Our experts answer questions from plastic surgeons.
- Are there suggested criteria to consider for patient selection for procedures?
- Yes. Begin by ascertaining the patient’s overall medical status and expectations of the procedure.Proceed with caution with any patient who:
Avoid patients who:
- Has undergone repeated surgical procedures by other physicians.
- Has sued another provider as a result of a plastic surgery outcome.
- Appears to be “doctor shopping.”
- Appears to have an exaggerated concern over a minor or nonexistent problem.
- Exhibits behavior that suggests possible fixations on particular physical features.
- Has recently experienced a major life change, such as divorce.
- Is anxious about a prior bad result.
- Appears to be looking for a quick fix to a long-term problem.
Candidates to consider for plastic surgery include patients who:
- Are angry, hostile, or abusive to your staff.
- Resent questions posed by you or your staff.
- Are demanding and have unrealistic expectations.
- Have a history of nonadherence or poor relationships with other physicians.
- Request repeat procedures on the same site without adequate reasons.
- Have realistic expectations about surgery.
- Are compliant with instructions.
- Have a spouse or family member who is aware of the planned procedure and agrees with the plan.
- Can afford the financial cost, including recovery time.
- Have a condition that requires a procedure you feel thoroughly comfortable performing. Do not experiment on aesthetic surgery candidates.
- How can I be sure that a patient’s expectations of plastic surgery are realistic?
- We recommend that you:
- Use patient information questionnaires. Suggestions for questions to ask can be found in our article “Patient Selection for Elective Procedures.”
- Be careful using before and after pictures of previous patients who have physical features similar to those of the current patient. Beware of making any implied warranty with the use of imaging. Make it absolutely clear there is no guarantee that the degree of improvement will be the same as that in the photos. Document this conversation in the record.
- Have an in-depth discussion with the patient as to his or her expectations from the surgery.
- Discuss the patient with staff members who may have made observations or heard comments that were not shared with the physician.
- Reconsider patients who bring in photographs of celebrities or models.
- Carefully document the discussion with the patient. It is critical to include details of the patient’s expectations and the risks and benefits of the procedure.
- A patient is requesting that multiple plastic surgery procedures be performed at an outpatient surgical center to save money. What is the best way to proceed?
- Ask yourself the following three questions:
If you answer no to two of the questions, decline the request. Patient safety must take precedence over price. The physician, not the patient, determines the standard of care for where a procedure should be performed.
- Is this patient a good surgical candidate overall?
- Do accepted and sound medical practices indicate that the requested procedures can be completed safely in one session?
- Would you recommend this treatment plan to a member of your family?
- An out-of-state patient wants liposuction. Because she is well known in her own state, she prefers to have the procedure performed in my state. Is this practice recommended?
- No. The first concern is postoperative care and whether the patient will remain in the physician’s state long enough to ensure optimal recovery and care. The second issue involves physicians who provide advice to patients in other states; providing advice to an out-of-state patient could be seen as practicing in the patient’s state without a license. A physician must take care when communicating by phone or email with a patient in another state in which the physician may not be licensed. This recommendation does not include situations in which the patient comes to the physician’s clinic for treatment (or is treated at a hospital) in the state in which the physician is licensed or has privileges.Care should be taken to avoid creating an expectation of a physician-patient relationship if you use social media or websites to provide additional literature or schedule appointments.
- A patient has presented for breast augmentation. She is a smoker who has promised to quit, but, at every appointment, there has been a distinguishable odor of tobacco on her clothes. What is the best way to proceed?
- To avoid mislabeling the patient, address the tobacco smell during a presurgical consultation. Perhaps she has stopped smoking and the tobacco smell is coming from a smoker in her family. If the patient continues to smoke after receiving extensive education about the risks of smoking and the associated complications, it is best to decline doing surgery on this patient.
This recommendation is based on The Doctors Company’s loss experience with claims in plastic surgery. Breast surgery represents nearly one-third of all our aesthetic claims, and our claims experience shows that almost 10 percent of those claims include complications involving smokers.
- A former patient had breast augmentation one year ago but now wants a revision to a size that is disproportionate to her frame. She stated that she will have her attorney call me if I refuse to do the surgery. Should I do the surgery and hope for no complications?
- If, in the physician’s best medical judgment, a revision of this type is not sound practice, decline the request. The standard of care to be met is that of a reasonably prudent physician, not what the patient wants. This is elective surgery; no one can prosecute you if you refuse the request.
To prevent this situation, conduct a thorough presurgical informed consent and educate the patient about what will be done. Avoid vague or subjective terms, such as “to the patient’s satisfaction,” in the consent form. A patient who makes veiled threats of legal action may not be an appropriate candidate for surgery.
- A patient has asked for removal of silicone implants and implantation of saline implants. She has a pending claim against her previous surgeon and implant manufacturer due to the silicone implants. The patient has requested that the silicone implants be given to her after the surgery. What is my best course of action?
- As with any surgical candidate, thoroughly assess the patient’s request and expectations for a genuine medical reason. Absent a biohazard exposure risk to the patient, or if there has been a prior request from a defendant in a pending matter, the implants can be released to the patient by using the following steps:
- Have a pathologist examine the implants and issue a report, similar to when a specimen is removed from a patient. The report will provide additional support to your surgical report on the condition of the implants at the time of removal.
- Photograph the implants to show their condition at the time the patient assumed possession of them, and keep the photos in the medical record.
- Have the patient sign a release that documents what was given to her, the condition of the released implants, the date of release, and that the patient assumed all responsibility for them.
- Retain a copy of the release in the patient’s medical record, and document what was released and when.
- A postmastectomy patient is seen for a reconstruction that is scheduled in six months. The patient’s husband attends each office visit and is demanding and abusive to the staff. Am I required to continue the care already commenced?
- The physician has an ethical duty to continue care until such care is no longer indicated or until the physician-patient interaction is no longer therapeutic. Attempt to resolve the interaction issues, and then decide if care should be transferred to another provider.
If the physician-patient relationship can be salvaged, explain to the patient, away from the husband, how his conduct interferes with therapeutic care. Then meet with the patient and husband to discuss the goals of reconstructive surgery and to state that abusive or hostile behavior will not benefit anyone and will not be tolerated. Stress the physician’s understanding and compassion for the patient and for her diagnosis, and reiterate that all parties—including the spouse—must cooperate to achieve an optimal outcome. Perhaps the communication and interaction issue to be resolved is the patient’s or the husband’s anger about the diagnosis. If the interaction issues cannot be resolved, work with the patient to establish care with another provider before terminating the relationship.Include your conditions of treatment as part of the intake process. The conditions of treatment outline your expectations of the patient. Conditions can include being compliant with instructions, appearing at all appointments both (pre- and postprocedure), taking all recommended medications, paying all bills in a timely manner, and requiring the patient and family/significant other to be respectful of the physician and staff at all times. Ask the patient to acknowledge your conditions of treatment, and discuss that failure to comply with any of the conditions may be grounds for terminating the relationship.
- The patient wants to pay for the procedure with a credit card. How can I make sure I will get paid?
- Permitting patients to use credit cards to pay for procedures has become common. However, if the patient is unhappy with the result, he or she may dispute the charge and ask the credit card company to deny payment. This situation impedes payment and may breach HIPAA if you are required to provide medical records. Careful consideration should be given when a patient wants to pay a large amount with a credit card. In these situations, we recommend that the patient sign an agreement that he or she will not dispute the credit card charge and/or execute an authorization to release medical records to the credit card company.