On BEING A HAIR LOSS PHYSICIAN

HELPING COMES FIRST

I am a medical doctor dedicated to helping people with 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 medical doctor.  Hair loss matters to every human on the planet - it’s an instinct as basic as taking note if one is too hot or too cold —- or too hungry. Hair loss 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 or come to accept the changes, but many do not.  Some people feel anxious. Some feel sickened & paralyzed by the whole experience.

Hair loss usually develops in some unexpected manner.    Many patients share with me that “ hair loss” was not something they would have predicted would become part of their personal story. And hair loss often seems to happen out of the blue. A patient years ago summarized it nicely: "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 his ever changing demands of 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. Some are skeptical based on past experiences and some feel abandoned. Some don’t know what to even feel any more. Part of my job is to better understand the emotions that my patients feel and better understand why they feel certain ways, do certain things and say certain things. Part of my job is to bring to the table factual scientific and medical knowledge, coupled with compassion and understanding to help patients. Understanding these finer aspects of my patient’s emotional health can sometimes be extremely important as we decide how best to treat the patient’s hair loss.   There is an intensity and pace to my job that is really quite hard to describe. I end most of my days at the clinic feeling energized, inspired, and triumphant on one hand and exhausted, worried and defeated on the other hand. It is intense at times but the magic of the whole thing is that I can’t wait to repeat it all over again the next day.

I understand what it’s like to feel terrified as one tries to figure out for themselves why they are losing hair. I understand how it becomes all too consuming to figure out if one should “google” more and more search options or just turn off the screen and try to forget about it for a while. I understand the sleepless nights. I understand what it’s like when the list of diagnostic possibilities seem so confusing and when one’s research leads them to confidently feel they have “Condition X” only to feel the next day that they probably have “Condition Y” instead. I know what it’s like to want to give up and what it’s like when one just does not know anymore where to even turn. I understand what it’s like to be blocked by the administrative assistant at the clinic who answers the phone or be dismissed in some manner or another by the physician who comes in the door of the examining room. I understand what it’s like to be made to feel like everyone you meet in your medical journey is doing you a favour just so you can get access to medical care. I understand what it’s like to be made to feel like one is simply overreacting and that everything will be just fine. I know what it’s like to feel that nobody cares and what it’s like to feel that one’s battle will need to be fought entirely on one’s own. I understand the imperfect world that we live in.

PEOPLE ARE UNIQUE

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 don’t really consider myself a “hair loss doctor.” Rather, I am a doctor who happens to specialize in hair loss. There is, of course, a difference. I see more than the hair because it’s more than the hair that really matters. It’s true that the patient who comes through my door has a concern about hair loss. But one will fail to recognize the diabetes that the hair loss patient has if they just focus on “the hair.” One will fail to recognize the heart disease, and cancer and infertility and kidney disease and liver disease and psychiatric diseases and neurological diseases and rheumatological disease and immune disease and eye disease and skin disease and bone disease if one wears blinders and only sees “the hair loss.”

I am a physician first. I am drawn to clinical medicine and taking care of people.

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. 

ONE NEEDS TO SEE THE WHOLE PICTURE

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 greatly shaped my current day hair clinic that operates in Whistler, BC. 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.'

In my opinion, the big picture is needed. In a similar line of 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 over many years with a deep 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 top 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 in the world 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.'

With this background, consider then, the patient with hair loss with the diagnosis of inactive (quiescent) 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 inactive (quiescent) 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 micropigmentation. 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 her 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 become pregnant 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.  We must not allow modern medicine to become so narrowly focused and pigeon holed that we lose sight of the patient.

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 travel to Whistler from around the globe for second opinions and then 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 somewhere in the world 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 Whistler office. 

My practice is focused on caring for the patient and his or her hair ... regardless of what the option for treatment may be.  

WHAT I PROMISE MY PATIENTS

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, I've likely read it.  And if I've read it, we've already carefully considered how (and if) it should be worked into our treatment plans for our patients. I spend dedicated time every single day of the year reading and thinking about hair loss. My office offers treatments based on science, safety and sensical thinking. For example, we don't start JAK inhibitors (tofacitinib/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 in my clinic or a patient is coming back for their 15th or 100th appointment, I treat my patients like I too want to be treated as fellow human being: with a respectful, non-judgemental and confidential approach. My clinic must always be a safe place for people with concerns about hair loss.  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. This is so important to what I stand for. I see patients from around the world, with diverse backgrounds, lifestyles and concerns. I approach every patient with a fresh mind. No story is too unusual.

3) Our third promise is that we will never promise results. I can respectfully yet very confidently say that my hair loss clinic sees some of the most complex presentations and types of hair loss anywhere in the world. I see very tough cases of alopecia areata or scarring alopecia or androgenetic alopecia. Uncommon conditions are commonly seen every single day in my office. I will do everything I possibly can that is within the reaches of current biomedical science to get hair growing or stop it from being lost - but I will never promise results. Never. 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.  I 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 the present day, 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 about hair growth by some clinic, I always advise to go with it! On the flip side,  I achieve success in a good proportion of patients.  Every day a patient arrives back to the office looking different than when I last saw them. Every day emails come in with patients sharing some story of their success. 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. But I do not promise results. But I do promise to do my utmost for my patients. 

THE FUTURE

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. It is happening slowly. We have a lot of work to do to support and fund high-quality research. It is happening slowly. 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. It will happen someday. The goals are lofty but achievable.   I will fight for my patients, and their rights as patients and consumers, and the integrity of my profession until the day I stop practicing. 

My sincere thanks for visiting our website.  I'm honoured that over 1 million people now visit our website every year.  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 do have hair loss, be sure to see a physician. 

……. thank you again,

Sincerely ,

Jeff Donovan, MD PhD

Whistler, Canada.