Every clinician knows the patient they should have turned away.

In this episode, a consultant plastic surgeon explains exactly how she says no: the question she asks herself before any treatment, what the "spidey sense" is really detecting, and why the patients asking for the wrong thing are often asking for a different kind of help.

Miss Nathalie Cain, also known as Dr Nat, is a consultant plastic surgeon specialising in upper limb and facial aesthetic surgery, an international fellow in cosmetic surgery, and a faculty trainer for Merz Aesthetics. She's building her new clinic, ENIA, in Nottingham.

WHAT WE COVER

— Why upper limb surgery and facial aesthetics belong together (it's the anatomy)

— Training the next generation to be better than she is.

— Failing her exit exam, and how it reshaped surgical training across the East Midlands

— The flood of new injectables: what's genuinely new versus newly marketed

— The critical conversation in aesthetics the public never hears

— "That's a facelift": setting honest expectations with the patient's own hand

— How to say no to a patient, and the question she asks herself first

— Building ENIA: staff, money, and the two things nobody teaches surgeons

— Why 75% of new patients still come from word of mouth, even with a marketing budget

ABOUT MISS NATHALIE CAIN

Miss Nathalie Cain (Dr Nat) is a consultant plastic surgeon with a specialist interest in upper limb and facial aesthetic surgery, an international fellowship in cosmetic surgery, and a faculty trainer role with Merz Aesthetics. Her new clinic, ENIA, is based at Balance in Nottingham. Find her at eniaclinics.co.uk and on Instagram - @drnathaliecain.

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Welcome, Dr. Nat.

Dr Nat: Thanks for having me.

Toby Goodman 2: Upper limb surgery and facial aesthetics to me seem like an unusual pairing. How did that happen?

Dr Nat: Yeah, fair enough. And there's probably only a few people in the world, and they'd all be plastic surgeons, who would understand why the two link together.

But the other place where anatomy is notoriously fiddly, variable and means that you have to adapt your operation or your non-surgical plan is the face. So I have always been interested in both of those areas from that point of view, and that's how the specialty developed. I was doing non-surgical aesthetics before I really positioned myself as an upper limb specialist in surgery, and it's the non-surgical side of treating the face has naturally flowed into the surgical side.

So yeah, I think it, it underpins an obsession with anatomy, and both areas are super interesting.

Dr Nat: So really early on in my, in, in my career in medicine, I think I recognized that even as a, as a medical student, you sometimes get made to feel like a bit of a hassle. So you're in the hospital, let's say you're in an operating theater, you've got a consultant and an anesthetist and a registrar and sometimes like seven or eight people who all have a clear role, and you as the medical student, you don't know whether you're allowed to scrub, whether you should stand back, what you should touch, what you shouldn't touch, and it makes you feel like, "Why am I here?

And I also think that the... what I noticed was that the people that were happy to teach were often the really good surgeons. And I think it's because if you're gonna position yourself as a trainer, it forces you to really stay up to date, because the people that are coming through are at the forefront of learning.

They're reading more papers, they're training, they're really inquiring, faster, younger minds. And I thought, "Yeah, that's where I wanna be." I never want to lose sight of where the field is going. And then this concept of I want somebody to be better than me is something I feel really strongly about.

They want to be delivering it. There's often a lot of money asscoiated with it as well. And that doesn't create a great training environment. But if you, in your career, produce something fantastic, you have to look at why we're doing what we're doing, and we're doing it for patients. Even in the private sector, in cosmetic.

You're trying to deliver the highest standard of patient care. Now, if I work really hard on myself for my 20-year career as a consultant or whatever it turns out to be, and produce great results for my patients, I'm gonna have an impact on them, and that's gonna be, like, a few hundred, maybe a thousand. But if I then disappear and leave, and that's it, gone, and I haven't passed that on to anybody, then I- my perception is that all I've fed there is my ego.

Somebody that's really good just doesn't pass it on. So as soon as I became a consultant, I decided I'm gonna make sure that I don't allow myself to drift into that sphere, and make sure that I constantly check in and say, "No, I'm gonna be challenged by the next people that come through."

And I want them to encourage that and say, "Why are you doing that? Why do you do that like that? What... Have you thought about this?"

but I'm comfortable with that because I want them to be encouraged, and I want them to do better than me because then we build something massive that means that what I discover and get good at benefits not just my patients but, the next round of it.

So you... it's two days of vivas face-to-face. And going into the exam, all of my trainers were like, "You're gonna do great. We're not worried about you. All the practice is going well," and all the rest of it. And I absolutely bombed. I failed. And I was the only one of, of four people that failed in my cohort.

And so that was a difficult path to walk. But I think the way you react to stuff like that defines who you are rather than it happening to you. I think it's about how you respond. And I... It really helped me to, when I went forward, go, "Okay, obviously I need to get through this exam, but now-" I've made it my mission that I'll be- I'll hold the baton in East Midlands for the person that failed the part B, and I'm not gonna pass it on.

These were the reasons." And when they're out practicing with me, I've developed ways of going, "I think this is what you're thinking. I think this is what's stopping you from answering the question." But I really believe that if I hadn't failed the exam, even though it felt horrific at the time, and I hadn't experienced that like negative training experience, and I hadn't forced myself to check in and stop myself going down that ego route, I think all those things have contributed to me going, "No, actually, this is not really about me.

Toby Goodman 2: Yeah

Dr Nat: it's about leaving it behind. I don't want these skills to die with my generation, and some plastic surgery skills, like y- you don't do them very often.

Toby Goodman 2: Right. Yeah. That makes sense. They do say the best drivers aren't the ones that pass first time as well, so- Ooh,

Dr Nat: well, I failed my driving test nine times, so maybe I set the standard.

Toby Goodman 2: Perfect. So the couple of other things that you said made me think of two things, which is, the best people, sometimes they aren't the best teachers, but sometimes they really are. And I was thinking of, you know, that thing unconscious competence versus conscious competence- Yeah ... and having to teach.

Dr Nat: Yeah ...

Toby Goodman 2: know he's known for taking time to speak and help younger players.

Dr Nat: Mm.

Toby Goodman 2: Which is cool.

Dr Nat: It's true, because when you're training- Yeah ... you run your day-to-day practice doing c- being unconsciously competent 'cause you've reached that level, don't you?

And then for me, when I have someone training with me, I have to force myself to go back and be consciously competent so that I can articulate the steps, and it is tiring. It's harder to have somebody with you. It's a longer day. Yeah. But you are... you have to think about the impact you're gonna have on more people.

Yeah.

Dr Nat: Yeah.

Toby Goodman 2: It's a whole thing, but it's really important, especially if you are...

well, regardless of whether you're doing surgery for medical reasons or, or cosmetic reasons.

Dr Nat: Yeah. Definitely.

Toby Goodman 2: I wanna talk to you about the flood of new injectable products right now and how you decide What's genuinely new versus what's newly marketed.

Dr Nat: This is a really great question because having been in the industry for quite a while now, I have seen various things come back around, and sometimes it's as simple as a product got dropped by one company and

And that was one of the reasons why I was really delighted to work with Merz when I got into the aesthetics industry a bit more because they are very pro research.

But you do have to stay in touch with what's being published in the aesthetics journal, what the key players and key industry players are looking at developing, and that's the beauty of being linked with a pharmaceutical company. You will know what they're trying to develop lab-wise and what they're trying to produce, and you'll know their product history.

I think it's a real worry if a company markets direct to patients as well as direct to healthcare professionals because you end up with patients who don't understand the indication seeking a treatment that might not necessarily be right for them, and that blurs your moral compass as a cosmetic doctor because they've come asking for it, it's harder then to go back a step and say, "No, hang on.

What's actually indicated here?" Because you've asked for something just because it's new or it's on TikTok or it's on Instagram or whatever. So I try and stay ahead of it because I'll know from Merz what they're developing, and you end up picking up other publications,especiallyy about all the biostimulatory products that are claiming to stimulate collagen.

So I will always try a product in appropriately consented patients, and this is still a totally licensed product, and do it as per the protocol from the manufacturer and objectively look at my results and go, "Did that actually work?"

But I'll always do that first, and it's made, it's led me to go down the route of discarding certain things that are, people are obsessed with on social media because I cannot show it, that it works in my hands. Even adapting protocols using different administrative techniques, I just will not do something that I don't think I can see and the patient can see an objective difference.

So you might not have the genetic marker that's required for you to get a response with this product. And you just have to be honest with patients, and if they're not happy to take that risk, I think that's fair enough, don't you? You wouldn't do many treatments where you say, "40% of people see no results.

That's 500 pounds please."

Toby Goodman 2: What do you feel is the critical conversation happening in aesthetics right now that the public never hears? I feel like you were on the cusp of that, but, the trends, et cetera, maybe the non-surgeon injectors.

And now we're asking for a lot more from our products. And it's a nice thing in a way because a lot of patients have steered away from trying to search for this overfilled face to actually what can I do to wind back the clock more authentically? And that's where biostimulation has come in. And biostimulation means any product that you inject which claims to have a tissue altering effect.

So to actually wind the clock back, stimulate the collagen and elastin, but produce this really much more youthful- Mix of growth factors and stimulation that gives you a more authentic age reversal process. So they're trying to rather than mask the signs of aging, which is what simple volume replacement does, they're trying to actually reverse it by giving you a different tissue composition because of the product that you've had injected.

'Cause now we're not talking about a new filler that may or may not need dissolving and may or may not have a good tissue integration profile. We're talking about something that is altering your cell biology. Now, what else does that? Like skin cancer alters your cell biology. Cancer is the ch- is a thing that changes your cell signaling pathways.

Don't, we don't need to rush into these products that claim to do that without proper safety data. But because the market's asking for it and it's being challenged, everyone's rushing to get to the ultimate age reversal product, and that's where things are. Yeah.

Toby Goodman 2: To that end, what do you wish every patient, client understood before they sat in the chair?

So there's a role for volume replacement still, and there's a role for bio-stimulation, which for me addresses the laxity 'cause it helps things to tighten up. So you've got the laxity and the volume side of things, but it doesn't happen overnight. So if patients understood that they could get a certain result quite quickly, but then prolonged patience, it, you'll see so much.

Over most of my patients see their peak result at nine, if not 12 months after first starting. And then they go onto a maintenance. So it's a real investment in their time and money. But then once they're on a maintenance, it's a very achievable option. And I think that's been a hard thing to articulate and change people's mindset on over the last couple of years.

in a facelift, and I know what a filler and a biostimulant can do by comparison. So I actually have now moved towards when a patient does that, I'll say, "Oh, do you mind if I explain? Because what you've just done there, that's a facelift." And then I'll literally move their hand and say, "That's what you can achieve with non-surgical results."

And in the build-up to it.

And actually showing them, "No, now you need to sit in the mirror and do that," and think, "Okay, she told me I need to invest this much money and this much time, and this is what I can realistically achieve."

Toby Goodman 2: Yeah. And the t- the time thing is huge, isn't it? Because people wanna just pay you and then walk out with a result, and there's almost nothing in the world-

Dr Nat: Yeah ...

Toby Goodman 2: it takes some version of practice. I just was working with a dietician And we were talking about, and we were working with the weight loss jabs.

Dr Nat: Yeah.

Toby Goodman 2: And it's the same... It's a version of the same story. People are taking the jabs, and it's getting a sort of a short-term win, but then it's causing some other problems around malnutrition and all of that. Yeah, and the- And actually, the partnership with her that we put together was with a pharmacist.

Dr Nat: Mm-hmm.

Toby Goodman 2: You don't just wanna look... you wanna be able to move and breathe and have fun and run around. You don't just wanna be skinny, right?

Dr Nat: Yeah.

Toby Goodman 2: And initially, some of them are just saying, "Do you know what? I just wanna be skinny." But once the weight's gone, now we're talking about health as well.

And so th- that partnership is amazing. Yeah. Because now, the, the pharmacist is selling with confidence, and obviously the dietician's got a, a, a waiting list forever, basically, which is fantastic.

Dr Nat: That's that's how it should be. Like, because medicine now, we have redefined...

the World Health Organization definition of health has changed, but health previously was, like, low down. On old scale, Maslow's hierarchy of needs- Yeah ... it's

Toby Goodman 2: right at the

We're not just accepting, because my leg's not broken, I'm healthy. We need that whole diet, mental health, wellness, exercise, happy, fulfilled. That's health now. So you can't expect a GLP-1 to- To solve it all.

Toby Goodman 2: What's a GLP-1?

Dr Nat: That's the injection, the- Right ... weight injection. Yeah. Right.

Toby Goodman 2: There you go.

Dr Nat: Yeah.

Toby Goodman 2: So an a- acronym hell!.

Dr Nat: So- You can't expect it to solve it all. But sometimes people need to get over that hurdle before they- Yeah ... can see, "Okay, now I do recognize I need everything." Yeah. And it, the healthcare professional should be there to guide them into that.

'Cause it's, it's bad medicine to just say, "Off you go." Yeah. But

You have to keep practicing health, and sometimes that's annoying.

Dr Nat: Yeah ...

Toby Goodman 2: I felt- yeah ... this very morning at the gym. How do you say no to a patient?

What's that conversation like?

Dr Nat: There's two really definite scenarios where I have to say no, and the first thing I do is I check in with myself about whether I'm uncomfortable, and this really applies only in the private sector. In the NHS it's a slightly different thing.

You do still have to say no, but it's different. It's so it really has... you have to force yourself to understand when you need to in the private sector. So I'm in my clinic, I meet a patient, do a consultation, and they explain what they want and I explain what's available, and I ask them what they like about their face, what do they not like about their face, what do they want to try and change?

It's a partnership. And if I think, I ask myself this question: If you had the worst complication possible, because complications happen to everybody, if you had the worst complication possible of the treatment that I've just deci- just designed for you, would I be able to sit in a room, face you, say sorry, walk you through it, manage the complication with you, and see you out of the other side?

So then at that point I'll say, "Okay, we've spoken about a lot today, and I want you to go away and think about it. I want you to have all the options available to you. I'll send you an email. I'll detail the treatment plan or I'll write you a letter, and I want you to go away and think about it." And that gives me time to think about it as well.

And then if the patient comes back, sometimes they'll have thought about it, taken it all in, and the, I'll get them to articulate what they want to try and achieve. And if I think the expectation is matched, then we can proceed. But if that patient comes back and I think I just can't get the result you want, then that's how I say no.

If you then don't feel better that's not right for me to pursue that. And the other time, and so then I don't have that happen very often, but the one or two times early in my career where I overrode the Spidey Sense, regretted it forever because you, you know, and it's the same feeling that you get in the NHS where you think, "Oh, this is gonna be a tricky person to deal with," because ev- we're all tricky in some ways. It's the same feeling, and you can't override it in the NHS because it's different. But in private, you have to know could you hold their hand through the worst complication ever. And it was a really well-known plastic surgeon that taught me that very early in my career a guy called Mark Henley, and it, that really has helped me to make those decisions.

If they're pushing towards something that I think isn't gonna use the products for what they're meant to do, which is anti-aging or, and facial rejuvenation, then I'll have an even more difficult conversation and say no. And in that moment- I have learned various ways to do it. I think when somebody's seeking something that's not reasonable, it's representative that there's something deeper.

Why are they in your clinic? It's not because they just genuinely want to seek some facial rejuvenation. Someone has said something horrible, they might be going through or processing trauma, or they might have a really serious mental health condition, and I normally say, "Okay, I'm just gonna say right now we're not doing any injectables today.

'Cause I can say, you're not seeking something that, in my professional opinion, is gonna make you feel or look better, so w- I want to understand why you're asking for it." And, there's the odd person who's like, "Well, I just want to be like that." That's fine. That's totally fine, but there are other doctors that may well be the person that can walk you through that, and that's okay.

But I've referred several people actually, and some with really sad stories, who needed support in a different way but they were seeking the help through injectables. I think they're quite a vulnerable patient group at times.

Toby Goodman 2: Yeah. And I'm sure then you have relationships and partnerships and people that you know that you can say, "I've got a friend," or, "I've got

a professional over there that you might wanna speak to about this before we proceed." Yeah.

Dr Nat: Yeah. It's exactly what we have.

Toby Goodman 2: That's awesome. Okay, let's talk about your new clinic in Nottingham.

Dr Nat: Yeah.

Dr Nat: Yeah, so I've done it before. I've run a clinic before, and there was... and it didn't work for a variety of reasons, so this is second time round. The problem with surgeons is we're all, highly driven, motivated people who, push through, problem solve, and do all sorts of things. And there's two things that we're traditionally, especiallialy doctors in general, but surgeons I think worse than most, not very good at.

One is managing staff, and nobody at medical school teaches you how to do that. And the other is money. We're just not very good at it. And it's hard to make the transition from a public sector environment to a private sector environment where suddenly you have to talk to people about the price of things, but then you have to also fight that overall instinct to give it away because you do have to run a successful business.

But yeah, I really struggled with managing staff in my first practice, and this time round I have a completely different business partner, and I think... we joke, but... And it's, but it's really only slightly tongue in cheek, I think he's the autism to my ADHD at times because he's got the, definitely got that skill set to manage things a lot more in a more structured, more kind of detailed way, and get to the very bottom of the minutiand I've got the insight to say, "I'm not actually very good at that side of it," which I didn't have when I first had my practice. So we've taken a lot longer to choose our staff this time round, and we've gone through the business plan and the finances in far more detail, even though it's the most boring part from my point of view.

Because look at who I am and look at what I've done." Yeah.

Dr Nat: Yeah, I see that

Toby Goodman 2: Yeah ... that, because our entire culture is like, "Oh, we don't wanna be salesy." But actually everything that you've said five, 10 minutes ago was about triaging the right patients in and show- and almost auditioning them, which is how I've, I teach sales and marketing to people, is you're just filtering really strongly with your message at the top so you don't have to deal with wrong fit patients and clients.

Dr Nat: Fair ...

Toby Goodman 2: the challenge that I have helped so many clinicians with is, well, they came into healthcare because they wanna help people, and I love those people 'cause I wanna help people as well, but not at the cost of their entire business surviving.

No, exactly. And especially if they've been in public sector for, for a long time, they just... No one taught them that. No. And no one taught them that it's an essential skill to be able to message and market. So that's really cool and , It's great that you've, you're going in again and you've got another partner who's got the complementary skill sets.

Dr Nat: Yeah, I think it's hard because some- in surgical training, particularly in the UK, you're not taught to value yourself and your skill set as you come up through the top. It's a very oppressive education in many ways, which I'm obviously trying to, be, approach it in a bit of a different way.

What do you actually know about cosmetic patients? Not everybody knows that much about them. And what I've noticed, and I think it's been really good for keeping my ego in check, is like my patients, they actually, they don't fundamentally care that much about how I got to being qualified and good at delivering the treatment.

They just care that the result is good, and that if they're worried about something they can reach out to me. And that crystallized for me when I was saying, "I'm taking some time off 'cause I'm doing my exams." And they were like, "What exams are you doing?" I've been injecting your face for five years.

Toby Goodman 2: Yeah ...

Dr Nat: it's really interesting when people come at exactly what you said, saying, "Oh, but I'm this qualified and I'm that qualified.

Why do I have to market myself? Because everyone should come to me 'cause I'm a plastic surgery registrar. I'm a plastic surgery consultant." But it doesn't work like that because it's a different patient group that have to want to work with you. Yeah.

Toby Goodman 2: So how do patients actually find and choose you, and how much of that at the moment is designed versus luck?

Dr Nat: So when I had the practice before, we audited it and looked at our referral system, where, 'cause our patients were growing, growing, and we had this social media campaign, and someone on the marketing, and budgets galore. And we're like, "Right, for the next three months we're gonna look at our referral sources," 'cause it's a button that you can click on the practice management software.

They were more like send a few messages, send a few emails. But the word-of-mouth referral is still so massive for us. Yeah. Yeah.

Toby Goodman 2: Any considered purchase a TV as a good example, right? You go out, back in the old days, you go and buy, what Hi-Fi, what TV or whatever, and like, this is the one with the five stars that's in my budget, I'm gonna buy that.

And you get on the phone to your friend, 'cause you're gonna buy the Samsung or whatever, and your friend goes, "Oh, I got the Sony though. It's really good."

Dr Nat: Yeah.

Toby Goodman 2: You go and buy the Sony like straight away. 100%.

So that's so important. That's why- I love a case study episode as a podcast. I love a, a consultant, a clinician talking to somebody they've worked with about where they were when they came in-

Dr Nat: Mm-hmm

They'll share it with their friends and say, "You wanna know why I got my nose done?"

Dr Nat: Mm. "

Toby Goodman 2: Listen to this. You wanna know why I got a facelift? Listen to this." And you can guarantee somewhere down the line in that social circle, in that network, your phone's gonna ring.

Dr Nat: Yeah, I agree. And then also, the person that's been recommended by their friend, they come for the consultation at a much more trusting level-

Toby Goodman 2: Yeah,

Dr Nat: you've got nothing to worry about

But then try not to give it away for free because then we're back in the same cycle.

Toby Goodman 2: Yeah. Hopefully you're not giving anything away for free.

Dr Nat: No, not anymore.

Toby Goodman 2: What a great chat. Thanks so much. Tell me about the Nottingham clinic, and tell me where people can find you.

Dr Nat: So our Nottingham clinic is Enea, which is we've only just launched the name of it and the, all of the branding behind that it's about energy and how energy devices as well as biostimulatory products as well as your whole energy as a human is a, impacts how you look, which impacts how you feel about yourself.

And that's why our new clinic is positioned at Balance Health in Nottingham, and that is a whole healthcare facility that is not fully up and running yet, but it's almost there. They're a group of surgeons that have put together this whole facility where one floor is wellness.

There's operating theaters that can go up to a certain level of operation. But then there's consulting rooms where there's... I think they've got 11 different specialties of medicine, secondary care providers that will consult out of there once all of their regulations have been met. So the reason that we positioned ourselves within that is because of this ethos that myself and my business partner, Jonathan Pollock, believe in so heavily, which is that it cannot be solved with just one injection.

Or they ask about something that we can't offer. Mm-hmm. So we wanted to be within that network. And I think what they're doing at Balance is really impressive, like when it gets up and running. I'm not on the board of the whole hospital facility. I'm, only in the plastic surgery side of it, but I'm excited to be in that space.

And then from an education point of view I'm mostly excited about what I'm doing with Merz because we're developing a lot of these anatomy training courses. And I think people learning their anatomy definitely makes you a better injector, and we underestimate the impact of that when you first start.

Personally, I'm getting into the surgical side of it, so like cosmetics surgery, actual facelifts I'm finally now booking. And that's exciting for me. And then overall, my other strand of life, the NHS job, I'm finally in my dream job at Derby, and That's a lifetime commitment,

Toby Goodman 2: Brilliant How do I spell Enia

Dr Nat: E-N-I-A.

Toby Goodman 2: That's fantastic. What will the website be for that?

Dr Nat: It's, eniaclinics.co.uk and then

Nathalie, thank

Toby Goodman 2: you so much!

Dr Nat: Pleasure

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