Last spring, inspired by (what else?) a TikTok, I began exploring CoolSculpting, a non-surgical procedure that freezes fat cells. While cryolipolysis can be used almost anywhere on the body, including upper arms, bra area, abdomen, and thighs, I was interested in putting its icy grip on my jaw. In the microvideo, I watched a girl like me go from lugging around an average jawline to proudly sporting an anime character’s diamond-cut chin—all for $750.
A quick Google search turned up a “medspa” two subway stops away offering the 35-minute treatment. I booked a consultation. But as I obsessively tried to understand exactly how this procedure worked, a supposedly rare side effect caught my eye: paradoxical fatty hyperplasia. In less than 0.5 percent of cases, researchers report, the body rebels and ends up producing more fat in the area targeted for cryolipolysis. Such a low incidence rate might have been reassuring for a life-saving medical procedure, but given that CoolSculpting is the very definition of “optional,” I was sufficiently frightened. I canceled my consultation and in the months since have only occasionally felt wistful about the chin that might have been.
When ’90s runway icon Linda Evangelista recently appeared exclusively in People magazine with her “fat-freeze trauma,” I was shocked but validated. Evangelista said her own CoolSculpting treatments left her with hard, painful protrusions on her jaw, thighs and bra line that two rounds of corrective liposuction have so far been unable to fix. Along with announcing a $50 million lawsuit against Zeltiq Aesthetics Inc., CoolSculpting’s parent company, Evangelista said she will go public to “help other people who are in the same situation as me.” . But how, I wondered, did so many other ordinary people (possibly including me!) find themselves in the same absurd situation as a world famous supermodel?
The answer lies in “VIP Syndrome,” a term coined by psychiatrist Walter Weintraub in 1964 to describe an intriguing paradox: throughout history, the rich and famous, with all their resources and outlandish doctors, have often received poorer medical treatment and suffered from poorer health outcomes than the average person. When doctors grant “special privileges” to their powerful patients, from “Mad King” George III to Michael Jackson, they seem to get sicker and even die. While Weintraub, a psychoanalyst, attributed the problem in part to doctors unknowingly annoying their influential patients, doctors seem simply to be impressed by celebrities and high-ranking figures. Despite their medical expertise, these doctors refuse basic tests for “privacy” or prescribe dangerous drugs for “comfort.”
VIP syndrome was once a problem limited to British royals and internationally renowned pop stars, but it has recently been democratised. Thanks to an endless parade of healthcare startups that have turned medical treatments into direct-to-consumer commodities, more people than ever have access to nurses, doctors, and more to cater to their medical whims. Unfortunately, we are often worse off.
CoolSculpting is just the tip of the iceberg. There are around 4,200 medspas in the US today offering the veneer of clinic with few prescriptions. In those malls and corner shops, anyone can out-of-pocket for botox, laser vein removal, dermal fillers, and other procedures designed to give us superficial signs of health: firm foreheads, smooth legs, plump cheeks. Online, the options for prescription drugs designed to streamline both work and life are seemingly limitless: stimulants, beta blockers, hair loss drugs, and erectile dysfunction drugs can all be delivered right to your door, often with minimal human interaction. Add in a craze for pungent over-the-counter skincare products and supplements that are plentiful in drugstores, and you have millions of people with individualized, unsupervised routines built around the idea that there’s an intervention for everything.
Traditionally, health care is provided by a GP who knows your medical history. When you come for your annual check-up, healthcare professionals will take your vital signs, ask you a few questions about your health behavior, and send you for a blood test. If you need specialists, they can refer you to someone within the network and, in theory, keep an eye on all of your treatments. Or at least that’s how it’s supposed to work. But healthcare in the US is increasingly fragmented – if you can access it at all. As the COVID-19 pandemic has shown, there is no such thing as a “health care system” and few people have a doctor to consistently turn to. Direct-to-consumer startups have taken advantage of this landscape — and started exacerbating it. They can provide accessible, ad hoc services to people who might otherwise feel like they’re falling through the cracks, giving startups a glow of social good. At the same time, they make the notion that everyone is a VIP an implicit part of their self-promotion: Hers is “tailored to you”. Roman does all the work “without a waiting room”. Nurx is “on your terms”.
Of course, cosmetic procedures have been popular for decades, and overprescribing has been a problem for just as long. However, recent developments have changed the way these services are delivered and to whom. Invasive plastic surgery, which requires a doctor with years of specialized training, has been partially replaced in the last decade by procedures with little or no recovery, such as injections. While they can still dramatically change a person’s appearance, treatments like dermal fillers typically only last a few months, lowering the barrier to entry for people who might be hesitant to make a permanent physical change.
Meanwhile, online stores like Hims, Roman, and Cerebral have essentially hybridized telemedicine (connecting patients and doctors) and pharmaceutical companies (selling prescription drugs) — two entities that have a hard time mixing responsibly. In the case of Hims, for example, when a patient chooses an erectile dysfunction drug, they can visit the website, fill out a questionnaire, and then chat with a company-employed doctor to obtain a prescription for Cialis, Viagra, Tadalafil or Stendra. Yes, a doctor can still refuse a patient a drug, but in 2020, Hims employees said they felt pressured by the company to keep up their numbers. It seems to be a pattern across the industry: Employees at Cerebral, a fast-growing mental health start-up, recently told Bloomberg that senior management wants 95 percent of all customers looking for a prescription to have one (100 percent, they were warned, might do). look like a “pill mill”).
The result is that the entire treatment circle is guided by the wishes of the consumer and not by the needs of the patient – in contrast to the prevailing principle of shared decision-making, in which doctors and patients are to decide together on the course of treatment. “We shouldn’t compare medical care to a good mattress,” says Henry Curtis, Ph.D. Candidate in philosophy at SUNY Albany and author of a treatise on the ethics of Roman and Hims. That’s exactly what DTC healthcare companies seem to want. But the fact remains, people may not always know what kind of healthcare they actually need. For example, erectile dysfunction can be caused by cardiovascular issues, depression, and even musculoskeletal issues like cauda equina syndrome — three things that cannot be treated with an ED drug. But so the “Very Important Patient” industrial complex continues, pushing people away from sensible solutions and towards new purchases that focus on correcting the symptoms, which inevitably have their own side effects.
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I get it: if finding a real doctor or therapist is so difficult, laser and lathering has immense appeal to your path to a healthier, happier life. But democratizing VIP services (and their risks) isn’t the solution — especially at a time when self-diagnosis is rampant. In an ideal world, direct marketing of prescription drugs would be illegal in the United States, as it is in most parts of the world. A patient’s autonomy would be respected, but a doctor’s duty of care would remain essential. And everyone would really have access to a family doctor who could coordinate all care. If healthcare fragmentation continues, “there’s a risk that the left hand and right hand won’t talk to each other,” says Caleb Alexander, an epidemiologist at Johns Hopkins University who researches prescription drugs. That’s when things go wrong.
While CoolSculpting may seem unique in how spectacularly bad it can go, each “solution” has the potential to become its own problem. If done incorrectly, laser hair removal can cause burns, blistering, and scarring. Stimulant abuse can lead to addiction and distressing withdrawal. And every few months, new trends seem to break out in the great gap between self-care and healthcare. But no matter what appears on my TikTok “For You” page, I don’t think I’ll set up any more Medspa consultations or fill out any other online prescription questionnaires. Because I’m not a VIP, I’m just a normal person. And regular, reliable health care is what we all deserve.
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