In this episode of Shorr Solutions: The Podcast, “Working with the Aging Face Patient”, we welcome our special guest Jonathan Grant, M.D.! As a double-board certified surgeon and the owner/medical director of Cascade Facial Surgery & Aesthetics, Dr. Grant discusses how to effectively work with the aging face patient, how COVID has given rise to an increase in even more aging face patients, and the importance of being upfront with these patients about what you​’re able and not able to do.

Dr. Jonathan Grant Introduction:

Mara: Dr. Grant is the owner and medical director at Cascade Facial Surgery and Aesthetics in Washington State. He is also double board-certified by the American Board of Facial Plastic and Reconstructive Surgery, as well as, the American Board of Otolaryngology and Head and Neck Surgery. Can you tell our listeners just a little bit more about who you are and about your practice?

Dr. Grant: Sure! I have a facial plastic surgery and aesthetics practice, we’re set up about an hour north of Seattle. I’m from West Texas, so I grew up in a rural area. My wife and I enjoy a lot of outdoor activities and we travel across the country. In our training, we’re exposed to a lot of different environments. Our last stage of training was on the east coast. We lived in Boston, but we found that we like to spend our weekends either going to the coast to be at the beach or going into the mountains up in New Hampshire, or heading out into the woods in Maine. When it came time to start looking for jobs, we both found opportunities just north of Seattle, and we thought you know, this is a fantastic fit. That’s how we ended up out here. My practice is about, I would say 70% cosmetic and about 30% reconstructive and most of my reconstructive work focuses on skin cancer reconstruction. I also do a fair amount of functional rhinoplasty, these are patients with nasal airway obstruction, deviated septums, obstructive sleep apnea who have trouble breathing through their nose. We do a full line of injectables, and laser treatments in office, as well as, in the operating room. We also offer aesthetician services such as, derma plains, micro needling, microdermabrasion,  those types of things.

Dealing With Turnover:

Mara: Talk to me about how you’ve seen a little bit of turnover. One thing that I have noticed in your practice is that you have team members that once they come, they stick with you for four years. So even though there has been a little bit of turnover, what have you done? What would you say you’ve done to credit this?

Dr. Grant: Mara, I think that’s a great question. When I was first starting up my practice, I was part of an ear, nose and throat group, working as an employee. I’m still amicably associated, even though we don’t have any business association. When I decided to go independent, I really decided to think about what kind of people do I want to have working for me? I began to realize that the longer you’re in practice, the more your patients will pick up, basically you’re cultivating your patient population, the person you are is a brand. I think you have to think about what kind of brand do you want to present to your patients. I like to do what I do, I’m passionate about my work and I truly love taking care of these patients.  I wanted to make sure when I was bringing staff on, that I was bringing on staff who felt the same way because I feel like that’s consistency is important in helping to promote a feeling of trust and confidence in your patients. We have had some folks, come in and spend some time with this and they move on to do something else. The ones who stuck are the ones who I find really feel as passionately about what we do here is I do and that’s actually the type of employees and staff that I want to have with me. We are a tight-knit group, we kind of think of ourselves as almost like a sniper unit. You don’t have a lot of people, you kind of move pretty fast and everyone has a very important job, everybody knows that everyone else has a very important job as do they. There’s a lot of trust with that and it’s, to me it’s a pleasure working with people in my office who feel passionate about what we do. I think that’s why our patients like coming to us.

The Balance Between Elective and Non-Elective Procedures Due to COVID-19:

Mara: Talk to me about your balance between your insurance procedures and your elective procedures. While we can certainly say and talk about what the balance was Pre-COVID, not really that’s it’s a fair scale anymore. Talk to me about what you’re seeing, now, as far as the trend with a practice that has both insurance and elective.

Dr. Grant: We got shut down in the middle of March. As soon as that happened, they pretty much shut the state down and they said as a provider, the only patients you’re allowed to see are emergency cases. At the time, the dermatologist we work with, some of their most reconstructive cases, which might have been a little bit more routine, for about three weeks became emergent because they had to get folks in and then get them back home so they wouldn’t have to come back in anymore. He talked about skin cancer reconstruction, I mean, that’s in terms of COVID-19, that’s a vulnerable population. Most of those patients are a little bit older, it’s given them the opportunity to have enough UV damage where they start growing skin cancers. The cases that needed to be tended to became more advanced, more severe cases. Those were ones that we ended up taking to the operating room, but then I’d see them for follow up in the clinic with myself and maybe one other staff member with all the appropriate measures in place, in terms of personal protective equipment and symptomatic screening. I would say, for three months, or for two and a half months, we weren’t doing anything except for those kinds of cases. We were still corresponding with our patients who made online inquiries and we still had some presence going on social media, but for the most part, it was predominantly skin cancer reconstruction work that we were doing. Since we’ve opened back up, we are still doing the insurance stuff and it is growing, but I’ve actually been surprised to see that the cosmetic surgery appears to be coming back a lot faster than I thought it was going to be.

Mara: What do you attribute that to?

Dr. Grant: I would say that has to do with people having a lot of time with themselves to sit and reflect about what they want to do with themselves over the last two and a half, to three months. I think another part of that is the increasing use of video chat. I think people are spending a lot more time looking at themselves on a video screen than they were pre-COVID because you could just go and talk to somebody, and aside from selfies on social media, a lot of my patients who are aging face patients, they don’t necessarily do a lot of the selfie stuff, but if they’re going to do zoom and talk to their friends and their family, they’re going to be looking at themselves the whole time that they’re looking at their family members.

Mara: That’s a really great point, have you started using that in your marketing at all yet?

Dr. Grant: We haven’t yet but I think we’re approaching that. We’re getting close to nailing something down to that effect but we’ve only been seeing cosmetic consults. Being in a rural area with an aging face practice I think it’s very different than in an urban practice with aging face. A lot of my patients, they’re baby boomers all the way up to octogenarians and a lot of them just don’t really like to do much social media. I have some patients who intentionally say, I don’t ever do email, but they’re out and they’re active in the garden and they spent a lot of time outside. One of the things about this area in Western Washington where we live is like it’s pretty temporary. If you don’t mind the rain you can be outside literally 12 months a year.

Reaching Aging Face Patients:

Mara: How are you reaching your aging face patients at this point knowing that you have some really great juicy marketing concepts there, but it’s just a matter of getting to the patient. How are you reaching that patient?

Dr. Grant: What we find is they’re actually reaching out to us. They’re on zoom with their friends and their friends feel great about how they look, you know, they’re starting to divulge more. A lot of the marketing has been through past patients and relating their stories. I would say in the two weeks when we’ve been seeing this influx, it’s not so much anything we’ve been doing except for what we did in the past, to just make sure that we’re providing excellent care for patients. A lot of these patients who have come in, in the last two weeks or people that I saw three, four and five years ago. Another interesting thing we’re seeing is,  people coming back and even though we’ve been open since last Monday, they’re not jumping on the schedule for surgery this month. They’re still a little bit nervous. They’re actually picking dates, in August, September, October.

Mara: Are they booking their surgery dates now?

Dr. Grant: Correct.  I think they want to make sure that as things open up, there’s not a big surge and they get caught in the middle of that. They have to whether going in and out to a doctor’s office because they have mandatory post-op appointments.

Changing Cancelation Policies Post-COVID Shutdown:

Mara: How long are you giving those patients to change their mind, get a refund, etc. if they do decide that they want to push it back a little further. How are you handling that from a policy point of view?

Dr. Grant: Honestly, our policy for booking is, you get a date on the schedule when you put down a deposit. Anything you pay beyond the deposit, and the deposits relatively nominal for a surgery with IV sedation or Mac anesthesia. The remainder of your balance, however, is due on the date of your pre-op appointment and that’s usually within 30 days prior to your surgery. We say essentially everything is refundable, except for the deposit up to 48 hours prior to the surgery date. If you cancel within 48 hours, then you forfeit half of your surgeon’s fee, facility fee, and anesthesia fee. Just because it doesn’t give the providers an opportunity to fill that block.

Curving Out Your Niche:

Mara: Knowing how closely you work with the aging face population, that really is your niche at this point. How did you carve out that niche for yourself?

Dr. Grant: What got me interested in facial plastic surgery to begin with was the reconstructive work, taking care of trauma patients, taking care of skin cancer patients, and just fixing these crazy wounds. Rhinoplasty was a big part of my training universe and at the Medical College of Wisconsin, I worked with an excellent Rhino surgery or rhinoplasty surgeon there Dr. Rey. It did not have as much aging face exposures I wanted to have so in my fellowship, I wanted to make sure I went to a place where I did a lot of aging face work, and that’s where, at the University of Missouri, I met Dr. farrier, who’s since retired. His practice was a very, very busy aging face practice. I’ve found it’s just an absolute pleasure taking care of these patients. I get a lot of warm smiles, we have a lot of people come in and see us two-three years down the road who even though they’re well past their post-op recovery period you know we monitor everybody routinely for a year they still come in just socially and say hi. I’m sure it’s similar for things like rhinoplasty and other types of plastic surgery but for whatever reason this population, I just really enjoy taking care of.

Helping Manage Expectations:

Mara: How do you help manage their expectations, for the expectation versus the reality of what it is that you’re able to provide for the surgery?

Dr. Grant: I basically make it plain to them in the consultation, we spent about 45 minutes with each of our consults, if not a little bit longer. I tell them, I’ve talked to my staff, I’ve seen when you booked your appointment, but I always like to hear from my patients straight from my patients, what is your goal? What is it I can do to help you? Some people kind of get taken back by that because like I said this before, this is part of the process, you getting to tell your story more than once. It lets you really think about what it is you want to focus on. The greatest predictor of our success and working together is if you and I are on the same page about what is our goal and my goal is not to tell you what you need, but to make recommendations about how I think we can as a team, get to where you want to go and then you have to frame it. I don’t promise someone the moon you, if I don’t think I can get higher than about 30 stories, so to speak. I’ve always been taught, and I’ve always tried to practice, under promise and over deliver. With aging face patients, we spend some time in front of a mirror together. I’d like to show you something and I try to show them as, as descriptively as I can, what I plan to do without getting into gory details. Then I try to tell them some things that they can do and some things that you can’t do. We walk people through the office and we show them canvases of before and after pictures and we say, “look I want you to see here, now the jawline is better but not every wrinkle is gone.” I always try to tell people that I want you to look better but I don’t want you to look like you look better because you saw a plastic surgeon. I just want you to look better and to feel good about how you look. Then you can tell whoever you want to tell why it is you look refreshed and you look more rested for your age.

How To Handle Negotiators:

Mara: I know some of our markets are very heavy in negotiators that come into a  practice and others are saying nope, I will pay full price. Do you find that with your patient base, that you get a lot of people trying to negotiate?

Dr. Grant: I think it’s just something you know, you get out of this city, and get out in the country and it’s part of this mentality of like, well, I may not have all the resources on hand, but let’s see if I can make it work with what I do have.

How do you personally have that conversation with patients?

Dr. Grant:  If you work with a patient care coordinator, if you have other staff who are helping you with these consultations, and I do think it’s important as a provider that you are not the main face of the financial aspects of the negotiation because you always want them to see you as the provider and you don’t want them to see you as a banker. I think this is something that with your team, you have to decide. We’ve done some barter things in the past, but in terms of discounts, especially when it comes to surgical procedures we’ve seen in the past, and if you just do the math, and you look at discounting, if you’re in a market where you stand to gain enough in volume from discounting, or negotiations, then it might be worth doing. Where we are, if we’re willing to drop 10%, on a surgery case, or 20% or 30%, it’s unlikely that we’re going to experience growth in excess of 10% or 15% per year, just because there’s not that many people up here. For us to pull that many people, we’d have to pull them out of the downtown Seattle area. Instead, what we’ve decided to do is really incorporate our pricing with our branding and make sure people understand what you’re getting here is something that in comparison to the larger urban market nearby is a tremendous value to begin with. We actually are priced for all of our surgery things at or just below averages for the Seattle greater metro area. We tell them that we can do that because our operating expenses are a little bit lower being out where we are. However, there is a floor that we don’t go under and that’s because you also have to understand that people will have a sense of you get what you pay for.

Mara: That’s a great point, knowing your ceiling and your floor. I think it’s important that everyone on the team knows what that floor is so that they have the authority and your patient care coordinator has the authority to say, I can give you a discount of X amount of dollars. It doesn’t necessarily have to be that while the medical director is running in and out of consults, and in and out of procedures, you have a PCC come up and tap you on the shoulder from behind and say, oh, real quick, Can I give a discount to you know, Mr. or Mrs. Smith, and you don’t have all the paperwork in front of you, but she’s trying to close the deal. I think it’s important to know what the pricing is and what discounts are available. You have to know when to say no, that this is as far as we can go at this point and this is the value that Dr. Grant brings to the table.

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