engaged my event mentality, event mentality coming from athletics that engaged my artistic nature from uh a background in drawing and painting that that engaged creative thinking as opposed to algorithmic thinking of many other uh medical fields that's dominated them. Um so have feeling like I get so lucky to do that, and again, remembering that on a regular basis. So, you know, we really have a passion for performance, and and you know, acutely the four number four is because you know, quality, integrity, safety, and service is really the cornerstone of everything we do. Quality, we want to be do things excellent. Uh, integrity, we want to say what we do and do what we say. Safety is for sure the most important thing of all, particularly when you're doing a lot of elective surgery. You know, I mean, we all know I personally feel way more pressure doing elective surgery on a patient who's perfectly healthy and doesn't need to be there than I did when I was, you know, jumping on holding pressure on a gunshot wound as we rolled them into the or in trauma surgery because I didn't shoot them. But in the case of elective surgery, you know, we're causing the wound and we're fixing it all in the effort to be incrementally better. And I do think that a lot of us can lose sight of that at times, uh, that this is entirely elective, and that while we want to, you know, and I there's a there's a fine line, we don't want to use safety as a cop-out, but safety is always should be paramount and foremost because these patients are healthy and fine in the in the elective aesthetic realm. They don't need surgery, they want surgery. They want, I don't care what they say that they accept risk-wise, they want surgery because they think it's gonna go great and achieve their goals. And if we we have an obligation to do procedures that we also feel are incredibly likely to get to their goals and with low uh morbidity. And when that starts to be out of balance, I think we really have to question whether uh that patient was full is fully aware of that. Now stuff happens, there's there's maloccurrence, but mallocrence should be a surprise in elective surgery, not a you know, completely accepted high-frequency event. Um, so uh that's safety is like you know, it probably should be first, but we think quality, but I think safety is part of quality, so quality, integrity, safety, and then service. You know, we're here to serve. As I mentioned, we're Yoda, not Luke Skywalker, we're the trusted aide and guide, and and keyword trusted, and we have to live up to that trust on a daily basis.

SPEAKER_00: 46:01

So uh one of my favorite parts of the book is where you review common procedures and skincare options. Um, can you give us, you know, just a couple of highlights? Is it just face, is it body, and um, you know, sort of what encourage you to write that section because that's like super fun.

SPEAKER_02: 46:21

Yeah, I thought it was sort of necessary a book on plastic surgery. At some point you've got to kind of get down and kind of go over the procedures. I didn't want to try to make it uh or represent it as a sort of an A to Z, everything included in the entire realm of plastic surgery. But I did want to, you know, the standard stuff I wanted people to be able to look up and understand uh the general kind of uh guidelines of what they should be looking at, what they should be looking for, what's possible, how how we generally approach these things as plastic surgeons. Um I think that you know, ironically, and then and then you know, obviously the non-surgical stuff, but everybody's always asking us about skincare. I don't care if you're a completely reconstructive surgeon. I'm sure if you're a plastic surgeon and you're out and about in a social setting, somebody's gonna ask you about skincare. So I think we're while we're we might not be the primary providers of that, or we might be, um, which is again a great thing about our specialty, is that we have that diversity from head to toe, from birth to grave, from all genders. It's great to be in a specialty that has so much variability and diversity. But uh I do think that we are obligated to kind of be able to help people with that. And what I try to do is help people by having a framework. So, for example, with skincare, you know, by by being having a framework that I present present for our um 4.6 skincare fix and and the you know, clan's correct, hydrate, and protect. So, you know, I think that gives people a framework. When people ask me, hey, what should I do with my skin now? You know, I don't start out with, oh, you should get this product. What I say, I always take a step back. And so look, these are the steps of skincare. Clans correct, hydrate, protect. Every single product uh you're ever sold, talked about in procedure is aimed at one of those things. Is it cleansing your skin and exfoliating your skin? Is it hydrating your is it correcting your skin? In which case is it a you know, an antioxidant, a growth factor product, uh, retinol? Is it uh hydrating your skin? Is it protecting your skin? And obviously there's overlap of products that do more than one thing, which is great, because then you don't have to have a whole pharmacy or or uh uh collection of stuff all over your vanity. So we try to make it uh straightforward and simple, but I try to actually empower people so that they can look at different products and kind of go, oh, that's a hydrator, oh that's a cleanser, okay. Now we're talking about the correction phase. Now we're talking about what I can do to kind of push my skin forward a positive direction. So I think that's a good example of where, as you said, we kind of go into something that that might seem really basic, but to empower somebody to not uh be sold the the$500 cream at Neiman Marcus that's basically just a uh you know uh high-priced uh uh lacquer over the surface of their skin and understand what they're really trying to do with their skin, um, I think is of value.

SPEAKER_00: 49:09

Um now I want to ask you a little bit about sort of the younger surgeons and maybe the use of social media. Um, you know, being from a different generation myself, uh this is not a tool that I am as familiar with, but do you think it's sort of um integral necessary?

SPEAKER_02: 49:28

I mean, I think it's not I don't think it's I don't think it's necessary. I do think it can be valuable. I think that I would encourage them, you know, the in entertainment they say the only good, the only bad, bad, well, any publicity is good publicity, right? And there's no such thing as bad publicity. I don't think that's true in our field at all. And I think in their own self-interest and in the self-interest of the field, I think people should really pay attention to their brand and pay attention to how they're presenting themselves and our specialty, because um again, not to sound like you know, an old man, get off my lawn, kind of, but I do think that um that when you present plastic surgery in a trivial light, you encourage the triviality and commoditization of it, which doesn't help anybody, the person doing it included, even if they think they get a couple extra likes and even a couple extra patience from it in the long run. Um, your brand is you're trivializing your brand. So I think everybody has a personal brand. I think be honest to it, be sincere to it. Doesn't mean you can't have fun with it, but um I would say that that's a little bit dangerous. I've seen things put it this way. I had had a friend who I was out of town, and she cut herself and had to go in the ER, and they were gonna get the plastic surgeon. She called and told me who the plastic surgeon was, young plastic surgeon. So I Googled it, looked it up, and came to a you know, I mean, first thing that came up was an Instagram video of them uh shimmying down the hallway of their office doing some music video. And I mean, I don't I would not want that person to sew me up in the ER. And then and I subsequently got to know that person, and he's a fine surgeon and he's well qualified. And so my I just don't think that's the way maybe not maybe not for the short term, but for the midterm and long term, that's not how you want to represent yourself again or the specialty. So I would say have fun with it, uh, but but don't try to avoid trivializing it, um, or know that that you know uh that that's gonna be hard to shake in the long run.

SPEAKER_00: 51:46

And um another area I wanted to ask you about was sort of the future of our specialty. I mean, I practice in New York and am involved in several advocacy aspects of classic surgery, and you know, there are, like you said, sort of dilution of our fields and almost some cannibalization. So if you could kind of comment on sort of where you see the future or specialty itself.

SPEAKER_02: 52:15

Yeah, I mean, I think we fight that. That's absolutely going on, but I think also the the you know, I'm kind of in the middle of the road where you know I was fortunate enough to come of age in an era where there were still legends, and there still are. We're a young enough specialty that that my gosh, we still have the high, you know, at all our meetings, you know, and and and offering insight and and and Robert Singer and and these people who's in my community and and these people who were kind of quote unquote there at or near the start. So and I, you know, I came of age with uh Steve Miller, Bruce Ako, or David Fernes, and Bruce Connell, and and you know, was so lucky to overlap with these people. And I think that they would all say, and now I see the younger kind of group coming up behind me. And so um I think change is inevitable. I think that I would say in our community, certainly, you know, the you worry more about yourself and your patients, and again, that quality, integrity, safety, and service, and the rest of it falls where they may. Now that's separate from the regulatory thing, and I think it's okay to pursue the regulatory stuff, but I think you pursue the regulatory stuff because you're again protecting patients. So I think it has to come from the right place, you know, not from a competitiveness or a paranoia or an insecurity, but simply from a patient advocacy. I think that plastic surgeons are the best providers of plastic and reconstructive surgery. We are uniquely qualified to do that, we are uniquely trained to do that, and believing that it's okay and proper to pursue funding for the procedures that patients need and regulations for who provides those procedures. But it comes from a place of serving and protecting patients and looking after their health and well-being. Um, and then on an individual basis, what we could do is take great care of patients and be that shining light. That's gonna serve our specialty well, and it's gonna serve ourselves well. So that's to be that's kind of again may sound cliche or true, but but that's I think really to have that standard and to kind of uphold that standard um is the best way forward for the specialty. And I care very much about the specialty, um, and it's given so much to me. I'm so passionate about it. And you know, when I got into it, it wasn't quite, you know, when I decided to do it, I should say it it was a little more less um media driven, and now I've seen that happen, and that so I think it takes all the more effort to resist the uh trivialization and certainly um realize that you're being kind of nipped at on all sides. But you know, I poked my head into one of these uh med spas recently that was in a neighborhood by mine, and I asked them who their medical director was and they couldn't tell me. When they finally looked it up and told me, and I asked them what the specialty was and they couldn't tell me. So um, you know, if we concentrate on educating our patients and educating the public, uh, I think that is when you're the most qualified and people can be aware of it, I think the rest can take care of itself.

SPEAKER_00: 55:32

And so, I mean, we've had uh a great conversation. I can't believe that our is almost coming to an end. Uh, but I also want to ask you a little bit about what final messages you want to convey, both uh you know, to patients, to residents, to fellow colleagues, um, and also tell me a little bit about how you see your practice. Like, are you planning to sell your practice? Like, what are you gonna do with everything that you've built to date?

SPEAKER_02: 56:04

Yeah, so uh to answer the the second question first, uh with my practice, I mean, I'm really enjoying it, and I really enjoy the uh the infrastructure of it, and then also dealing with patience and feel like I feel like um worked a long time to get right here and really enjoying it and riding them. So I'm at the crest of the wave. I don't think I'm on the downside of that wave right now. Um, and you know, we run it in a way, again, I we're we're not a big conglomerate, you know. So I I couldn't tell somebody how to run a practice with with 25 employees, uh, but I could tell somebody how to run a practice with six or seven. And so um the way we run our practice and that we have our practice set up and with our patients now, you know, we're in this sweet spot where where that flow takes care of itself. So um really enjoying that. And you know, I I actually had the good fortune of uh one of my patients was a kind of a high-level consultant for a big company, and so I picked his brain one day and I said, you know, hey, I have a friend who's commoditizing his practice and switching the name and hiring secondary, you know, uh assistants and other lower level providers and doing all that stuff, specifically with the idea of setting up his practice for sale. And he said, Well, that's one way to do it, but when you've got plenty of patience, why don't you just you know add one more case a week, put that money in a separate account, and then you know, when you're ready to go, if somebody wants to take over your practice or buy your practice, so be it, great. And if they don't, you just take the money from that account and you know satisfy your mental feeling that you have value by by you know mentally buying yourself out. So uh from a monetary standpoint, yeah, I run my practice and I enjoy the income of my practice, and it it helps us uh me to do things I want to do in my life, but I'm not looking for some big payout at the end uh if that happened. From a from a legacy standpoint, I would like to pass it on ultimately when the time comes, and we'll see how that kind of plays out. Um and I think that you don't bring my my what I've I've kind of studied this for a while because I get I I shared space with a couple people when I was getting started, and I would not bring somebody in unless I was ready to make sure they were successful. And I would, as we said with employees, I would bring somebody on slowly, really make sure it's just the right person and with the right personality and motivation and everything like that, and then um and then I would be so committed to their success that you know it could not lose, could not fail. So when that time comes that I'm ready for that, it'd be a bit disruptive in life, so you have to be committed to it. Um, but it can't just be about it has to be a win-win uh at that stage. So I'm not really there thinking too much about that. Um, with regard to message to residence, I would just say, you know, we're we're endowed as plastic surgeons uh with you have to have vision, you have to have skill, and you have to have will. And I think the vision part is having an aesthetic sense, which sometimes can be lost as people are going into plastic surgery earlier, and maybe there's some um other motivations for people as they go into plastic surgery. But I think a plastic surgeon without any aesthetic sense or vision of what they're trying to create and restore uh is gonna be frustrated. The skill, obviously, technical skill is is critical, and we ought to have that. But the the part that doesn't get included enough is the will. You know, who's gonna stand in there and take the time to do it right and do it well and be there for your patients, both before, during, and after surgery. And I think that you know, having that full commitment is you know, calling and following up on your patients, you know, be an active participant in their recovery so they don't feel like you cut and run. That would be my message to residents is that you know, use your vision skill and your will to enable patients to stay. Taller, smile brighter, and embrace life with more confidence. That's our job. You know, it might be, we might think our our niche of how we do that job might be restoring and rejuvenating, but at the end of the day, our real mission is to help patients stand taller, smile brighter, and embrace life with more self-confidence and self-esteem. And that's that's what we are looked to for, and that's the promise that we need to fulfill.

SPEAKER_00: 1:00:28

Well, thank you so much, Dr. Miller. I I really want to uh take the time to give us, you know, from all of us uh gratitude for sharing your thoughts and your enduring commitment to the quality and really the integrity of our specialty. And for those who haven't read it yet, your book, Authentic Beauty, is uh where where would they be able to get a copy?

SPEAKER_02: 1:00:57

Uh it's on Amazon. Um obviously it's at Barnes and Noble on Amazon, and there's a couple of other books called Authentic Beauty. If you get the wrong one, you might be reading a romance novel. But Authentic Beauty, defining a new standard of for care and results in plastic surgery. Um it's on, as I said, Barnes and Noble, it's at Barnes Noble and Goodreads and all the other areas where you uh you find books. But Amazon's probably the easiest uh route, usually, as long as you get to the right. Uh author wise, it's Scott R. Miller MD because there was too many. There's a sports writer named Scott Miller who's quite good, but he's not writing about plastic surgery. So uh yeah, those are all the nuances of making sure that it's uh findable and achievable because you know I didn't write it to to um to have it sit in a closet. So it's great that it's been it's so rewarding to see it well received and and um and that people are finding it useful, and I that's really gratifying.

SPEAKER_00: 1:01:51

Awesome. Well, congratulations, and once again, thank you so much.

SPEAKER_02: 1:01:55

Oh, I appreciate it. Thank you.

SPEAKER_00: 1:01:57

We hope you enjoyed this episode of the Enhance Your Practice Podcast series brought to you by ASPS University. You can listen to our other episodes on other podcast platforms, or you can download recordings directly from ASPS Ednet. New episodes coming soon.