RECENT Q & A
I am a physician dedicated to helping those affected by hair loss. I am drawn to a very unique field of medicine that addresses the diagnosis and treatment of hair loss. The individuals who step into my office are cared for as my patients - not as my clients and not as customers of my clinic. The stories and descriptions of how people feel when they discover they are losing hair has stuck with me since I first became a doctor. Hair loss matters to everyone. And it matters to quite a significant degree in quite a large proportion of people. Losing hair speaks to the very essence of what it means to be a human. Many individuals who experience hair loss feel self-conscious. Some lose that feeling of self consciousness with time, but others do not. Some feel anxious. Some feel sickened & paralyzed by the whole experience.
Hair loss is usually unexpected. It seems to happen out of the blue. As someone once said to me years ago, "hair loss can strike a person at any time and often when they are riding high on life." The 4 year old about to start junior kindergarten with enough worries about school itself let alone hair loss. The 14 year old dealing with the pressures of being a teenager who now has to figure out how to cope with hair loss. The 23 year old with hair loss who is juggling school, family, work, dating and friends and now must factor in how hair loss affects each one of these. The 43 year old whose hair loss only adds to the pressures felt in their ever changing demands of their work, family life and social life. Or the 104 year woman who told me once that her changing hair bothered her more than any of her other health concerned combined. Hair loss matters to a significant degree in quite a large proportion of people. But hair loss also affects other individuals who are part of the patient's life. It can affect the patient's parents, children, spouse, partner, sisters, brothers, grandparents. It can affects the patient's boyfriend or girlfriend, friends, coworkers, teammates, and teachers. Hair loss affects communities and our society. Hair loss has more an impact than we speak about in the present day.
My typical day in the office bears witness to nearly every human emotion that exists ranging from joy, happiness, anger, sadness, fear and surprise. Part of my job is understand these emotions my patients feel. Sometimes the emotions the emotions are misplaced - the case where a patient is fearful when there is no need to be fearful. Understanding these finer aspects of my patient can be important as we decide how best to treat the hair loss.
As a physician, I need to understand many aspects of the patient's experience with his or her hair loss to understand how best to treat their hair loss. It is not uncommon for two patients with the exact same hair loss condition to leave the office with different treatment plans. In my practice, there are no templates for treating hair loss. There is no rubber stamp protocol for treating genetic hair loss. There is no rubber stamp protocol for treating scarring alopecia or alopecia areata. There are no rubber stamps for anything. No two patients that visit my office are the same, and it follows that the treatment plan that they walk out the door with will likely differ as well. To read more about my views and general principles for treating hair loss, click here.
Second, I am a dermatologist sub-specializing in the field of hair loss. The science behind hair growth is very interesting. The molecular and cellular mechanisms governing how a hair grows and how it sheds is both fascinating and bizarre. The growth of hair on the beard vs eyebrow, ear hair vs nose hair. Grey vs. black, blonde hair vs. red hair. Hair is interesting! I enjoy the detective work that goes into properly diagnosing hair loss.
I am focused on my patients. I started my career with the basic premise that if I could help patients with their hair loss I would have accomplished something worthwhile and good. Some patients would hopefully feel more confident and proceed to take on new goals in their personal life, work life or social life. Some would at least feel less anxious. And some would stop feeling sick about it. I hoped that some of my patients would be very happy. Of course, we achieve these goals a good amount of the time, albeit not as frequently as we really need to.
My practice has evolved to what I believe offers patients comprehensive care. My previous experiences in both the academic medicine and private practice settings have shaped my current day hair clinic. One of the greatest concerns of my patients has been that modern medicine has become far too focused and some even might say narrow-minded. A heart specialist treats the heart but not the liver. A liver specialist treats the liver but not the heart. Clearly, there is a tremendous need for this level of expertise - and without it we would not have come very far. But who looks at the big picture? Abraham Kaplan is his 1964 book, "The Conduct of Inquiry: Methodology for Behavioural Science" stated very nicely the problems that exist when we become too specialized.
'Give a small boy a hammer, and he will find that everything he encounters needs pounding.'
The big picture is needed. In a similar thinking, consider these fictional examples I have created. Suppose an individual has a goal is to get to and fro from work over a distance of 10 km, but at the same time he or she wants to get some exercise while commuting to work. If that individual finds themselves in a car dealership, will that individual be advised that what he or she really needs to fully address the stated goals is to purchase is a bicycle ... and not a car. Or consider the man who is searching for simple options for emergency lighting for his house whenever the power & electricity go out. A search online for emergency lighting directs him to a nearby store specializing in lighting options. Will he be given the option to consider a buying a flashlight or even buying a candle, or will that individual see the only option being the purchase of a complicated emergency lighting system for the home.
My practice evolved with a deeper understanding that individuals with hair loss want to first and foremost understand what exactly is causing their hair loss (i.e. their diagnosis) and what is the short term and long term prognosis. In fact, I believe that one my best skills is my ability to diagnose hair loss - especially complex and unusual presentations. What is causing the hair loss... and what is going to happen over the next 5, 10 and 25 years? Second, individuals with hair loss want to know all their options for addressing their hair loss and they want to know just how realistic these options are as solutions. Many current hair centres and clinics are extremely focused on one aspect of treating hair loss. Some do it very well, but the options presented to the patient are often limited. A reminder of Abraham Kaplan's reference to the quote 'Give a small boy a hammer, and he will find that everything he encounters needs pounding.'
Consider then, the patient with hair loss with the diagnosis of lichen planopilaris that finds himself or herself in a hair transplant office. The particular condition they have is inactive and strictly speaking the patient is a candidate for surgery. Is it a good option? Well for this patient, yes. It's a great option. But consider the next patient with the diagnosis of lichen planopilaris finds himself or herself in a hair transplant office. Is it a good option? For this particular patient, a hair transplant is not really a good option even though technically speaking it's one of the possible options. A far more satisfying option for camouflaging hair loss would be consideration of a wig or even scalp micro pigmentation. Modern medicine can't address this particular patient's goals with hair transplant surgery.
Consider too, the 28 year old female with the diagnosis of androgenetic alopecia who finds herself in a wig salon. She's devastated by the hair loss and wants full thick hair again. Is a wig a good option? For this patient, yes. A well designed hairpiece is a great option. It can be life changing. But consider the next 28 year old female with the diagnosis of androgenetic alopecia who finds herself in a wig salon. Is a wig a good option for her? For this particular patient, it is a good option, but a far better option would have been first to see a physician about the hair loss. Further work up by a physician would have revealed that the cause of her androgenetic alopecia is in part due to a hormonal abnormality known as polycystic ovarian syndrome (PCOS). Her diagnosis of PCOS has implications for her health, her risk for diabetes and heart disease and even her chances of becoming pregnant in the future should she want to in the future. A wig is a good way to camouflage her hair loss but it did not address an important underlying issue she has and does not give her the opportunity to take control of her own future health decisions.
And so, my practice has evolved with an entirely different line of thinking. In 2017, I made a decision to stop my hair transplant surgery practice and modify my existing non-surgical practice to allow me greater flexibility to focus on the much 'bigger picture' for my patients. Many patients who step into my office remain long term patients. Some are seen every 2 months, and others every 2 years. But a proportion of patients are seen just once. Some come in for second opinions and return to their own physicians for ongoing care. If a patient comes to my office for a consult and hair transplant surgery is indeed the best option for them, I refer them to a trusted colleague specializing in hair transplantation. If a patient comes to my office for a consultant and a wig or scalp prosthesis is the best option for them, I refer them to a trusted colleague who focuses on wigs, hairpieces, toppers and hair systems. If the patient requires non-surgical management, and close follow up for any one of a number of hair loss conditions, they remain a patient under my care in the Vancouver office.
My practice is focused on caring for the patient and his or her hair ... regardless of what the option for treatment may be.
My practice is based on three promises to my patients.
1) The first promise is that we will provide patients with diagnostic and treatment advice that is based on the most up-to-date scientific and medical research. If some aspect of hair loss research has been published in a medical journal, we've likely read it. And if we've read it, we've already carefully considered how (and if) it should be worked into our treatment plans for our patients. We offer treatments based on science, safety and sensical thinking. We don't start JAK inhibitors (tofacitnib/ruxolitinib) in patients with alopecia areata who haven't tried other treatments first. We don't recommend PRP in patients with androgenetic alopecia who haven't carefully considered other treatments first. The same type of common sense applies to how we approach scarring alopecia and hair shedding issues.
2) The second promise is that we will provide patients with care that is respectful, compassionate, confidential and rooted in trust. Whether a patient is coming for a second opinion and will likely never be seen again or a patient is coming back for their 15th or 100th appointment, we treat our patients like we too want to be treated as fellow human beings: with a respectful, non-judgemental and confidential approach. If patients need greater degrees of privacy from the public for their appointment with me, we will accommodate (with advanced request). My office, and my practice, must always be a safe environment for everyone.
3) Our third promise is that we will never promise results. I can respectfully yet confidently say that our hair loss clinic sees some of the most complex presentations and types of hair loss anywhere. Uncommon conditions are commonly seen in my office. We will do everything we possibly can that is within the reaches of current biomedical science to get hair growing or stop it from being lost - but we will never promise results. We can not be so bold as to think humans can 'fully' control and navigate how hair follicles grow and don't grow. This approach is simply not correct. It is a wonderful goal for the future, but not a goal that is with us yet. We will never promise results. Is it disappointing when a patient does not achieve the results we hoped for? When a patient claims that they expected a whole lot more results? Yes, this is disappointing, but that speaks to the limitations of modern hair medicine. In 2017, the field of hair medicine has a rudimentary understanding of hair growth mechanisms. This rudimentary knowledge actually gets us pretty far - just not far enough. There are no such things as guarantees for any hair loss condition. If a patient is given a guarantee, I always advise to go with it! On the flip side, I achieve success in a good proportion of patients. It's the success that one can achieve with a methodical and meticulous approach to treating every relevant aspect of a person's health that first drew me to this field of medicine. In my clinic, there are many success stories, touching stories, happy outcomes that leave patients with smiles that help me to keep doing what I'm doing despite some patients not achieving success. I don't promise results. But I promise to do my utmost for my patients.
This website has changed many times through the years and I can only imagine that it will change again. The changes reflect my personal views. Here are but three examples.
a) My Views on Patient Photos.
I no longer have what is frequently referred to as "before and after" photos on our website anymore. I have removed most of these - not for privacy reasons (as we always obtain full patient consent for any postings, research, or studies we do including our social media postings). Rather, I have come to believe that before and after photos are misleading far too often in the field of hair loss that I am in. Generally speaking, photos posted on websites show the most dramatic results, and sadly I can confidently say that many photos I see are either not the same patient in the 'after panel' or the 'after panel' has been manipulated in some way. (How many photos do I see where a female scalp with the head tilted down does not even have a 'normal' bit of scalp showing! How many after photos have reduced lighting to accentuate the appearance of density! How many after photos are probably not even the same patient! ). Of course, not all photos are like this and not all professionals practice this way.
Photos that show the most outstanding of results are misleading to the public. I believe that the public deserves to see results of what one should reasonably expect with a given treatment rather than the most incredible result. Do you want to see a hair transplant results that it outstanding? I have the albums. How about photos of full regrowth in alopecia universalis? I have those too. What about regrowth scarring alopecias which are otherwise not supposed to regrow at all? I have many of those photos! But what is more important to me (....and hopefully to the public) is: 1) what is the reality of the results one should expect? and 2) how often do these results occur? and 3) how often do patients receiving the given treatment have no results or less than desired outcomes?
b) My Views Patient Reviews
I don't allow patient reviews or testimonials on our website and I do to not under any circumstances solicit testimonials or reviews from my own patients that become published. I believe this is an area of extreme concern in the modern practice of medicine. I am saddened to say that our profession is filled with fake reviews, deceit and misleading information online. This is problematic in much of cosmetic medicine but it is particularly problematic in the field of hair loss. I must reiterate that this is not everywhere of course, and much of what is published is likely genuine. However, the public can not distinguish fake from real and the public is very much swayed by the opinions of others. Many medical societies have stepped up to the plate and stated that soliciting reviews and publishing reviews and testimonials on one's website is unacceptable - however the practice has become the norm and these recommendations are ignored and not enforced. Many physicians are not even aware of them. What is acceptable and unacceptable will soon become rewritten and this information written above will likely soon come to be viewed as archaic.
c) My views on social media
I enjoy the opportunity that social media presents to help teach others about hair loss. Our various social media pages are unique, and as a physician, it's something that I take very seriously. Our social media pages don't contain content about the hair or hair loss of any sporting figures, public celebrities or politicians. In the same light, I don't post pictures (or selfies) with any of my myself and my patients regardless of how honoured or privileged I might be to be involved in someone's care. My office, and my practice, must always be a safe environment for everyone.
In recent years, I have come to see that the bigger picture has some very lofty goals. We have a lot of work to do to train more physicians to recognize the importance of hair loss and to provide appropriate care for all types of hair loss. I continue to teach other doctors with the hopes that new doctors might also consider this field of medicine to be interesting and consider pursuing it as a career. We have a lot of work to do to help insurance companies and health care providers understand not only the impact of hair loss but also the impact of helping people achieve hair growth. We have a lot of work to do to bring safer, more effective treatments to our patients. We have a lot of work to do to support and fund high-quality research. We have a lot of work to do to remove from the world those ineffective products & services that prey on the vulnerability of those with hair loss. The goals are lofty but achievable. I will fight for my patients, their rights, the rights of my colleagues to practice safely and the overall integrity of my profession until I stop practicing.
My sincere thanks for visiting our website. I'm very honoured that over 50,000 people now visit our website every single month. I hope you'll find it informative and helpful in your personal quest to find information and answers. If you have a question, type in in the link here: MY QUESTION. There's a good chance something helpful will pop up from one of the many hundreds of articles and blogs I have written. I also enjoy answering patient questions on my blog posts, as well as websites like Realself.com. My daily Instagram posts are a great way to learn about hair loss and also provide a means for individuals to ask questions about hair loss. But nothing replaces an up close examination of the scalp and full review of one's hair loss story - so if you have hair loss, be sure to see a physician.
Thank you again,
Jeff Donovan, MD PhD