S03E27 - "SNAPCHAT SURGERY" - Social Media & Plastic Surgery

What could possibly go wrong mixing social media and plastic surgery? Our special guest is Dr. Christian Vercler, MD, MA, HEC-C, Clinical Associate Professor of Pediatric Plastic Surgery at the University of Michigan C.S. Mott Children’s Hospital. He serves as Co-Chief of the Clinical Ethics Service of the Center for Bioethics and Social Sciences in Medicine at the University of Michigan. Dr. Vercler is a board certified plastic surgeon who specializes in craniofacial surgery.

Dr. Vercler has written extensively about the complex ethical issues regarding social media and plastic surgery, and how Instagram, Snapchat and Tik Tok may lead (or mislead) both surgeons AND patients into choices which may result in problems.

You can get every episode of Botox and Burpees wherever you listen to podcasts, YouTube, or go to botoxandburpees.com. Thanks for watching and listening! #thoughtfulplasticsurgery #podcast #plasticsurgery #cosmeticsurgery #boardcertified #plasticsurgeon #beauty #aesthetic #botoxandburpees ⁠#bestplasticsurgeon #boardcertifiedplasticsurgeon

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S03E27 SOCIAL MEDIA PITFALLS IN PLASTIC SURGERY VERCLER

[00:00:00] Dr. Sam Rhee: Thank you and welcome to another edition of Botox and burpees. And this is a very important and special episode for us. And I'm glad to have our guest today, Dr. Christian Vercler. Dr. Vercler is an associate professor in the section of plastic surgery at the department of surgery in Michigan medicine, which is where I trained for my plastic surgery residency.

Dr. Vercler serves as the co-chair of the clinical ethics service of the Center of Bioethics and Social Sciences and Medicine at the University of Michigan. And he is a diplomate of both the American Board of Surgery and the American Board of Plastic Surgery. Dr. Vercler received his bachelor of science degree in biology and master of arts at theological studies from Wheaton College in Illinois.

And he attended medical school at the University of Illinois College of Medicine. He completed his general surgery training at Emory University and Plastic Surgery at the Harvard Plastic Surgery program, he then did an additional fellowship in craniofacial surgery at the University of Michigan. Dr. Vercler has a special interest in medical ethics. He completed a fellowship in clinical ethics at the Emory University Center of Ethics and earned a master's of arts degree in bioethics from Trinity. Dr. Vercler serves as the chair of the pediatric ethics committee of CS Mott Children's Hospital. He is co-chair of the ethics committee for adults at Michigan Medicine.

And he also serves as the ethics committee on the ethics committee on the American Society of Plastic Surgeons, a chair of the Michigan State Medical Society ethics committee, and is the chair of the ethics interest group of the American Cleft Palate Craniofacial Association. That's a lot of hats to wear.

[00:01:36] Dr. Christian Vercler: Yeah, too many. Luckily I just rotated off the ASP S ethics committee. So that was a three-year term. And I just finished up as chair of that. So

[00:01:45] Dr. Sam Rhee: Right. And you, you focus primarily on pediatric plastic surgeon, cranial facial deformities in children and adults. And I know you have an extremely busy clinical practice as well. I do know your staff Kim who keeps track of your schedule and I really appreciate you taking the time out of your really busy schedule to talk about social media and plastic surgery today.

[00:02:06] Dr. Christian Vercler: Yeah, my pleasure. It's a passion of mine.

[00:02:08] Dr. Sam Rhee: Okay. So I just wanted to talk about social media itself and how powerful is it, as a means for advertising for plastic surgeons today?

[00:02:17] Dr. Christian Vercler: It's incredibly powerful. If you think about advertising and being effective advertising, you want to be where people are and everyone's on social media. So, it's funny these days when you still see a plastic surgeon advertising on a billboard, because that's like so old school, because everybody everyone's imply, everyone lives in a social media mail you.

So the idea that if you're not in social media, you're not relevant is a strong well, that's a strong idea that I think is pervading our specialty, but it's not just our specialty. I think it's for anyone

[00:02:48] Track 2: I think it's funny that as a specialty, we, as plastic surgeons have a lot to catch up on. And I think some of my older colleagues, they will still say in conference, don't worry about social media. Just build up your word of mouth. All you have to do is do good work, put your nose to the grindstone and everything will be just fine, is really missing the point of how rapidly things have changed in terms of how people consume their information, how they make choices in terms of their daily lives, including choosing a surgeon's choosing their medical care, choosing cosmetic surgery, particularly, and.

I feel like this rapid change is causing some growing pains and dissonance and conflict in our specialties, amongst us. And I wanted to delve into it a little bit and see if we can make some sense about what's what might be great and what might be not so great about social media and plastic surgery.

[00:03:46] Dr. Christian Vercler: Yeah, sure.

[00:03:46] Track 2: So I know you've written some articles about med U tainment, which is basically defining, defined in your article as using the patient physician relationship as a source of entertainment in which to increase notoriety or attract patients, which demeans the surgeon's protective duty toward the patient.

So what does that mean?

[00:04:08] Dr. Christian Vercler: well, so I, I, I tried to coin it. I think one of the persons used it in the literature before me, but it, it's this idea that, oh, I'm just putting this out there to educate the public when it's clearly objectifying the patient or taking advantage of, their trust in you to show their body which, what's interesting is that, you and I are used to viewing the naked body all the time.

We're plastic surgeons. That's like what we do. Our journals that we, that we get every month have all kinds of naked photo pictures. And then that sort of, we're used to that. The public sees that in a perceptual lies in a different way. And so, when we take things that we think are sort of routine and we put it out in the public, it takes on a different meaning in, it gets a lot of hits.

It gets a lot of engagement because it's something they don't see everyday stuff. This is kind of routine for us is, is not routine for the general public. And so, I think that how I got into this whole thing was basically medical students and residents walking up to me with their phones out going Dr. Vercler, have you seen this? Like, is this okay? And w w seeing this content and seeing people say over and over yeah, I just do this for patient education and you realize, well, no, it's actually pretty sensationalized stuff that isn't really that respectful. And so. That idea of meditation is really using our privilege relationship that we have and leveraging that for, for likes and tweets and retweets and follows and that sort of thing.

And I think the whole, you can be educational and not sensational and not derogatory to patients. And I think that's a kind of the fine line when you need to walk in that sort of yeah.

[00:05:50] Dr. Sam Rhee: And what is that line? And I think that that's where I think a lot of people will have disagreement about. I would say, and we could use different examples, but if somebody, if a surgeon is showing surgery of a patient on social media, is that sensationalistic and entertaining or is that education.

[00:06:14] Dr. Christian Vercler: Yeah. It's I think it's, it can be both. The interesting thing, there's a Canadian, I guess he was a sociologist or communications theorist named Marshall McLuhan who coined the phrase, the medium is the message. And really, this is like in the mid 20th century, but the idea is that the medium in which the message is expressed really determines a lot of what the meaning is.

So even if we intend a message to be educational, then the content may be the same, but in. Contexts, it takes on a completely different meaning. So even though we may earnestly put out something that we think is educational in the wrong medium, for example, like Tik Tok which is, I have really young kids and I try to keep him off Tik TOK, but they're always on Tik TOK.

So if you look at the average age of Tik TOK users is pretty young. And so certain surgical procedures in that context may take on a different meaning given the context. And so this stuff sounds kind of nebulous, but I think it's, it's real. And that the context and when, within which you put a message, it really plays insignificantly on how it's interpreted.

And so that's the tricky thing is that people may be interpreting things a certain way, even though we intend them to be fully educated,

[00:07:34] Dr. Sam Rhee: Is that our responsibility as surgeons though, because we don't control the context in which it's displayed. The social media companies are algorithmic. They display this stuff to people based on certain algorithms based on that user's behavior. So it's not like we are proffering this to everyone out there immediately.

If you're not interested in a particular subject, you're going to be sh not shown that, or you won't see it on your, your tick tock. It, it zeros in on what you particularly are interested in. So we're not really controlling that context. Are we.

[00:08:15] Dr. Christian Vercler: It's, it's interesting. We don't, and that's actually one of the scary things is that content that we might put out is, is out of our control. And so the algorithm starts to control who sees it and whatnot. It's interesting professionally. The ASP has code of ethics says that we sort of have a responsibility to the public as physicians as well.

And w whether it's our responsibility or it's Facebook's or Meta's responsibility, it that's, that's like what's being debated now in this country. Because it's interesting that the Instagram blocks stuff that's hashtag thin SPO or fitspo is, is very tightly regulated because they know that people who are suffering suffering from anorexia, for example, can use that hashtag to get into these spirals.

And they know it's bad for their mental health. And so that's pretty tightly regulated. But apart from that, not much else is, people can think the elections are stolen because of these algorithms that feed people certain kinds of information. Us as what we as physicians, how our responsibility is, is tricky, but being a prudent person, I always think we should probably take that into account

how the things we put out maybe interpreted.

[00:09:32] Dr. Sam Rhee: Given how difficult it is for us to control our content and given especially for many of us in private practice, having significant exposure on social media can make or break your practice. I have seen personally the power of social media when you have something that is of great interest to people, it just takes off like wildfire and I've seen that.

And I've seen other surgeons exploit that. Now I ha I do agree that there are some surgeons out there that in my opinion, and I wouldn't, I wouldn't know what other opinions are out there, but they might cross the line where I would feel comfortable, but I feel very wary telling other surgeons what the line should be for that. In my opinion, if they're maintaining appropriate patient care, they're not compromising a patient outcome for medutainment, then where are we to say that, I don't know, dancing in the, or, or something like that while not something I would do. Not particularly respectful, maybe you might say of what an operating room is.

But it's does that blur the line between what is appropriate and inappropriate?

[00:10:43] Dr. Christian Vercler: Yeah, I think, I think it does. I think it is a, it's a, it's a gray area, what's interesting is that the ASPS code of ethics which, because I was on the ethics committee. So for so long, I always had it printed out on my desk because I dealt with all the ethics violations that would get reported.

But you know, one of the things in the preamble here, it says, treat, treat people with ultimate respect and treat the profession with ultimate respect. Strive to use accurate and respectful language and images and all communications. And so where those boundaries are is, is a question that we, as a society, try to try to answer.

And specifically, I mean, the American Society of Plastic Surgeons, because being a member of a professional organization is a choice. And it's something that we try to, that we pride ourselves in being members of, because we think it sets us apart from, from guys who are out there just selling their cosmetic products and not prioritizing patient care over everything else.

As members of ASPS and board certified plastic surgeons, we think, you know what, we hold our heads high. We hold ourselves to a higher standard. And one of those higher standards is this kind of professionalism piece. Some people try to separate professionalism and ethics.

It's difficult to find a bright line there, in a lot of professionalism complaints come to the ethics committee and it's all dealt with in the same way. But when it becomes unethical is when you sort of like, at the very least you have to get informed consent from your patients, right.

And some people aren't even doing. So that, so it's like that that's like the very, the floor that you can't go below clearly. That's like unethical. And then again, there's a large gray area which I think is open to interpretation. I go ahead. Well, I was going to say one of the things I'm always telling our residents, if you look, and I think it was the most popular tick-tock of 2020, I think it was 2020 was Bella Porch bobbing her head to a really catchy tune.

I'm not sure if you've seen it, but it had millions and millions and millions of views in it. It's, we're as plastic surgeons where we pride ourselves in innovation and her little cute thing was the most viewed tick-tock. And it wasn't sensational. It wasn't trying to be sexy.

It wasn't anything that was walking any kind of line. And so I think there's interesting ways to put out interesting content that isn't like trying to walk the line and be overly objectifying patients' bodies.

[00:13:19] Dr. Sam Rhee: I think you're right. I think it's extremely difficult to be a savvy social media person and do that as a physician because that's not really job. And I have tried on the advice of others, like silly stuff, like eating pizza or doing this, and all sorts of other things.

And, and it's, it's a funny thing, social media, you can't ever determine what's going to go viral. What's going to catch people's interests. And, and everyone, I think makes that choice, what, what they're going to commit themselves to within that medium. And I think that that's really why I feel as a private practice plastic surgeon. I always have some concerns about our professional societies mandates because I wonder where those thoughts are coming from. I do read those ethics bylaws. I do agree with them, but I also want to approach it from the most practical standard as well. Because I do remember when I was a resident, I was told you really shouldn't post your before and after pictures on a website, they are legal minefields.

You are promising some sort of result to patients that you may not have because that patient that's in that before and after it is completely different than the person looking at it. And now look where we are at this point. I feel like our society is very slow to respond to a number of issues that we on, we who have our boots on the ground, can maybe not feel like there isn't as much of a response to, and, I trained at Michigan and Michigan is is probably the best place I think in America to train.

There's no doubt that the faculty and the surgeons and the, the level of care there is unparalleled. And I am who I am because I trained at Michigan, but I also realized that the situation clinically and professionally at Michigan is pretty much unlike any other place that I've seen or been to. And I've been to a number of academic hospitals in New York and New Jersey.

I've been in private practice. When I remember my mentors telling me back then not to post before and afters. And I also look at what's coming out of our professional society. I wonder, are they even able to keep up with the changes and what are we teaching our young surgeons? Because we might be handicapping them.

Like you said, there are a lot of people out there that are not licensed, or, not in a professional society, like ASPS who have no ethics, or I don't want to say that, but are not following sort of the, the code of conduct that we generally follow. And, and yet maybe we're overly hamstrung to the point where we are not helping our young surgeons navigate this arena.

And we're just telling them, just avoid it basically when probably not the best message for us to begin.

[00:16:19] Dr. Christian Vercler: Yeah, for sure. I think telling them too, yeah, I I've written a lot of stuff that seems pretty down on social media, but it's, that's not my view, my view at all. It's avoiding, it's definitely the wrong answer. In fact, we have a moral obligation to be on social media posting appropriately.

The fundamental principle behind this stuff is not deceiving the public and not trying to, where it comes from is this idea that look, we know a lot more about what's going on with the patient's body then they know, and there's a a difference in, and we can use that for good or evil basically.

Right. We can, we can do some smoke and mirrors and get patients to sign up for stuff, or we can be as straightforward as, as possible and make sure that they aren't being deceived. It's it's true. Some people used to think that before and afters was somehow implying certain things.

So that might be deceptive. The thing that I see now on social media is people showing before and after in completely different light. We know, and a part of part of our training is how to take proper photography to document what things look like and ASPS photographic standards or the plastic surgery, the American Board of Plastic Surgery photographic standards are often not followed on social media.

And so I think in that in some ways can be deceptive to show up. In a certain light in a certain pose to show postop in a certain light, in a certain pose plus minus being airbrushed can be deceptive. So those are things that we train, we should go ahead and say, that's wrong. Don't try to deceive the public in that way.

And that's what the ASPS code of ethics says, in your posts, make sure you're not, that you're maintaining photographic standards. And I have a colleague in in New York, Rick rice, he, he posts, he was a junior resident of mine. He's posts. He posts, you should follow him. He, but he has beautiful rhinoplasty results in all of them are posted in following the photographic standards so that anyone can see the results aren't doctored, aren't shadowing his offer anything.

He occasionally posts patient selfies, but they're in the mix with the photographic standards. So I think that's, I always use him as an example of someone who's a young guy killing it in cosmetic surgery in Manhattan, who's maintaining appropriate standards of of photographic standards and doing it the right way in a, in a way that's not deceptive.

Yeah. think that's the big, that's the biggest concern, you know, I think really the two biggest concerns really are deceiving the public in some way, or misusing the patient's trust to have them let you use essentially naked photos of them, because those are much more interesting to look at online than anything else when you're scrolling through your feed.

Whoa, what's this, and so, so those are the biggest, I think, ethical things to worry about. And then the rest of it is a lot of gray.

[00:19:04] Dr. Sam Rhee: Do you, what do you think in terms of our responsibility and the patient's responsibility at this Because I know you put you in one of your articles, you had a hypothetical where there was a young patient who had breast reduction surgery, she felt pressured to sign consents uh, for social media.

And then she was very surprised, shocked, and disappointed when her images were posted. Social media, but and I assume it's a hypothetical, I don't know if it's true, but you also mentioned in this situation, this patient was an avid social media fan. She followed this surgeon on all of his social media and she saw exactly what this surgeon's social media stream was.

So wouldn't it also be incumbent on the patient not to be shocked when she sees all these other patients being posted on social media, she's asked to be posted on social media and then she's surprised and disappointed when, when she's on social.

Uh,

[00:20:04] Dr. Christian Vercler: yeah, that, that hypothetical was kind of a conglomerate of a couple of different issues that, that I've heard people experienced, but we advocated in some, some of our publications that you should really to get truly informed consent, you should show the patient the post before it goes up so that they know what again, what the context is.

There there's been, some people who've gotten in trouble for showing part of a patient, on the Mayo stand and then whatever it's hashtagged can change the meaning. Right. Or be extremely derogatory. And so, again, well, Hey, can you, we're going to cut this thing off of you.

Is it okay if we show it? Okay. Sure. Well, what are you going to put as the hashtag, that that potentially could be again, change the meeting to something that you didn't really think you were signing up.

[00:20:50] Dr. Sam Rhee: Absolutely. If you hashtag it beautiful change, that's very different than say disgusting piece of meat cut off of some whale or something like that.

[00:21:00] Dr. Christian Vercler: Right. Yeah. Late. They had this lazy bastard who couldn't go to the gym. So we now added,

[00:21:05] Dr. Sam Rhee: right. Yes. I, and I understand that, but does that really mandate pre clearing this with the patient because we don't pre clear anything that we've posted for any other medium for the patient, as long as we get informed consent for before and afters or other things like, or even for example I know hospitals and other physicians do interviews with patients.

They post those for their hospitals in terms of patient care and, and, maybe a journey that they've had in terms of some sort of medical care they've received. I've never seen hospital media departments pre clear that with the patient or patient's families in order to say, is this okay?

They just, they require they get their permission to record. They do it. And then essentially the patient's trusting the surgeon not to abuse or, or somehow show it in a, in an unflattering light. But that, but then that's not really, that's not a legal, that's just scummy on the surgeon's part.

Isn't it.

[00:22:02] Dr. Christian Vercler: right. Yeah, I think, I think that's, that's probably right. I think hospitals though, I haven't seen a lot of derogatory stuff being posted by hospitals, but I have seen a lot of plastic surgeons posting derogatory stuff about patients. So, that's the difference and I think why we're even talking about this is that, I think everybody knows that they've seen some stuff that raises an eyebrow by plastic surgeons or, or people doing cosmetics.

And so, again, I do live in a bit of an ivory tower, I guess, but I also have a group of faculty ethicists that are my colleagues and when they see stuff on social media, they're outraged, we live in a we're, we're, I'm talking to other plastic surgeons most of the time.

But when I have folks who are physicians, who aren't plastic surgeons, or who are just ethicists, they just can't believe some of the stuff that gets posted and want to know how has that okay for you guys to do that?

[00:22:54] Dr. Sam Rhee: I agree, but the problem is, is that I feel like these are sometimes my personal feelings. So like for example, I did see on Tik TOK, there's a plastic surgeon and he likes to play around with breast implants. So sometimes he's kicking them. Sometimes he takes a third gun and he's, thera, like, doing a pressure gun onto them.

And he's doing all these sorts of things, which I found not particularly to my taste and I really disliked it actually. But when I talked to my colleagues about, and I said, did you see this guy? He was taking these implants and dancing and kicking them. They're like, yeah, but. Like he, if he's not compromising patient care, these are probably, these are samples and, obviously they're not once he's actually using like, so it's in poor taste and I wouldn't do it, but is that unethical?

And maybe borderline unprofessional, but how am I supposed to say to someone else? Because it's relative to a certain degree.

[00:23:52] Dr. Christian Vercler: Yeah, so I think that's, those are great. Definitely. You're not unethical, probably not smart. Not prudent, if you go through life trying to figure out how to avoid problems rather than, I don't, I'm not a mountain climber. I don't take a huge risks, but yeah, potentially you could argue that's unprofessional is not maintaining the dignity of the profession, which is how the ASPS code of ethics states it. Would behavior like that look good in a court of law,

if let's say someone said I was treated I D it was treated in some way that, that, and they're trying to Sue you for malpractice and, your defense attorney has to try to explain why that's, cause they're gonna make the case. This guy behaves. And then, do you want that stuff in front of a jury again, not prudent, but I'm not sure that I'd say it's, it's unethical per se, that sort of clownish behavior.

A lot. I think that's, that's, that's the thing that, where I might say, that's fine. If you're using social media to brand build and you want your brand to be a jovial kind of jokey person that's I think that's probably fine. It may get you in trouble. It may not. But I wouldn't necessarily say that, that stuff again, while again, we, we might find it distasteful.

I don't know that that's unethical, this stuff that I see that makes me really a little bit concerned is, is where it's, the, the greased up BBL post-op patient with playing rap music with very suggestive lines, zooming in and zooming out where it's almost like you're. trying to make some sort of sexy rap video with the patient's naked body on the or table.

And that's one of those things where I say consent is necessary, but not sufficient, cause people will say, well, I got consent the patient consented for me to do that. But is that truly like, really maintaining the dignity of the patient to treat them in such an objectified way.

[00:25:38] Dr. Sam Rhee: Let me take devil's advocate there. I w I agree with you, but I would say that there were, there would be some that would say this is an expression. If it's done, not only with the patient's consent, but say with their explicit instruction, maybe I want you to show off my booty. I want you to show off how snatched am.

I want you to do this. And in fact, I endorse it. Would that not be considered maybe an expressive, you know, free expression of agency, owning your body, owning the fact that you've had plastic surgery, not being afraid to display it in a sexual and proud and free manner and not hiding it basically, or trying to be reticent about it.

Okay.

[00:26:16] Dr. Christian Vercler: No for sure. And I think that that's, that's where the word D with a little distinction. So whether it's it's you posting that or it's the patient posting it I think is a little bit different. You're certainly, we wouldn't want to say that our professional society or our professional obligations as physicians w should, we should tell the patients don't post pictures of yourself like that you, we want us, this is why we do what we do.

We want patients to feel so good about their bodies, that they're happy to do that. The thing that's a little bit, again, a sketchy, I think is, is showing things like that, where you might say, oh, look at me, I'm just educating the public. Well, no, actually, that's, that's pretty interesting content to a 14 year old.

In ways that's not necessarily what you're intending to show, and you really are treating the person like a piece of meat. And so let the patient post their own thing, but think about your responsibilities to society and the dignity of the profession, as well as the patient's own dignity. And try to kind of uphold that, that line.

What I often say is that, you know, the, what the secular trend is so to speak, isn't always what, again, that high standard of what we say, our professional societies hold us to, which makes us better. You say, okay, we did all this extra training. We're always going to put the patients' concerns above all of their concerns as part of our professional responsibility.

So we're not always just going to go to the lowest common denominator for the most number of likes.

[00:27:48] Dr. Sam Rhee: Agreed, I would say it's it's I have friends who are in con I, I don't feel like they're in competition, but they feel like they're in competition and sometimes it's a race to the bottom and I wish we could provide them with better advice about how to deal with those types of situations where where there are people doing that they might feel a lot of pressure to do something similar and, I wish we could help them to navigate it professionally without having to course in themselves. And, be like you said, to get to that point.

But, but like you said, it is difficult.

[00:28:23] Dr. Christian Vercler: what's so tough. I think it's so tough because we're, we are surrounded as plastic surgeons by extremely visually interesting content, right. Our lives. I What we do everyday is really awesome and really, and really cool. And that's why we love doing it so much. And so. It seems like, well, if I just put this out there, people will like it and they do, but is that, are we crossing the line?

And so it's just, it's just so hard, I think for us to get out of our own way and take, get perspective on, on what it really means when we do that kind of stuff. Because it's so, it's so easy to just say like how awesome these breasts are now. Let's put those online, is, is that, is that the best?

know it just means to talk about breast dog post-ops, but but I think there's, there's ways to do it w this better and worse.

[00:29:09] Dr. Sam Rhee: Let's talk about the surgeon's role in providing or pressuring patients into normative appearances. So part of what social media and the argument is, is that we're pressing people to adhere or we're telling people, this is the standard of beauty, this is what this body parts should look like.

And I know you discussed this about aesthetic generals genital surgery as well as all types of surgery in general, you know, that that's been an ongoing issue. I think for society, for plastic surgeons who do aesthetic surgery or non aesthetic surgery, even we are certainly even in reconstructive surgery trying to maintain an aesthetic ideal and are we pressuring patients to achieve that aesthetic ideal?

Let's, let's start with that. And, and how is social media making that worse in some ways? Yeah.

[00:29:57] Dr. Christian Vercler: Yeah, that's tough. That's cause you know, as you mentioned, I do pediatric craniofacial surgery. So I take care of a lot of kids with cleft lip and cleft palate and one of my mentors at Boston children's hospital, there was every single kid he could, he would say, let me make your face look better.

And he'd book him for surgery. And then these kids would get lots of revisions and they looked great. But I remember as a trainee going does, but if it's not bothering them, maybe we shouldn't do it. And so just from a very early age, thinking like we should be operating for patients, not just on them.

And I, the line I always use to parents too, is that, look, I can find something wrong with anybody's face. The question is whether or not it's bothering them and whether or not we can make their lives better by addressing it. We know that there's a phenomenon. This psychologists have studied this, that, that people viewing content on social media feel bad about themselves afterwards. There's a, there's some, several studies that show I'll be like college age women, you know? okay. Scroll on social media for half an hour and then take this wellness exam or whatever, and it drops. And so there is something about how the algorithm feeds stuff to you that can put people into these looking at highly curated photos of things makes them feel bad about themselves.

The thing about reinforcing norms is just a big philosophical issue that, that I always bring up to students when I'm teaching them. Does the existence of our specialty, is it, is it somehow a bad thing for society? Right. And undergrads, I used to teach an undergrad class called the philosophy.

And that really would blow their minds right, to think about. And obviously we're not going to stop doing what we do, but I think it is an interesting philosophical question of, of what does it mean to be human and what does it mean for us to make people look more human or less human and better than average?

Very, very, a lot better than average, and, and why would we do those things and when is it appropriate? When is it not appropriate?

[00:32:01] Dr. Sam Rhee: Yeah. I feel

[00:32:02] Dr. Christian Vercler: those are, yeah,

[00:32:03] Dr. Sam Rhee: no, I feel like these are issues I grappled with when I was doing cleft craniofacial surgery. I'd had it both ways where patients or parents would say, I want my kid to be normal. And you're like, normal, wait, what's normal. And your kid looks pretty, pretty normal to me. I, or alternatively, I would feel like, you know what, I could make this look a lot better.

And they would say, it's okay, we're done. We're happy. And I would feel like, but I didn't really. Do the job I was supposed to do. And I feel like if I did, I could, I could get there. And, and so I felt like, it, it went both ways and oftentimes it's great if you and your patient or your patient's family could come to an agreement on, on what the goal is and achieve that goal.

But, but oftentimes, and this is often the time in aesthetic surgery too. If you're not harmonious with that goal, it, it can be a huge problem. I

[00:33:00] Dr. Christian Vercler: Yeah, absolutely. And you're totally right. It's like the hardest thing in the world to look at a kid and go, I know I could make that better. Please let me make that better. But I don't say that out loud. I know. I try to, I, cause I, yeah, I don't want to be that guy. I just, I just don't want to live that life where I'm telling people, please let me make you look.

I want them to, as you say, you want their goals to be harmonious with what we deliver. And I think that's the best way to get the best outcomes.

[00:33:24] Dr. Sam Rhee: So let's flip it into aesthetic surgery. So are we, for example, and we were talking about aesthetic general genital surgery, like labioplasty are we reinforcing or imposing our perspective on what normal genitalia is by posting these types of procedures or pictures on social media?

[00:33:46] Dr. Christian Vercler: Yeah. I wrote an article about this cause I think it's, I think so. I think it's really interesting. I have some in my wife's a urologist, a pediatric urologist and I'm friends with some of the gynecologists here and, and there's some gynecologists who are really, really angry about.

Labioplasty and one of, one of my colleagues has a book called pedals. It's by some photographer, it's just have a picture of like hundreds of genitalia of labia. And she has that book in her office and she hands it to patients who come in seeking labioplasty and says, look, what you have is normal.

See you later, w w so you, and I know that there's some patients who have functional problems or minor functional problems. That's I don't think that the operation is a bad operation, but I do worry about having a significant, like, if let's say someone's Instagram feed, I guess it wouldn't be Instagram, let's say their, their Snapchat feed or even their website is just a series of photos of normal female Tanner stage four genitalia pre-op and then post-op looking Tanner stage.

Hairless with visit with the menorah, unable to be seen. It starts you start and then it's so it's, pre-op, post-op, pre-op, post-op that ingrains in you, abnormal, normal, abnormal, normal pathological corrected. And so I don't know what that does on a social media feed when we know that women have worse feel bad, worse about themselves when they view certain kinds of images on social media.

And I'm not the only person to bring this up. I think there's, there's plenty of, of authors have had done studies on this to say, Hey, are we contributing to, or are we pathologizing normal? It,

[00:35:34] Dr. Sam Rhee: let me ask this first. So I think our first assumption is, is that female genitalia as a aesthetic part of the anatomy is somehow different, special then say aesthetic breasts or aesthetic face. And I felt also reading article that it was because it was intimate, it was hidden. It was not something that is typically displayed.

Although I don't know how often breasts are really displayed, but and so people. Should treat this subject of surgery on women's genitals to be somehow held to a different standard. Is that true? Because like you said, there are, and I do know some gynecologist and we've actually had a recent conference where several of them were very adamant that any aesthetic labioplasty or genital surgery is mutilation, it's not appropriate.

And like you said but isn't that them imposing their thoughts about what appropriate is, because they're just basically saying anything is appropriate which is in its own way, imposing a viewpoint about the appearance of women's genitals.

[00:36:43] Dr. Christian Vercler: Well, I think if they don't want to do it, I think that's fine. I think the idea is that if you are putting out into the. If your message is that normal is abnormal and that people consume media in certain ways, that's going to make them. So they'll internalize that maybe what you don't want to do is induce feelings.

That what they have is abnormal. So they must seek out surgery. I think we can agree that that that shouldn't be okay. That the idea that if you're fine and then you're scrolling through social media and you start to get this sense of, like, I think there's something wrong with me.

I need to go seek out this surgeon to fix me that that's not really, that really shouldn't be what physicians are about. . If we can agree on that, then, then I think we think, well maybe there should be some ways about advertising about that or the way we label before and afters to try to minimize that potential trap or, or pitfall.

[00:37:39] Dr. Sam Rhee: I wonder because I feel like this issue is not something I've needed to deal. And I'm an N of one. So it really, it's not a very valid scientific viewpoint, but I will say in my experience, patients will have their own issue about their dissatisfaction with the appearance of their own genitalia.

An oftentimes if you really dig into it, it's, it's a partner or, some casual hurtful comment or something in their life that was traumatic, just that, that really instilled a great deal of insecurity in general about their body. And that's when they will approach, they, then they consume a lot of images about genitals online on social media in it, and let's face it. It's also good and bad all, they're all available now because, before they had nothing to use in terms of looking at resources and now they have what, maybe an overabundance of resources out there, like you said, that might be skewed, but at least then they will generally come to a surgeon and ask what it is that can be done, what their thoughts are about the surgery.

And most of the time I will give them my honest opinion about what's technically possible. And is that technically advisable, not aesthetically advisable, but is it technically advisable? And I have seen a wide variety of anatomic wants and. Patients in my experience have been fairly specific.

And in a few cases I will, or, or a fair number of cases, I will not necessarily recommend surgery, but I know that they will go find someone else, probably to do what they want. I just don't feel comfortable doing it, but, but in the end, the patient it's patient driven and the patient will find somebody.

So I wonder how much of this is really in our hands and how much of it is our responsibility. And ultimately like you said, social media is so difficult for us to control. How do we actually display the, these procedures? If not on social media, we can't really post them anywhere else, even on social media.

There's only a very, like you mentioned on your article, there are only a very few number of programs that will allow you to show nudity at all. And what if you are someone who is interested in it legitimately, I think you have to take the good with the bad, right? So maybe you do see a lot of genitals and that's available to you.

Unfortunately, maybe a large majority of them have some sort of normative value that someone else is imposing on on them. But but shouldn't, we trust the patient ultimately to make that choice because we see stuff that's skewed all the time. Everything is skewed in terms of the, our media consumption.

And this is just one more thing that's skewed as well.

[00:40:34] Dr. Christian Vercler: Right. Yeah. So I think, yeah, I think this is having the female genitalia, being an object of aesthetic scrutiny by society. I'm not the first person to think that that might. We call the patriarchy there needs to be overthrown, that idea that, that the male gaze of the female body is normative.

And that we should be okay with it. Or should we bring up that it could be problematic and that may be and that maybe also consuming images of augmented breasts is also pathologizing normal breasts. And maybe that could be problematic as well. So I think that the kind of arguments that I wrote up in that paper are more along these kind of feminist critiques of society where the idea that like women's bodies are normal the way they're made, and that it's a specific a specific way of consuming images of female bodies. That that's what that would be. The court considered the male gaze a very male way of looking or consuming a woman's body visually is finds it lacking in certain ways. And that women internalize that feel bad about it and then seek out cosmetic surgery so that they can fulfill this standards of the male gaze.

And so, again, that's a larger feminist critique. I'm not the author of that, but I think it's, it's definitely out there. It's definitely not anything that we talk about as plastic surgeons very much because it's, again, kind of a larger social critique of, the winds of style in our society.

So I think it's reasonable though, to, for us to know about those things. And I have three daughters. I don't want them to feel bad about the way they are and see stuff on social media that makes them feel not good enough that they would have to seek things out. That's just again, my viewpoint, but I think it's definitely a viewpoint that's out there as well, that we should kind of maybe be cognizant of.

[00:42:35] Dr. Sam Rhee: I agree. I would say there's no doubt that society, in my opinion, shows a lot of, I guess you could call that patriarchical perspectives on what. Women's bodies should look like a lot of businesses like Hooters are based on it. What w what we see in the media shows what these proportions are either exaggerated or idealized in a lot of ways, Barbie, you name it.

has been ongoing for decades, and this is not something I think us as plastic surgeons can really fix. I don't even know if we can really fight against it, honestly. And unfortunately we are probably we're profiting from it. Let's just put it that way. There's no doubt that we're profiting from it, and that's a bad thing, but, , it's difficult to address on an individual level.

I think some of the things that we can do as plastic surgeons, one is it's always typically been a male dominated profession. And the fact that we have more and more women entering our specialty is going to be one appropriate way of addressing this. I think if you look at how society is, a lot of higher education is becoming more at least equal in terms of gender.

And probably I think if you look at the new undergraduate classes in a lot of colleges, there's, there's more women than, than men in, in some of these colleges. And I think that that's going to reflect in medical school and then eventually in our surgical specialties. And then just having that, that diversity of viewpoint in terms of gender will hopefully help to change these things, because most of the people in positions of power who often determined.

These things are no longer just men. And I think that we're seeing a societal shift in terms of sexual harassment, what's appropriate behavior. And I think plastic surgery will also catch up in some ways in the year 2021. I don't know as me as an individual, I can necessarily say, well, I'm not doing breast augmentations anymore because I feel like I'm giving into the patriarchical viewpoint of w what an idealized breast should be like.

That, that I, I don't think I can realistically do what I think I can do is speak individually with each of my patients and try to harmonize what their goals and what can technically be done and achieve something that is satisfactory in a long-term. Like, I know there are a lot of patients out there that don't necessarily know what they want, and I'm very careful not to. A particular viewpoint or opinion, or thought in terms of what they should do. I'm very, very particular about that. And I think as plastic surgeons, if we do have patients who are unsure, I think that's very helpful. Rather than just say, well, everyone is getting this, so you should, you should do this.

[00:45:17] Dr. Christian Vercler: Right. For sure.

[00:45:19] Dr. Sam Rhee: and I feel like that's, that's, that's only a little bit of scratching the surface.

[00:45:24] Dr. Christian Vercler: what I'd say to that's cause this is about social media. I think, how, how we, what we put on social media is, is that's where we can kind of express that. I would say, I know you probably, you probably know Sheila Nazarian. She's got a great social media following. So, so, Sheila calls herself the small brown.

Right. And so she, her posts are always have very subtle breast augmentations. And I think that's her way of saying you don't have to put in 500 CC implants, she's, she's trying to show a different aesthetic. And I think that's, I think that's interesting and, and kind of cool. And so again, how we, what we choose to post and how we post it and, she brands herself as that.

That's one way I think of potentially, being in conversation with that larger issue that we just talked about.

[00:46:11] Dr. Sam Rhee: So I do know that there are some private practice, plastic surgeons who livestream labioplasty is they will actually have their patients almost self record as they're doing procedures. Is that appropriate? Is that, is that okay?

[00:46:27] Dr. Christian Vercler: yeah, I think it's, yeah. I guess that's the one.

I, I, I'm a trained ethicist, so it's always, the answer is like, it depends. Right. So you know, all the details matter if it's I, I saw a live stream of that one time. And the patient was speaking Spanish in the physician was speaking English to the PE Spanish speaking patient. And I thought to myself, what was the Hinson foreign, Spanish? What does she understand? What's actually happening? You just think about like, does, do people really understand what they're signing up for that, that idea?

Again, there's so many what I call them ethical pitfalls that you can get into in these situations. Like, is it bad? Full-stop no like the very few things that we might say like I said, if he did it without consent, that's bad, full stop. But if the patient consents to it, do they really know what they're doing?

Do they know what the intention is? Do they know what format it's going to be in? The problem with Snapchat is that it's the, it is the one where you can do show anything on it, but the average age of the users as well, below age 18. So the, and so you're basically putting pornographic stuff in one context that would be considered pornographic, but it's on Snapchat.

It's called it's educational for patients. But the vast majority of people who consume that content are probably not your patients.

[00:47:45] Dr. Sam Rhee: we be regularly? Should we be regulating these tech companies? Because this is this not their responsibility.

[00:47:52] Dr. Christian Vercler: I think that's what they were talking about in Congress. When they were, testifying and saying, Hey, Facebook is trying to do this stuff and it's aimed at kids. And, and so I think, I don't have the answer, but it seems, there's been some New York times articles recently just saying how dangerous, like they said, the most dangerous object in your house is your phone for your kid.

Right. Cause they can get on it and they can get, and they can start getting into content that can lead them down a rabbit hole, which is bad for their mental health. And so th so it was interesting that that particular article in the New York times tried to make some analogies to other products that you would never let a kid have access to, and then show that how much more dangerous certain aspects of social media are to a kid's psyche.

So I think it's probably gonna have to be, or, so that's the question is where should it be regulated? Should it be regulated. Professional level where we say I would never post any content that could be taken out of context that could potentially ever lead to some bad outcome or be consumed in a way that would not be consistent with my intention.

Or should that be coming top down from the government? Generally, a lot of people think top-down government approaches, not the best approach. But that's what they do if we don't regulate ourselves. The professionals are given a lot of leeway to self-regulate. And so if we don't regulate ourselves, then we get things come down from the top down, like the FDA warnings on breast implants.

Now, that's like, that's a very draconian way of like making sure we're really doing what we, what we said, we're doing this.

[00:49:22] Dr. Sam Rhee: Right. I feel like as a professional society, the surgeons that I know who are ASPS, who are plastic surgeons, generally are pretty good. There's always outliers. The issue is, is that it's the non board certified plastic surgeons, the people who are cosmetic surgeons, are not board certified who are not plastic surgeons, who I are really causing patient harm.

They're not even following the most basic responsibilities in terms of patient care. And those are the ones that are going to drive some of the most egregious outcomes. And I think generally speaking, even when it comes to physical harm, you always see that, right. There are some times, no, no specialty is I'm faultless, but I feel like it's very difficult for us as plastic surgeons when we are dealing with, and I don't want to keep pointing at others because, I understand that I have a bias I have my own self-interest here.

But I do think that there are a lot of non board certified surgeons out there that are causing significant issues on social media in terms of what they do. In misinforming patients which is problematic. And I think we can certainly hold ourselves to a higher standard, but short of not being able to help regulate these on art certified surgeons.

I don't think there's a whole lot. We can do. Just because I'm driving onto the highway properly and I'm observing the stop sign and the red lights and making all my proper right. Turns the guy next to me, who's driving like a maniac and smashing into five people. Like, I can't do anything about that.

And it's frustrating. I think.

[00:50:58] Dr. Christian Vercler: Yeah, no. So I think, I think that's a good case for w why the social media companies probably should take a more hands-on approach to regulating what gets posted.

[00:51:08] Dr. Sam Rhee: What do you do as a parent personally? Cause I have a son and a daughter. Are older, they're in, they're in high school. So honestly the horse probably left the barn for me at this point for social media. But what advice as an ethicist would you give to others about children and consuming social media?

Because short of, locking them away in a closet and hiding their phone, like there's really no way you can prevent them from being part of society.

[00:51:35] Dr. Christian Vercler: I don't think so. Yeah, I, my kids are always on a device. And so, I, I certainly don't personally have it figured out I try to watch what they're on and have the YouTube, whatever things set up. So they can't find crazy stuff there. Tik TOK, I try to only let them watch it while I'm around.

So, but that's difficult too, because you can, again, it feeds them stuff. And before too long, what the heck are you guys watching? Yeah, it's tough. I've, I've got some colleagues. I work in a children's hospital primarily, and so I have a lot of pediatric colleagues who say that there's lots of evidence that the longer that you can delay kids access to.

Constantly being bombarded with this the social media feeds the better and more resilient they're going to be emotionally.

[00:52:23] Dr. Sam Rhee: So what

[00:52:24] Dr. Christian Vercler: So I don't know. I've I actually haven't met it's too late for me. I My four year old is on my phone from like the minute she wakes up, she walks in and says, dad, give me a breakfast and grabs my phone off the nightstand.

So, yeah, I, I, yeah, no one should follow my example in that regard, but it's scary. I don't, yeah, I don't have any easy answers for that, but I know that there's evidence that the longer you can delay and the more you can try to keep them off of it. The better they're going to be, but it's so hard.

It's a constant struggle and, especially, yeah, well, I was gonna say I've a good friend of mine. Her biggest lament of the Penn. Was that she said to me, I spent my whole life preventing my kids from there. They had a screen-free existence up until the pandemic, and our kids were like school age and she, it was so hardcore.

I I'm in Ann Arbor. So you can imagine there's some hippies here who really no screens for their kids. And now the kids gotta be on the screen all the time for all of their engagement. That's the only way they can engage is, is CRE. So it was undoing all the good that she thought she had done for the entire existence of her children was like gone in an instant with a pandemic.

So, I think we're all, all of us were sorting that out and I don't have any easy answers. And I certainly personally am probably not someone to hold up as an example, exemplar

[00:53:39] Dr. Sam Rhee: It's, it's funny. I think I don't have any really good ideas either. All I can tell you is I try to practice what I preach, but I still consume a lot of social media. And so I can't legitimately have any moral grounds to stopping my kids from a reasonable amount or unreasonable.

I don't know, whatever you want to say in terms of consumption, but I certainly want to practice my set an example. So in situations where I don't think it's appropriate, even if I want to use social media, or be on my phone, I'm not. And then the other thing is, is I try to offer experiences. That are positive, which don't necessarily involve social media, but involve our family.

And I hope that that helps. It probably is not enough. But the third thing that I have hope is is that our kids are resilient. As children, we've gone through a lot of crazy stuff and most of us are half okay. Having grown up. And I just have hope that my children will also find a way to navigate and be resilient.

And they've always surprised me in terms of what they can do. And I hope that they'll continue to navigate things and continue to surprise me. So that's, that's just really what I, that's what my hope is.

[00:54:47] Dr. Christian Vercler: Yeah, the ECC summarized it. Well. Yeah, exactly.

[00:54:53] Dr. Sam Rhee: Well, Christian is really a pleasure to talk to you about these issues. And it's so funny. I thought with an emphasis, I would have these clear guidelines about everything. And it's, it's refreshing to know that a lot of it is, is very situational and specific. And that, that gives me hope that as a plastic surgeon, I need to look at every situation make my best judgment in that situation, not apply a hard and fast rule to everything.

It's really about figuring out what is best in that particular situation. And a lot of it seems like it's common sense, honestly, as an ethicist. Is that the way it seems like, I don't know.

[00:55:30] Dr. Christian Vercler: so I think that I I get a lot of lectures on, on ethics in general, and there's a lot of different ways to define what is ethics. And I always say that my favorite one is that is disciplined reflection on moral ambiguity. And so that you're basically in, but disciplined also meaning taking a discipline that exists like philosophy and logic, and trying to apply that to these areas that are morally ambiguous.

Social media didn't exist 20 years ago or whatever. So we're, we're looking at so how do you answer these questions? We'll try to take some basic principles and apply them to the circumstances as they are existing in reality. And so I think that's, that's how we do it and try to.

It's morally ambiguous. It's neither. It's neither good nor bad. It's just, we have to try to struggle through these things.

[00:56:20] Dr. Sam Rhee: Well, thank you very much, Christian. I appreciate it. And I really hope I have a chance to talk to you again in the future about other issues. It's been really, really.

[00:56:29] Dr. Christian Vercler: Yeah. It's been a pleasure. Go blue.

[00:56:31] Dr. Sam Rhee: then go blue. Let's do it.