QUESTION OF THE WEEK

THOUGHTS & PERSpECTIVES FROM HAIR LOSS SPECIALIST Dr. Jeff Donovan

ON EXPERTISE & BEING A HAIR LOSS SPECIALIST

“Although the internet gives anyone the ability to acquire new knowledge, the internet does not lend itself very well to creating new experts. Real expertise develops slowly from many years of repeatedly making errors in judgement. Unfortunately, there is still no good app for that.”

“We commonly overestimate how often our patients adhere to our treatment recommendations. Some patients are so busy with life that they can barely remember to pick up the kids from daycare. For others, taking any treatment that could be categorized as a ‘drug’ goes against their steadfast beliefs. Some patients dislike looking at or touching their hair which makes any sort of topical treatment difficult.

One needs to understand each and every patient. Standard templates for treating hair loss frequently fail.”

A patient does not need to be like you or like you or even like your recommendations and they may still consider you a key member of their healthcare team. The patient-physician relationship is a relationship like no other.

You don’t always need to feel pressure to make a diagnosis. Sometimes the passage of time provides the diagnosis. In fact, a good number of things in life eventually make sense with the passage of time and the cause of hair loss is no exception. It could take a while, but there’s often clarity that comes with the passage of time

“The problem with the modern style of referring to patients as “clients” is that we can too easily forget and neglect the many fine details that went into the decade long process of becoming doctors that care for patients.

At last check, most medical schools are still teaching about the doctor-patient relationship rather than the doctor-client relationship.

There is no guarantee, of course, that this concept will always remain.

“Hair specialists need not themselves have “good hair” or be affected by hair loss to become a good hair specialist – any more than kidney specialists must have good kidneys or be affected by kidney disease before entering that profession.

A mandatory requirement for hair specialists, however, is a genuine desire to help one’s fellow human with hair or her hair loss concerns.”

“Health care providers hoping to acquire a complete understanding of a given medical condition will rarely achieve this goal if they omit from their patient interactions an ingredient known as understanding.

Understanding starts with understanding.”

“Despite a world population of nearly 8 billion people, and countless previous generations, there has yet to be two people who think about their hair or about their hair loss in an identical way.

Our cumulative experiences from birth to the present influence how we view many things in our lives, including our hair. No two people share an identical life journey and no two people have identical views on the significance and meaning of their hair.”

“Medical professionals often incorrectly assume that patients who have just a little bit of hair loss are emotionally affected just a little bit by their hair loss and patients who have a great amount of hair loss are emotionally affected a great amount by their hair loss.

This type of thinking should be abandoned as it is not supported by any hair loss study and does little to build the requisite therapeutic alliance between patient and practitioner.”

“In many parts of medicine, you expect patients to accept your diagnosis. When a cardiologist tells a patient they have a leaky heart valve or some type of heart failure, it would be surprising for the patient to respond by saying they don’t think that’s the right diagnosis. When a kidney doctor tells a patient they have kidney disease, they don’t expect to hear that the patient read something different online or heard something different from their friend over dinner.

Being a hair doctor is a strangely and perplexingly unique experience.

I tell junior doctors that if they choose to enter the field of hair medicine with an expectation that patients will wholeheartedly accept your diagnoses and won’t challenge your clinical judgement or even refute your diagnoses until you are both blue in the face… then you have chosen the wrong field. As a hair doctor, you must understand that your advice will ultimately find a position among other advice that patients have received from every magazine or online article the patient has ever read, every TV advertisement they have ever seen, every hair stylist they have ever visited and every chat they have ever had with a close friend.

Time, however, is truly one of the best judges. You simply need to practice evidenced based medicine together with good old fashioned care - and time will set the record straight.”

“Scalp biopsies are wonderful tools to help diagnose disease - but are not always needed if the diagnosis is clear. One of the more common errors I see performing scalp biopsies is taking the biopsy from a less than ideal location. If you are thinking this could be disease X or disease Y or disease Z then think about taking the biopsy from the most common location you know that disease X, Y or Z are usually found. If you know that disease X usually happens in the middle of the scalp then it’s probably not ideal to take the biopsy from the back of the scalp.

If you are looking to perform research on mosquitoes, don't set up shop in Antarctica because there are no mosquitoes in Antarctica. If you are looking to participate in an extravagant elephant safari adventure, don't book a vacation in Canada. You won't find them roaming wild here.

Always choose your location with care.”

It’s wonderful thing to be unbelievable. Quite the compliment.

Well, unless, of course, it’s true. In that case, there’s a serious need for reflection, self improvement and a change in one’s ways.

“Nobody knows their hair and what it means to truly experience hair loss better than the patient. I am privileged, however, to be invited by many patients to be second on the list and advise them in ways that they themselves can not. To me, the patient - physician relationship is about being a team.”

10B

If you work in a store that sells shoes, you really need to understand at least something about all the different types of shoes sold in the store. You never know what the next customer coming into the store will want to buy.

Being knowledgeable about the shoes in the front of the store does very little for the customer who wishes to buy the shoes found in the back of the store. The same information may not apply.

If you work in a store that sells chocolates, you need to understand at least something about all the different types of chocolates sold in the store. You never know what the next customer coming into the store will want to buy.

Being knowledgeable about the chocolates found in the right side of the store does very little for the customer who wishes to buy the chocolates from the left side of the store. The same information may not apply.

If you work in a hair clinic, you need to understand at least something about all the different types of hair loss that can affect people. You never know what diagnosis the next patient coming into the clinic will have.

“One must not underestimate the role of the hair stylist, hairdresser or barber. They may serve as friend, confidante and advisor to the person with hair loss. They have a much more important role in affecting what the patient’s hair will look like this evening than will any hair specialist on the planet.

Even though the stylist may not examine the scalp in any objective manner, the opinion of the hairdresser or stylist is very important to the patient. Many hair specialists never come to fully respect the key role that the hair stylist or hair dresser actually plays in the patient’s life.”

12A

“It is true that low levels of fuel can be one of the reasons that a car does not run properly. But if one fills up the gas tank such that fuel levels become normal and the car still won’t work properly, one needs to consider other reasons why the car isn’t working. One should no longer focus on the fuel levels.

This simple logic is too often forgotten when treating hair loss.

It is true that low levels of iron can be one of the reasons that a hair does not grow properly. But if one fills up the body with iron such that iron levels become normal and the hair still won’t grow properly, one needs to consider other reasons why the hair isn’t growing. One should no longer focus on the iron levels.”

12B

My dear colleague, Dr. Google, is very nice. Full of Knowledge. Tries hard. Available 24 hours per day and 7 days per week. Even holidays. Speaks many languages.

But my colleague, Dr Google, is an extremely poor listener. I don’t recall the last time Dr Google really listened to a patient’s story.

And I must say - with all respect - Dr Google is a tad lazy too. Refuses to examine anyone’s issues

Dr Google likes to dabble in the hair loss profession. It’s a difficult endeavour because the only way to really diagnose hair loss is to listen to the patient’s entire story and properly examine the scalp.

If we can work on those two skills, Dr Google will be a hit.

“It’s possible for two different physicians to recommend the exact same medication to the exact same patient and in one scenario have the patient fill the prescription and in the other scenario have the patient throw the prescription in the garbage out of fear.

There is a whole lot more to prescribing than writing prescriptions.”

14A.

“The most important question that we can ask our patients relates to how they are doing. Not the “how are you doing?” that has become synonymous in today’s society for a hello-type greeting but a formal inquiry into how the hair loss is impacting their life. Many patients have never been asked by the doctor”

14B.

It seems like pretty good advice that if a practitioner does not feel in his or her heart of hearts that a treatment is going to help, that treatment should generally never be prescribed. Patients intuitively sense the unspoken. To prescribe the treatment in this case only serves to weaken the precious relationship.

On the contrary, it seems like pretty good advice that if a practitioner feels in his or her heart of hearts that a treatment is likely to help, that treatment should be prescribed with the appropriate dose of hope, confidence and enthusiasm.

I once was asked by a group of medical students what it takes to develop expertise in an area of medicine. The answer is quite simple actually: a courageous curiosity. One must be courageous to admit to himself or herself that they do not know something and then must be curious enough to search out the answer.

Suppose you have set out to hypothetically be an expert in recognizing the shapes of objects. You recognize three basic shapes - squares, triangles and circles. You have mastered the basics of shapes and certainly you are skilled to comment on shapes. I would not say you are an expert in shapes but I would leave that to you.

An important lesson for all professionals who wish to advance their expertise is what they do when faced with situations that they have never encountered before. What does the person do when faced with new shapes - such as a rectangle, diamond or oval (difficulty level 1) or heart, shamrock or star (difficulty level 2).

Should you choose to call a rectangle a special type of flattened square, it will probably make little difference and the same is true for calling an oval a special type of flattened circle. These are not so far off from reality. But what about the star shape and heart shape? What will you choose to call them if your knowledge of shapes is mainly that of circles, triangles and squares?

It takes courage to say “I’ve never seen anything like this before!” and it takes courage to say “I just don’t know what this is!”. It takes more courage to say it to someone else than to say it quietly to oneself. It takes a bit of curiosity to figure out the answer to the unknown. Opening a book, searching the internet or seeking advice from others can sometimes lead one to the correct answer.

Expertise builds overtime when one goes through their professional life with courageous curiosity.

15B
We always need to open the textbooks to understand where we’ve come from. The textbooks give an overview of current disease and treatment models and current ways of thinking. However, now is not the time to pigeon hole ourselves into trying to explain everything we see with current models we read in the textbooks. Current models are used as a necessarily framework in order to build and renovate our thinking. Sometimes, we just need to realize that it’s okay to use the textbook to prop open the door in order that new ideas can enter the room.

“The patient is and always has been the chief executive officer of his or her own health. A physician must assume that their advice is only one of many sources of information the patient will gather in the quest for improving some aspect of health. These sources of information include the internet, media, printed literature, other physicians and allied health professionals, family, friends as well as what has been termed the patient’s own “gut feeling” about things. Physicians may be on the team, but they are not team captain.”

“Each person with hair loss needs to determine for themselves who to trust. If a person truly feels that the trusted person is a sales agent on the other end of a toll free telephone call, then I say go with the advice of the sales agent. This is assuming of course, the patient has done their due diligence seeking out advice from all sources along the way and that the patient is truly making their decision with what is termed “informed consent.”

Helping patients consent to treatment involves helping patients understand the risks and benefits of the chosen treatment as well as to understand the risks and benefits of alternative treatments. The health care field is one of only a handful of remaining professions where society calls upon health care professionals to discuss both the winning treatment as well as alternatives to treatment.

In the end, the individual is the final decision maker and chooses who to trust and whose advice to go with. Some patients do not take my advice and I’m okay with that provided the I feel the patient is making informed consent. Some of my patients sprinkle my advice with the advice of others - and that’s okay provided the I feel the patient is making informed consent.”

“The field of hair loss seems deceptively simple. But anyone new or old to this field must be humble to the fact that one does not know what one does not know.

You don‘t ask key questions to patients that you don’t think you need to be asking.

You don’t order the kind of tests that you don’t think you need to be ordering.

Patients don’t tell you the key pieces of information that they don’t think they need to be telling you.

The field of hair loss seems deceptively simple.”

“No patient ever wants to have a serious case of hair loss. But all patients with hair loss do want to have their case taken seriously.”

“A car mechanic often can't tell the reason that a car isn't working properly without examining the car and looking under the hood. We would all be a little suspicious if a mechanic walked up to the car, tapped on the front hood and offered some immediate recommendations.

Similarly, one needs to be at least a little concerned if a hair specialist offers immediate advice without a closer inspection.”

“There are some 3000 varieties of tomatoes. Why does it surprise people that there are hundreds of reasons to lose hair.”

21B.

After a 20 minute lecture on hair loss, one can feel that it all seems to make sense. Confidence runs high. One can make an increasing number of diagnoses. Eyes of the learner are wide open. He or she stands so tall.

Over the ensuing 20 days, 20 weeks and 20 months of studying hair loss, a most fascinating and perplexing transformation takes place in the learner. Confidence progressively diminishes as the learner comes to realize the expanding complexity of the field of hair loss. The learner increasingly questions his or her ability to confidently reach the diagnosis. Brows often furrow and eyes don’t pop open in the same way. One stands a little less tall and heads may tilt rather than be held high.

If the learner can endure this period and if the learner can thoughtfully equip himself or herself with the additional important pieces of knowledge necessary to push away the clouds of uncertainty, one can emerge on the other side with real expertise.

Even then, there may still be periods of uncertainty and one may never return to the feeling of confidence one had at the end of the first lecture.

“The reason that a “cure” for hair loss is potentially even possible is because of the hair follicle’s intrinsic tendency to want to grow despite all the messages it receives to the contrary. The resiliency of the hair follicle is awe inspiring.”

“At some point during nearly every appointment visit, the patient will take the time to let one or more people in the office know how much their hair matters to them. Some people are comfortable being more direct and the message comes out very clearly. However, much of the time, such messages are unspoken and easily missed.

However, at any time from the first greeting through the door to the final goodbye most patients will convey several messages to let either me or my office team know “I’m here today because my hair matters to me.”

“My patient sometimes ask me for help in making decisions on what treatment to choose. They usually ask me what I would recommend if they were my mother or daughter or sister or wife… or if I were there brother or father or son. I’m not sure why we need to have different rules for care and compassion simply because someone is not a part of my family. If we are not caring for patients like they are our family, something must not be quite right.”

“The words we choose are important because words carry meaning. The people who walk into church or a synagogue or a mosque are called worshippers. I think you’d agree that hearing a religious leader refer to them as customers or clients would seem strange and even inappropriate. What should we be calling the people who walk through the doors of a doctor’s office? Is there really more than one option? ”

25B

I am a big believer that individuals with hair loss should be strong advocates for their own health. I encourage patients to learn about the types of hair loss, their symptoms and signs and to learn how hair specialists treat these conditions.

There are some aspects of the patient journey that are misused - both by patients and by practitioners. One of these is trichoscopy or the use of various polarized or non-polarized magnification devices for the purposes of diagnosing hair loss.

The use of Trichoscopy to diagnose hair loss is far more involved than patients realize. Despite the ability to get a device for $20-40, that does not equate to the ease with which one can learn about trichoscopy.

If anyone wants to buy a stethoscope to listen to his or her heart… I say go for it. It’s fascinating to listen to the heart. I got my first stethoscope at age 3. It was plastic but never let me down.

It takes 30 seconds to get the basics of how to use a stethoscope. It takes about 6 months and a few hundred patients and a whole lot of reading to become really good at it. It takes a few years and a few thousand patients and a whole lot of mistakes, misjudgments and wrong assumptions to really become a pro.

A patient should not buy a stethoscope with the purpose to diagnose his or her own heart disease. Despite the ease of learning the basics, it takes a very long time to learn the requisite skills. One simply does not know what one does not know.

If the public wants to buy a trichoscope or magnifying device to look at his or her own hair and scalp… I say go for it. It’s fascinating to look at the hair and scalp with high magnification.

It takes 30 seconds to learn the basics of how to use a trichoscope. It takes about 6 months and a few hundred patients and a whole lot of reading to become really good at trichoscopy. It takes a few years and a few thousand patients and a whole lot of mistakes, misjudgments and wrong assumptions to really become a pro.

A patient should not buy a trichoscope with the purpose to diagnose his or her own hair loss. Despite the ease of learning the basics, it takes a very long time to learn the requisite skills. One simply does not know what one does not know.

“When it comes to understanding hair and hair loss, there are just so many variations of considered “normal.”

One of the most valuable skills for hair specialists to acquire and develop over time is the ability to recognize what is normal. As soon as the brain can routinely recognize what is normal, it can spot something that is abnormal and proceed to solve even the most challenging of diagnoses.

Hair specialists spend far too little time during their training examining normal unaffected scalps, eyebrows, and eyelashes. The ability to recognize what is abnormal comes from knowing what is normal.”

27
When deciding on what treatment the patient should use to treat his or her hair loss, the practitioner and the patient together must communicate with each other.

The practitioner who does not understand his or her patient will often choose treatments that the patient will not use, can not use, or can not tolerate.

Similarly, the patient who does not understand the viewpoint and experience of the practitioner will often choose treatments that are ineffective for them, poorly tolerated for them or less than ideal for them.

Shared decision making is the ideal structure of the patient-physician relationship.

“I am a hair specialist but it’s not hair loss that I treat. I actually treat patients. It just so happens that I have chosen to specialize in an area of medicine where the patients that I help all have hair loss. The patient must be central to everything we do.”

“The practice of medicine is different nowadays. We advise patients on their options and help them figure out what’s best for them. Physicians no longer tell patients to “do this or that.”

The old saying “take 2 aspirins and call me in the morning” no longer applies. Nowadays, we say something closer to “you might consider taking 1 or 2 aspirins if you are comfortable with the side effects we reviewed together or you might consider pursuing one or more of the other options we discussed.”

There is one important exception - and that is the acutely frightened, scared and terrified patient who has what we can an “acute stress reaction (ASR).” An example a patient experiencing an ASR is a patient with rapid hair loss. Many such patients have lost the ability to think clearly due to fear. These patients need more guidance than simply leaving all decisions up to them. Asking the patient “what do you think?” about certain recommendations the hair specialist gives has many challenges when the person sitting across from them cannot think clearly due to fear.

The entire issue is open to lengthy discussions about ethics and what really constitutes informed consent. Many patients suffering acute stress reactions (ASR) are left to figure things out on their own and some are taken advantage of by aggressive marketing. Many patients with hair loss experiencing ASR’s will choose any reasonable sounding treatment option that they are presented.

In my view, there are times when we need to hold on to the steering wheel of the driver and there are times when we can offer suggestions from the passenger seat. Above, all, we need to help our patients in the same manner that we someday would want to be helped. It’s certainly not easy, but it is certainly how things should be done.”

“We know that hair loss impacts the way some people feel about themselves. For many, the regrowth of hair following treatment is accompanied by a variety of transformations.

Consider, for example, something as simple as the posture of a person who has experienced an improvement in his or her hair - the way a person sits or stands ... and the way he or she walks. I don’t exactly know why posture improves so much when a human improves the density of his or her hair and why so many seem to stand about 2 inches taller. But it does and they do.

Perhaps it’s related to the air tasting better that helps inflate the lungs that much more. Some patients actually look like they are floating.

Perhaps it has something to do with the feeling that the weight of the world has been lifted off of the patient’s shoulders.

Over time, one slowly comes to realize that the job of the hair specialist is so much more than just helping grow hair. It’s about helping people live as fully as they can - without letting issues pertaining to hair loss interfere. It’s not about helping people return back to their old selves as much as it about helping people welcome a new self that is far more aware of just what sorts of adversity they are capable of overcoming. The transformations that follow improvements in hair are limitless.

If changing hair can transform something as simple as posture, what potential do you think it has for transformations that occur in the life of the actual patient?

We do have quite a bit of work left to do to convince the public as well as the medical profession that it’s not “just hair.”

We spend the first decades of life with the view that every question has a right answer.

“2 plus 2 is 4.”

These are challenging and informative years. Questions get more difficult over time. We get some answers right and some answers wrong. As we read more, learn more and reflect more on past errors, we generate consistently better, more precise and more accurate answers.

Then suddenly, as adults, we soften the requirements for accuracy and precision quite a bit through the creation of something called “professional opinion.”

“In my professional opinion, I’ve seen cases where 2 + 2 is not always 4.”

“In my professional opinion, keeping the view that 2 + 2 equals 4 can lead to a lot of problems”

The public relies on professional opinion. Professional opinion must be generated from the same rigorous steps that the individual used during his or her early years: from reading, from learning and from reflection on past mistakes. Professional opinion must never be a guess. Professional opinion must always be selfless and always offered for the good of others. We must never let professional opinion be anything else but the closest reach for truth.

In my professional opinion, professional opinion must be kept sacred.

Regarding the complexity of human emotions and actions that stem from hair loss, I have certainly heard a great many stories through the years. However, I am quite certain that I have not heard all the possible stories about how hair affects the way we all choose to lead our lives.

We as humans are far too complex for this type of bold statement.

What a wonderful world it would indeed be if we could someday not only stop fearing hair loss but stop the hair loss in the first place.

I am confident we will slowly get better in both areas.

32
We need to cheer for our patients.

Granted, we do need to be objective and not let every emotions consume us and impact our decision making. However, call it what you want - cheering, sending positive thoughts, or wishing for the best for patients, it’s important to care if we are to provide care.

33
Knowledge can change the world but so can ignorance and misinformation. We need to ensure knowledge prevails.

My favourite part of the story is the part when the two superheroes named Knowledge and Experience enter onto the scene and tell Worry and Fear to be quiet and go sit in the corner next to Ignorance and Misinformation.

You will meet many people along this journey and each and every one of them can teach you something.

You will meet those with varying degrees of knowledge and varying degrees of certainty about their knowledge. It ranges from informed to uninformed and from ignorance to arrogance but each person can teach us a great deal. That is - provided you know this simple fact.

You will meet those who simply know, which is just one step down from those who confidently know that they know. There are those, of course, who also know that you know they know. But you must also be ready for those who think they know but actually don’t know. That is a scary situation and I would urge a bit of extra caution when engaging with those who think they know but actually don’t know.

But you will meet people who really don’t know and even meet people who know that you know they don’t know. It’s always okay not to know. Offer help to those who don’t know in the best way that you can - provided that you know.

Keep in mind that not everyone you meet will know that you know if indeed it’s the case that you do know. So let others know you know when it’s appropriate and put your knowledge to good use if you find yourself in this situation. Knowledge can change the world.

Not knowing is always okay. In fact, this is a far better state to be in than what people get themselves into when they really don’t know that they don’t know. That too is a scary situation and I would urge a bit of extra caution.

You will meet plenty who know that you know or at least think that you know. But there will be many too who really, really, really hope that you know. These people count on you. Just do your best.

Sometimes you will meet those who know you don’t know. That’s quite okay as it’s always okay not to know. One must never be too concerned in this situation. There will be quite a handful that you’ll meet who don’t know that you don’t know. Be respectful to your fellow human in this situation.

I know it’s a strange world and I hope that you know this too. But everyone can teach you something that you truly need to know.

35B

Thinking “outside the box” is a phrase used in the English language to describe a creative and new way of thinking about an issue or problem.

One must not forget that the ability to think outside the box comes from a thorough understanding of what’s actually inside the box.

Mastering the basics of any endeavour is so important. It’s a solid grounding in the fundamentals that allows the next steps to unfold so seamlessly.

One should not read the second chapter of the book without getting through the first chapter. One should not take the advanced course without taking the beginner course. One should not try running without giving walking and crawling a solid try first.

One must not forget that the ability to think outside the box comes from a thorough understanding and deep appreciation of what actually takes place on the inside of the box.

ON LISTENING

“It is very important that the clinician listen carefully to all the details of the patient’s story of hair loss. The patient also has specific expertise when it comes to his or her own hair – albeit a different type of expertise than the clinician.

Nobody will ever have more cumulative days and years of experience with the hair issues in question than the patient in the room.”

“Being hair doctor is similar in many ways to being a heart doctor, eye doctor or a lung doctor. We listen closely to what has transpired in the patient’s life, examine the area of concern and then apply key principles of anatomy, physiology, and pharmacology with the goal to make people’s lives better.”

“Many patients will say that there is no universally ideal thing to say to a person experiencing hair loss. A comment that is appreciated by one person might not be appreciated, or even resented, by another person. Furthermore, a comment that upsets a patient today might trigger a genuine smile in the same person one year later.

What is generally agreed however, is that a focus on active listening, rather than exactly what to say, consistently helps the most.”

“The woman who once shared that the family dog was her greatest support was neither exaggerating nor seeking to be funny. Despite her myriad of friends and close family, the dog won the position.

The woman’s story allows us all to reflect on some of the most important qualities we might all endeavor to offer someone in need of support. Few things are fundamentally more important than simply being present and listening.”

If you are lucky enough to observe a grandparent interacting with a grandchild, you will often observe a critical skill that they don’t teach fully inside the walls of a medical school.

When times are good and the child is happy and jumping for joy, and the future seems bright, you’ll note that the grandparent smiles, cuts up a few pieces of fruit for both of them and just listens.

When times are bad, and the child issues scared or angry or impatient or screaming and kicking and the future seems dark, you’ll note that the grandparent smiles, cuts up a few pieces of fruit for both of them and just listens.

The response of the grandparent goes unnoticed by the child on that particular day but is never forgotten.

40C

Every patient with hair loss has a story. That story needs to be told - somehow and somewhere - and to someone. That is among the most import parts of the healing journey.

“It is indeed possible for a person to have neurological disease even though a basic neurological examination by a physician seems normal. A good amount of listening to the patient’s story gives valuable clues to the diagnosis. In these situations, we often just need to stop examining the nerves and just listen to the information being presented. The answer to the diagnosis may be right there.

It is possible for a person to have a heart disease even though a basic cardiac examination seems normal. And so too, one can have a lung disease even though a basic respiratory examination seems normal. A good amount of listening to the patent’s story gives clues to the diagnosis. In these situations, we often just need to stop examining the heart and lungs and just listen to the information presented. The answer to the diagnosis may be right there.

With those basic fact, it should come as no surprise that a person can indeed have hair loss even when a scalp examination performed by a physician seems normal. A good amount of listening to the patent’s story gives clues to the diagnosis. In these situations, we often just need to stop examining the hair and scalp and just listen to the information presented. The answer to the diagnosis may be right there.

If listening to an expert its still viewed by society as a good thing then listening to the patient is certainly on that list of reasonable endeavours. The patient is a special kind of expert. The patient knows what is normal. The patient knows what seems abnormal. How extremely easy it is to reach some diagnoses if we just listen to the patient. How impossibly difficulty and insurmountable some diagnoses are if we refuse too listen.

41B

Every coach, parent and teacher comes to recognize that there are moments when taking the time to teach or instruct are absolutely necessary for the ultimate benefit of the trainee, child or learner.

The wise coach, parent or teacher, however, also comes to recognize that there are plenty of times when standing off to the side, staying quiet and letting things proceed uninterrupted are precisely what is needed for the given situation.

As hair specialists, it’s useful to remember these tips.

Telogen effluvium (hair shedding) is one particularly good test of patience for the hair specialist.

Sometimes in hair shedding disorders, the hair specialist needs to intervene. The specialist needs to address all the issues that contributed to the abnormal hair shedding in order to recommend treatments that encourage the hairs to regrow. TE from low iron, medications or thyroid disorders are examples. Affected patients generally require treatment.

There are many other times, however, when the wisest plan for the hair specialist is to remain on the sidelines and not intervene and simply allow the intrinsic resilience of the patient’s own hair follicles to work things out. TE from acute stress, an acute infection, post partum shedding or short term dieting are examples. Affected patients may not require treatment

There are many cases of telogen effluvium whereby the best plan is not to intervene.

41C

Every health care provider - at some point - also becomes a patient. When I sit in the waiting room as a patient myself, I usually try to spend the time thinking about all the essential questions that I want to be ready to ask my doctor when the final question gets presented to me….”do you have any questions, Jeff?”

Sitting in the waiting room, my mind nearly always takes me to a fantastic list of questions that my own patients have asked me over the years. My favourite and most memorable questions, by far, are the questions that spontaneously emerge from the mouths of children in the age range 3-6 years of age- and usually at the most unexpected times during the appointment visit. Some of the most cherished include:

What color are you?

My dad wants to know why parking so expensive here?

What did you bring for your lunch today?

How old are you?

Why do you talk like that?

Do you know my teacher?

Did you take the elevator or the stairs ?

Why don’t you look like the picture on your name tag?

Questions of this kind bring great joy. If you listen to questions from patients you come to realize the common theme of all the questions - are you really suited to be my doctor? Someday, I hope to systematically try out each of these questions with my own future health care providers… and just see how it goes. I admire the spontaneity, thoughtfulness and truthfulness that many of my younger patients bring to the day.

41D

There is tremendous value in a person listening to songs and lyrical creations in languages that he or she does not understand or comprehend.

There is much meaning that can still be uncovered.

If one cannot grasp any sort of meaning in what is being sung, one simply needs to listen again.

A quieter room and quieter mind and fewer distractions may help.

The speed of the music and the duration that notes are held by the singer are all clues to the intended message.

If one still cannot grasp any meaning of what is being sung, one simply needs to listen to the song again … and perhaps even again.

There are many similarities to listening to music and listening to one’s patient.

If a practitioner is not sure how a patient is truly feeling or coping with his or her medical issue, the practitioner must certainly not hesitate to directly ask the patient.

But the practitioner must also not forget to listen to the patient because not every patient is comfortable to give a full and precise answer to every question at every stage of his or her own path to healing.

If a practitioner still cannot grasp any real understanding of how the patient is feeling, the practitioner simply needs to listen again. A quieter room and quieter mind and fewer distractions may help.

Consideration to what is not being said by the patient may be more relevant than an exhaustive review of what is being said. The things that a person decides not do in his or her life may be more relevant information than the things that a person does. All are clues to the message the patient wants the practitioner to hear.

If one still cannot grasp any clear understanding of how a patient is doing, one simply needs to listen to the patient again … and again.

41E

If a patient feels that he or she has a medical problem, then there is a problem. The problem remains until the point in time when the patient declares the problem is no longer really a problem.

For example, if a patient thinks that he or she has a thyroid problem, then the patient has a thyroid problem even if his or her doctor does not feel there is a thyroid problem. Even if all thyroid tests and all related endocrine evaluations point to a normally functioning thyroid gland - there is still a problem until the patient declares the thyroid issue resolved.

If a patient thinks about his or her thyroid gland every single waking day despite the practitioner’s reassurance that there is no problem … is this not a type of thyroid problem?

If the patient changes his or her diet to eat greater quantities of thyroid friendly foods or frequently discusses the thyroid issue over lunch with friends or through online forums despite the fact he or she does not actually have a thyroid gland disease ... is this not a type of thyroid problem?

If the patient seeks practitioners who will agree to repeat the thyroid measurement over and over or worse yet prescribe some sort of thyroid supplementation… is this not a type of thyroid problem?

Indeed, the patient has a thyroid problem. Despite the fact that there is no problem with the actual thyroid gland, there exists a type of thyroid problem.

One can replace the word thyroid for many words. The outcome is the same.

If a patient feels there is a problem, there is a problem until the patient declares that problem is resolved.

ON THE CONCEPT OF HOPE

“I'm often asked by doctors how I give hope to people who are suffering. I tell them, first off, that I don't feel that I'm ever really giving anyone hope. The hope must be present first and that's the key to what hope is all about. You don't create hope or invent hope or give hope. Hope is different than encouragement - although the two concepts are often confused. Hope is here right now. All I do is open people's eyes to something that is there. You can open the doors and close the doors to hope but I don't feel you can really give hope or take hope away as the saying goes.

You do not own the hope of another fellow human. The hope of someone else is not yours.

You simply help them see the hope that is present right now and the hope that is rightly theirs.”

42B
It's a lot easier to hope for the best than to spend one’s energy focusing on all the possible alternative outcomes.

The latter takes a great deal of creativity and imagination and far too much effort.

“In some countries, patients and colleagues refer to hair loss more commonly by the term “hair fall.” I have come to like this term.

Whether it’s a person of an object that falls, there is some degree of implied hope that the fallen object can somehow get up again. The loss of something, however, implies a disappearance. Whether it’s the loss of keys, a wallet or a person, there is some degree of panic. Hope seems somewhat less obvious in these situations associated with loss.

There must always be at least some amount of hope in every storm.”

“Hope is not about making people believe that they might awaken some day with a full head of hair.

Hope is really about helping people realize that no matter the circumstances that life deals them, they will somehow be able to find the strength to get up in the morning in order to see if today will finally be the day their mind has long been rehearsing.”

“The four pillars of hope can be remembered by the four letters of the word hope - H.O.P.E. Hope is Honest, Optimistic, Patient and Evidence based.

Hope is honest. Hope builds its supporting foundation from honesty.

Hope is optimistic. Hope relies on an optimism that something positive could happen in the future.

Hope is patient. Hope centres around a willingness to wait. There is no predicted timeline for when someone will feel that hope exists.

Hope is evidence-based. Hope relies on facts and refutes anything that destroys hope through misinformation.”

“I used to have a dream catcher displayed in my office. It was a gift to me and I took it with me through all my offices.

It was a good reminder to me that really what we’re trying to do as physicians is get people back on track to dreaming.

I had to discard my dream catcher after it was getting in pretty rough shape and no longer looked anything like a dream catcher.

We are programmed as humans to dream.

Take away the distractions of the world … and people dream.

Hair loss interferes with dreams people have. Not necessarily the bedtime dreams but the dreams people have for the direction they wish to take their lives.

It shouldn’t interfere with such things, of course, but it does for too many.

I once received an oversized card in the mail from an anonymous patient that read “Thanks for supporting me to dream again.”

That card, I’ll never discard.

ON LIVING & COPING WITH HAIR LOSS

“A ‘whatif’ is a condensation of the words “what” and “if.” Individuals with hair loss often spend a great deal of time and energy thinking about the various “whatifs” and what they will say or do in various situations.

Whatif someone asks me about my hair loss?

Whatif someone sees my hair loss?

Whatif I lose all my hair?

The reality is “whatif” events don’t happen as often as our mind wants to believe they should. Even if such events do occur, they are typically far less severe than the mind first prepared itself to imagine.”

“Everyone has different mechanisms of coping with their hair loss. No matter the strategy, one should continue to be kind to his or her hair.

Wash it. Cut it. Color it. Style it. Touch it.

Far too many people ignore the hair that is still present out of fear of making something worse.”

“New research has identified 27 emotions that humans can experience.

Hair loss can evoke all 27 of them.”

450

“It’s going to be okay.

Today, it might not feel like things are ever going to be okay. Probably not even next week or next month. For some time into the future, you may not believe that it will ever be okay again.

But one thing is for certain – it’s going to be okay.”

“When a person expresses concern about a tooth issue they are experiencing, it would be strange to respond by advising the person that they still have plenty of teeth and that they should not worry themselves so much.

When a person exposed concern about an injury to his or her finger or his or her toe, it would be strange to respond by advising the person that they still have plenty of fingers or toes and that they should not worry themselves so much.

It’s a rather peculiar thing that the societal rules and norms change so much when a person expresses concern about hair loss. It would seem silly to respond to a concerned person by advising that he or she appears to still have a good amount of hair left and that they should not worry themselves so much.

Such a response, however, is unfortunately all too common.”

51B

When children play doctor, outcomes of the pretend patients often occur in one of two ways: patients are either cured or not cured.

As we grow older, many continue to view medical outcomes in this simple binary manner without acknowledging another key patient outcome measure: patient healing.

The healing of the body and mind takes on a different course than the curing of the disease. One can be cured without being healed and one can heal without achieving any type of cure.

As practitioners, we help the patient get as close as modern medicine allows towards a cure but too often the healing part of the journey is left entirely to the patient.

The concepts of healing and curing sound the same but are not. While curing is defined as the removal of the disease state and the return of the patient to a more normal state of physiology, healing is quite different. Healing is the return towards a state of wholeness whereby the medical condition is no longer able to deliver an ongoing impact in emotional, social and and spiritual dimensions without the patient’s full permission.

It is with forgiveness, acceptance and compassion towards ourselves that we allow ourselves the chance to heal and get back on track to the constantly evolving person we want to become. Curing may allow the body to get back to the way it once was. Healing allows the individual to finally catch up to becoming the person he or she has been planning.

Health care practitioners are taught a variety of ways to show patients compassion and empathy. The emphasis here is on what the practitioner should do .... or not do - and what the practitioner should say .... or not say.

These are essential skills for all practitioners.

The practitioner’s toolbox of essential skills must also include skills that practitioners can use to support their patients to develop what has increasingly been termed ‘self-compassion.’ We must not forget that there is so much that the patient themselves can learn to do ... or not do, and so much that the patient themselves can learn to say ... or not say that will radically transform his or her own personal journey of healing.

These are essential skills for all patients.

“The future, dear child, is difficult to predict with precision. You might grow up someday to be shorter or taller than others around you. You might keep your good head of hair or perhaps lose some with the passing of time. You might run faster or laugh louder than anyone else or perhaps you will come to find those sorts of things more difficult than others.

Whatever happens in the future, there will never be anyone better to fill the role of you... than you. You are perfect for the job.”

“The experience of hair loss by any given person always affects more than one person. That could be a spouse, parent, family member, friend, school, community or nation.

Directly or indirectly, knowing or unknowingly, hair loss affects far more people than simply the person experiencing it.”

“The experience of hair loss is vastly different from person to person. Some patients can describe the first moment they realized they were losing hair with detail and vividness that even the finest of authors could never quite capture in any descriptive text. They know the date and time and place where they first realized they were losing hair. They know the sounds and colours and feelings that resonated in the body at that moment. They know the exact feeling of heaviness they felt in their legs or chest. They know the sounds of the outside world at that moment and how those sounds suddenly became muffled.

Yet other patients are equally affected by their hair loss but can’t even recall the month the hair loss started.

We all approach this very differently.”

“We need to get past the concept that people simply want to improve their hair to improve the way they look. It’s so much more than that and sometimes not even the patient can explain all the underlying conscious and unconscious reasons why they want to address their own hair loss. But one reason is fairly consistent - the patent sitting in front of me wants to improve the way his or her hair looks in order feel that much closer to what they themselves interpret as ‘whole.’

We all carry around in our mind an image of ourselves that defines who exactly we are. For the people that reach out to my office - that person simply has more hair than their current self.”

“There are three main types of patients that walk through my door. The most common scenario is the patient who is truly experiencing hair loss but nobody around them believes them. They are told by others that their hair are fine. They are told they are imagining the hair loss. They are told it’s not that bad. Even their own doctors think their response is a little excessive - and so do their partners, spouses and family. These patients suffer from frustration, anxiety and confusion.

The second scenario is the patient who is experiencing hair loss and the hair loss has got to a point where others start to take notice as well. These patients suffer from a wide range of emotions - including anxiety and embarrassment.

The third scenario is the patient who feels they are experiencing hair loss, but they aren’t really experiencing hair loss in any way, shape or form. The scenario is the least common of the three scenarios but I see 1 to 5 patients in this category per year as well. These patients also suffer and often have a wide range of underlying emotional and psychiatric issues.

The basic rule that I share with doctors is that all people who ask for your help regarding some aspect of their hair need your help. They have been judged enough already.”

“Hair loss evokes emotions in some people to a level and magnitude that they did not know was even possible.”

“Everyone is emotionally affected to some degree when they experience hair loss. At one point in our evolutionary past, paying attention to hair loss was likely an instinct that protected us from the environment and on occasion probably even saved our lives.

There’s nothing vain about being concerned about changes we notice with our bodies.”

“When an individual first experiences hair loss, it is normal to become very aware of the hair density not only of one’s own hair but also the hair density of other people. Routine assessments of the hair in complete strangers is a common but rarely talked about phenomenon.”

“Intellectually, patients with hair loss know that there are worse things that could happen in life than the hair loss they are currently experiencing.

Emotionally, however, the patient sitting in the office today might not be able to list any.”

“Hair doesn't really weigh all that much, but hair loss sure can weigh heavily at times.”

“It is helpful to have the emotional support of a few close people when dealing with hair loss. One must always keep in mind that everyone offers their support a bit differently and not everyone who offers their support to an individual with hair loss will be able to offer the right type of support that is needed and the right amount of support that is needed at exactly the right time that it is needed. Nevertheless, the connections we have with others are very important to healthy coping strategies.”

“We must also work to develop and nurture our own inner awareness in order to find our inner peace. In the end, it is the patient and only the patient who ultimately decides how he or she will feel about his or her hair loss.”

“Individuals with hair loss often carry around some degree of uncertainty and uneasiness as to whether their hair loss concerns would be viewed by others as vain.

Wishing one had more hair is no more vain than a patient with poor vision wishing their eyesight was better or a patient with stiff joints wishing the joints moved a little easier.”

“What partly defines us all as humans is our ability to choose how we feel about the changes we see happening in our bodies. We have options.”

“Individuals with hair loss are often concerned that hair loss will change them and make them different people. It will and it does. It would be a mistake to think otherwise.

Every event in our life will change us. Who you meet in the grocery store today will forever change you in some way. What you read in news today will forever change you in some way. Of course, the changes are quite subtle and we never really think about them all that much. But we are the summation of all our small medium and large life events and who we are as an individual is a summation of how we have chosen to cumulatively respond to all these life events.

My hope for my patients is that not only that their hair loss issues can be solved but that the experience will change them somehow in a positive way.”

“Hair loss can make it difficult for some to see clearly. There are times when the world is calling but the future way forward looks a bit blurry.

Sometimes, hair loss can make it difficult for some to hear. The world is calling but the brain registers only parts of what is said and many sounds are muffled.

Hair loss can some sometimes make it difficult for some to feel. The world is calling but there is a numbness that impairs the reply.

Being a hair specialist is so much more than helping improve people’s hair. Treating hair loss is about helping people so they can feel again, see again and hear again and give the world again in all the ways that the world so desperately needs from them.

69A

There are three basic principles of shampooing the hair in the shower:

The first principle is that everyone’s voice sounds better in the shower. Some people first realize their hidden vocal talent through time spent in the shower.

The second principle is that everyone’s hair looks thinner when wet. Some people first realize their thinning hair only after emerging from a shower with wet hair.

The third principle is that one should ideally keep singing after emerging from the shower until the voice returns back to its original state regardless of how long that may be - and avoid any attempt to sing to one’s own reflection in the mirror.

These are 3 important rules.

69B

Acceptance of a diagnosis does not mean “I have given up.”

Acceptance of a diagnosis does not mean “I gave given in.”

Acceptance of a diagnosis acknowledges that “I am on track to heal.”

ON SOCIETY’S RIGHTS TO ACCURATE INFORMATION

“Society must continue to protect the ability of a given individual to express his or her opinion.

The opinion of another person, however, must never share the same spotlight with factual information that was obtained and validated using the principles of scientific inquiry. Society must continue to protect its access to accurate information.”

70B

Our relationship with published medical & scientific research is a very special relationship that ideally needs to proceed somewhat counter to what we are taught about the general principles of healthy relationships.

How much better off our patients would ultimately be and how much quicker we would advance the world of medicine if we were all even just a bit more skeptical of the published literature, and a bit more critical of it

“The internet can be a very, very wonderful resource for anyone with hair loss but the internet can also be very, very harmful to an individual with hair loss.”

“The worldwide community of hair loss professionals is so varied. On one hand, we have those professionals who are deeply frustrated and concerned at how little they feel they can offer their patients. If the world is fortunate enough to have these professionals continue in the field and not leave the field to pursue other endeavours, these are often the professionals who end up offering the most to patients and/or end up advancing the field the most.

On the other hand, we have professionals who are energized every single day with bold claims of what they can offer their patients - and yet these are often the professionals who often offer the least and unknowingly push the field back into the dark ages.”

72B.

We still debate about the short term, medium term and long term side effects of some medications - despite the fact that those medications have been in the world for 20, 30 and 40 or more years.

It’s a strange thing in the medical profession how we often feel so comfortable commenting about the long term side effects of some drugs that have not been used all that long term.

If a drug has been thoroughly studied for 5 years, then one can only comment about the safety of the drug for use up to 5 years. Offering any comments about how safe the drug is over 6 years, 10 years or 20 years of use is unreliable and unreasonable and some might even say unacceptable and unprofessional. At minimum, it’s unsettling.

It’s okay that some questions are unanswerable at the present time. It is okay that some answers are unattainable at the the present time. It is okay that some patients travel in uncharted waters and truly lead the frontiers of medical science and go where no patient has gone before.

It is okay to be certain that some things are just uncertain.

“So many of the world’s advertisements for hair loss products and hair loss treatments show photos of people who don’t actually have hair loss. It’s not up to me to make the rules, but these sort of photos only add to the challenges of building a field of medicine that people trust.”

“I’m sad to say that much of my chosen field is still rooted in what has generally been termed “snake oil.” It takes years and years of seeing patients to realize that the use of snake oil actually does work for some - and so do a lot of the other products that might otherwise be categorized as useless. If you allow me to select the right patient, with the right hair loss condition and start treatment at the right time of year, I can promise you with 100% certainty I can get their hair growing with snake oil. Mind you, what I neglect to tell you is that their hair would have improved anyway even without the snake oil. What has happened in this situation is that we created a very, very happy patient who now loves the improvement in his or her hair and who feels dependent on snake oil for a very long time. I assure you that this happy patient will run from your office if you simply tell them snake oil doesn’t work. They are living proof that their use of snake oil changed their life and hair for the better.”

74B

Don’t argue or debate with anyone about hair loss. Simply state the facts - back up the actual proof with evidence - and move on.

“Nowadays, there are two ways that physicians can be handed the precious trust of the public. The first way is through a well constructed marketing campaign and various strategies of self-promotion. The second way is through a consistent record of providing good old fashioned patient care. One of these methods of obtaining trust from the public can be fully in place by tomorrow morning; the other takes many years.”

“Even if we had a 100 % “cure” for hair loss sitting on the pharmacy shelves, one that was 100 % guaranteed to be free of any side effects and 100 % guaranteed to regrow all hair forever, there would still be a need for hair specialists. Some patients would not believe the product was really helping to grow hair. Some would worry that the product would eventually stop working. A proportion of patients would still feel they are getting side effects despite the fact the treatment has none. Competitors would be out in full force with scare tactics to dissuade people from buying the product in favour of their own product. Imitation products would surface that promise faster, safer, better results. And some specialists would still recommend their own, less effective, office-based treatments.”

“Visual evidence of some kind of hair growth happening on the scalp is no more a sign of healthy hair than hearing a heart beating in the chest is a sign of a healthy heart. Sprouts of hair can be seen normally as well as in many hair disorders. Too many patients are told that hair growth is seen on the scalp and then interpret this as a sign of healthy scalp or successful treatment outcome.”

“Respect and acceptance are different. We can respect the view of a person who says that they believe the world is flat rather than round. We should listen to why this person feels this way and hope that through open dialogue that the principles of science will prevail. I think we all agree that as a society we would never allow this view to permeate the classrooms and textbooks of our children. Similarly, we can respect the view of a person who says that they believe a certain treatment for hair loss will help. We should listen to why this person feels this way and hope that through open dialogue that the principles of science will prevail. Without proof, we must never allow this view to permeate the classrooms and textbooks of our hair specialists.”

“An elevator doesn't know if the user standing in the elevator today is running late for a meeting or not. The elevator moves at its preprogrammed speed of one floor every so many seconds. An elevator technician could make the elevator run faster but that would require the technician to get to the control panel in the basement.

Hair follicles don't know if a patient is in a rush to get the hair growing back or not. If a hair follicle decides to make the journey upwards, it grows at a fairly constant rate of about 1 cm every month. How fast the hair grows is largely determined by the some pretty complex genetic programming that lies deep within the hairs of the scalp. We don't yet, however, have access to the genetic control panel of hair follicles.

Advertisements that promise faster hair growth must be approached with caution and skepticism.”

“The journey the public must take when navigating through the world of hair loss is a most unusual one.

I often compare it to a roadway.

Like any roadway, the world of hair loss also has street signs. However, none of the street signs you will see in the world of hair loss are properly labeled. There are no signs that tell you exactly where you are. There are no signs that tell you how far you have yet to go in order to get to your destination of “improved hair”. There are no signs that tell you which direction to head. However, there are signs that indicate that this direction of travel or that direction of travel worked well in the past for some of the travellers. Dotted along the road are many signs that incorrectly take you down paths that lead to dead ends and only serve to waste the precious time of the traveller. Some of the paths have very expensive tolls along the way.

Unfortunately, you won’t see many hazard signs in the world of hair loss.

Although it’s easy to feel lost inside the world of hair loss, there are many people along the way who can be asked for guidance on how best to proceed. However, everyone has a different motive for offering you an answer, and in turn everyone seems to have a different answer for you.”

“Scientific methodology involves rigorous study, testing and validation to explain the world. It does take skill, experience and training.

Anyone can have a "theory" about how the world works, including theories about how hair grows or does not grow. The convenience of proposing a theory is that it does not necessarily require skill, experience or training to propose one. Some theories turn out to be correct over time at which time it is more appropriate to call it "fact."

The age of the internet has greatly facilitated the ability of various "theories" to be fast-tracked and awarded the false status as "facts." This has certainly proven true in the world of hair loss.

History has repeatedly taught us how extremely difficult it can be to challenge and disprove something once it has been deemed by society to be a “fact.”

We must work hard to prevent false theories from being awarded status as true facts.”

ON THE TREATMENT OF HAIR LOSS

“The ideal type of diet (vegetarian, vegan, non-vegetarian) to support the healthiest hair possible remains to be precisely determined.

It is clear, however, that the chronic consumption of too many or too few calories is associated with various types of hair loss. It is also abundantly clear that a healthy diet is associated with a longer lifespan to enjoy whatever hair one has.”

“When one’s automobile stops working, it would seem intuitive that the vehicle must be taken first to an auto mechanic for careful evaluation. Taking the car to the car wash instead would seem rather silly.

Similarly, when one experiences hair loss, the first step should be a careful evaluation. Searching for new and more expensive shampoos is, of course, rather silly, but is all too common.”

“If an individual cannot state the cause of his or her hair loss in one sentence and with one breath, this is usually a good indication that he or she should not be starting any type of treatment quite yet.

One’s hair is far too precious for experimentation.”

“One can never guarantee – with 100 % certainty – the outcome of treatment for any type of hair loss. Fortunately, many types of hair loss do show benefit with available treatments. Sometimes there are remarkable benefits.

But we just not forget that we are not yet master technicians of the hair follicle control panel. The room to the control panel is still locked.”

“Patients come to see me looking for what is commonly called “treatment.” I tell every young doctor who trains with me that I some aspects of treatment don’t actually involve any sort of treatment. The first greeting you extend to a patient is a form of treatment and so is the final word you give them before they leave. Patients remember these things for a lifetime and the actions and words of the physician have the potential to both heal - and harm.”

“Treatments for hair loss must be always be S.A.F.E - safe, affordable, feasible and effective.”

“Knowing when not to prescribe a medication is just as important as knowing when to prescribe it.”

“There is a relatively new field of medicine known as evidence-based medicine or “EBM.” It’s wonderful. Practicing evidence based medicine is what allows you to advise the patient that they have a 51.3 % chance of success if they choose treatment A and a 42.9 % chance of success if they choose treatment B. All good doctors incorporate evidence based medicine into their day to day practices.

The art of medicine, however, does not rely solely on practicing evidence-based medicine. Patients come to you looking for so much more than simply numbers and statistics - they can find this sort of information themselves on their own home computers. Doctors are not computers and doctor are not robots and doctors should not endeavour to become computers or robots. Patients come to you because of how you combine evidence-based medicine with old fashioned values of placing their best interest at highest level.

The patient’s “best interest” must always win out over the “best chances.” Yes, it’s true that most patients will choose treatment A or B, but some will choose treatment C, D or E even though the statistics for treatments C, D or E suggest they are less likely to be helpful. Some patients will leave the office without any treatment and will be extremely happy with their decision and the help you provided.”

“If you treat children with hair loss, you must remember that the child brings along a few other people. These might be mom, dad, grandma, or grandpa or a caregiver. The care that you also provide to these people directly impacts the child. By definition, caring for the adults and family members is all part of the grand treatment plan for the child.”

“From time to time, advising the patient to try a new type of treatment will be best considered experimental research rather than routine clinic practice. Patients need to be told and fully understand when they have crossed the line from being a patient to being a research subject. Too often the distinction is blurred.”

“It is unethical to deliberately sell placebo pills (“sugar pills”), placebo ointments and placebo lotions for treating hair loss. However, dozens of clinical trials show that a good proportion of patients who have used a placebo treatment are still satisfied by use of the product even when they have no idea that they have used a placebo. Some will even feel it helped improve the hair.

A good number of today’s products on the market are essentially placebos and many patients are very satisfied using them.”

“When it comes to treating hair loss, I regret to inform that what is popular and trendy is not always what actually helps the patient. However, I have come to learn that what actually helps the patient is always going to be very popular.”

“Everyone wants to go "deeper" when it comes to diagnosing hair loss - including patients and physicians alike. Patients want blood tests and they want more of them. Patients want hair analyses. Patients want genetic tests. Patients want the most complex hormonal tests. Patients want food allergy tests. People love these things. The deeper you go in your testing the happier you will make most of your patients, that I promise you. The happiness is temporary but your patients will leave the office quite pleased.

But does anyone actually take the time to go “less deep” which is to figure out what's happening up there on the surface scalp? That's really where the answer lies for most people - not buried deep within some extravagant test.

Many patients I see with binders full of wonderful test results have never really had a proper examination and have never really been given a proper diagnosis.

I do not encourage doctors to set out each day with the goal to make their patients happy - this should always be a pleasant side-effect that comes with good patient care.”

“There have been situations over the years whereby my asking one simple question forever changed the life of a patient. I imagine that one such day was probably the day that I changed my practice and made it a point to have every patient complete a very detailed questionnaire before I even agree to accept them into the practice.

I don’t set out each day with the goal to diagnose early inflammatory bowel disease in a patient with hair loss from low zinc levels or to diagnose impending early menopause in a young woman with hair loss and irregular periods - but if the evidence surfaces that this is what we need to be thinking about - we need to delve deeper.

Each patient must be approached with a fresh canvas and a fresh outlook. Standard templates just don’t work well.”

“ Middle age is a strange cut off for men. Many males who develop hair loss in their teenage years and early 20s feel they just want help with their hair until they get to age 35 or 40. Men have an illusion that after this age, their appearance won’t matter at all. For some this is true, but not for all. As hair specialists, we need not necessarily fight, challenge or contradict the views and opinion of the young man, but we need to assist patients in making a long-term plan for treating hair loss that will potentially last them into their 90s. Short-term poorly-planned treatments usually are not successful. This applies to both medical and surgical treatment but particularly to the field of hair transplantation.”

“ We underestimate what words of genuine kindness and compassion can do for our patients. They should be part of any patient’s treatment plan. They require no prescription. There are no insurance companies to fight with for approval of the treatment. They don’t interact with other treatments. There are no blood tests to monitor. The duration of the effects of genuine care and concern can last days, months and - in most cases - even decades.

ON THE FUTURE OF OUR SPECIALTY

“There are a far greater number of hair loss conditions and hair loss patterns than are currently recognized in textbooks. What we have now gives us a framework – but it is incomplete.”

“Someday, we will be able to precisely control how we send injured, dormant or diseased hair follicles into the active growing phase (anagen phase) with the same ease and precision that we send a satellite into orbit or send an e-mail across the world.

It would appear that hair follicles are far more complex than we all would have imagined.”

100

“Every hair loss discovery adds to our collective knowledge but not every discovery needs to be reported by the media as infinitely amazing.”

101
Traditions are wonderful.

We all have traditions for the many different types of life’s celebrations. Holiday traditions are particularly important for so many people.

Despite the positive association and often warm feelings we have with our various traditions, it’s not usually ideal to practice medicine based on tradition. Doing things the same traditional way does not always benefit the patient. Sometimes we need to consider breaking tradition and doing things a little bit differently in order to improve the clinical outcomes for our patients.

Relying on updated evidence based medicine to guide clinical decisions rather than relying on tradition usually works out best for the patient.

ON TEACHING

102

“I owe a lot of my past mentors and preceptors. I certainly owe a lot to my alma mater and the wonderful training programs that accepted me and trained me.

I owe a lot to the wonderful textbooks and articles that have been produced that I have read.

But I owe a great deal to my patients. My patients have taught me the subtleties of medicine that are difficult for anyone to put into written or spoken word.”

103

“If the subject of hair loss comes to be viewed as being a bit difficult or overwhelming for one of my students, I gently encourage them to read a little bit more. Perhaps another chapter in a textbook or another article from a journal. It is amazing to me how quickly the feeling of being overwhelmed will fade and things will no longer feel quite so difficult to students the more they read and come to know about the incredible field of hair loss.

In contrast, if the subject of hair loss comes to be viewed as being fairly simple or straightforward for one of my students, I gently encourage them to just read a bit more. Perhaps another chapter in a textbook or another article from a journal. It is equally amazing to me how quickly the feeling will fade and things will no longer feel quite so easy and straightforward to students the more they read and come to know about the incredible field of hair loss.”

104

“When I first started lecturing about hair loss, my lectures were actually fairly simple. As I learned more about hair loss, my lectures became more complex.

Over the years now, my lectures have returned again to being simpler and simpler. It’s clearer and clearer over time just how many simple lessons there really are.

I know that many of these lessons would have once seemed too simple for me to even accept.”

105

My hope when I teach medical students and residents is twofold: I hope that they will not only build upon their prior knowledge but also quickly appreciate when something is completely new to them.

It is the ability to recognize that something is beyond one’s prior knowledge and experience that drives the learner to excel. That’s how we build expertise.

106

“Teaching others about hair loss has certainly helped me develop my own skills as a hair doctor.

I enjoy teaching medical students and junior doctors. Their enthusiasm and energy is uplifting. They challenge you with great questions. They are polite and respectful. But you’ll never really know if you’ve truly done a mediocre job, good job or great job teaching them. There is a certain formality in our field. You just hope that they have learned something and that the patients they will help in the future will benefit from all their accumulated knowledge.

I also enjoy teaching the public through various social media channels that I participate. The public is very critical. There are no formalities. Many people are polite, but many are not. They challenge you with the toughest questions imaginable. The public is not afraid to share any and all feelings, opinions and critiques. The public is not satisfied with general comments - they want specific pieces of information. Facts matters. A single word you type or say can infuriate.

Social media continually pushes me to understand my field with an entirely new critical eye. Participating in social media has its challenges - but I am grateful to have the challenge.“

107

“You must teach medical students and junior doctors with the goal that during your time together, the student will have a series of “aha moments”. These are the moments when the information you have presented just makes complete sense to the learner. There is no need for them to memorize anything - the information is as logical as logic should be. It’s wonderful if you can somehow incorporate these “aha moments” into your teaching sessions.

Years down the road you hope your learner is able to make some helpful recommendations to his or her own patients simply because it makes sense to them. Imagine the medical student or doctor you are teaching today - sometime way into the future. Imagine they may be in the middle of a busy clinic, running 2 hours behind, with chaos unfolding all around them. They may not have slept last night because they were up with their child at home or they may find it hard to concentrate because they are starving to get to lunch.

You just want the student you are teaching today to someday in the future to offer help the patient in front of them in a logical manner because it makes sense for them to do so. It’s the “aha moments” during teaching that can really profoundly impact the future.

108

“Some of the most amazing teachers across the world are the most amazing story tellers. Some the most incredible clinically oriented experts of the medical field are the most incredible story tellers.

Story telling is really about communication - and these individuals have developed a particular mastery of the oldest forms of applying learned information”