Patient Selection for Elective Cosmetic Procedures

James E. Vogel, MD, FACS, Associate Professor of Plastic Surgery, The Johns Hopkins Hospital and School of Medicine, and Susan Shepard, MSN, RN, Senior Director, Patient Safety and Risk Management Education, The Doctors Company

Many claims originate with patients who are not appropriate candidates for procedures. Having a well-planned and carefully executed patient selection process can help you identify patients who are good surgical candidates and those who may not be able to achieve satisfactory results.

Two fundamental principles apply to risk management and patient selection: First, if a patient does not get the expected result, that patient will not be happy. Second, if a patient is not happy with a cosmetic surgical result, it is most likely NOT because the operation was done incorrectly. Thus, it is the physician’s job during the consultation to make sure the patient knows what to expect. 

The successful outcome of a surgical procedure begins during the initial consultation—not in the operating room. If the patient is not satisfied with the anticipated results communicated during the initial consultation or does not agree to the realistic expectations outlined by the surgeon, the plans for surgery should not proceed. Consider the following strategies to reduce risks when selecting patients for elective procedures.

Assess Prospective Patients

During the patient’s first visit, take time to ask questions and document the answers. The following questions can help you assess prospective patients:

• Is this a repeat surgery or repair of another doctor’s work?
• Has the patient sued another provider?
• Is this a workers’ compensation case?
• Does the patient’s spouse or partner know about the procedure? If yes, does the spouse or partner agree with the decision for surgery? If no, why?
• Is the patient financially able to handle the costs associated with the procedure and any additional procedures?
• Does the patient have a history of compliance with post-op instructions?
• In the two weeks prior to surgery, will the patient experience extended sedentary periods (e.g., air travel, bed rest, or car journeys)?

Warning Signs

Assess the patient’s body language and behavior for signs that may warrant additional consideration prior to an elective procedure. Examples of patient warning signs include:

• Appears angry or hostile, has a sharp tone of voice, defensive body postures, or negative facial expressions.
• Resents questions, makes defensive responses, or provides short or one-word answers.
• Is demanding, self-centered, or lacks sensitivity to others.
• Is overly complimentary of the doctor and office staff.
• Has unrealistic expectations.
• Blames another doctor for previous treatment.
• Appears to be “doctor shopping.”
• Has difficulty paying attention, is unfocused, interrupts, or changes the subject.

Informed Consent

Questions asked during the patient selection process do not replace the informed consent process. Issues may surface during the informed consent process that indicate the patient is not a good candidate for the elective procedure.

• Encourage patient participation through shared decision making. (See AHRQ: Shared Decisionmaking.)
• Use the teach-back method to ensure patient comprehension. Avoid asking questions that can be answered with only “yes” or “no.” (See AHRQ: Teach-Back Method.)
• Document the informed consent discussion, including the proposed treatment plan, potential risks, complications, benefits, alternatives, and the patient’s understanding and acceptance.

See our article, “Elective Surgery Informed Consent and Shared Decision Making During COVID-19.”

Staff Input

Many factors affect a surgical outcome. Office staff can contribute valuable information in the selection process.

• Obtain a more complete impression of the patient through a discussion with staff on the patient’s behavior during the office consultation.
• Listen when staff members voice “gut reactions” regarding a patient or a patient’s partner or family member and allow them to contribute to discussions of denial of care.
• Request a second consultation before committing to surgery if any concern or hesitation exists on the part of the surgeon or staff regarding the selection of a patient for surgery. The explanation for the second interview can be described in a manner to emphasize the physician’s caring and professional approach.

For example, “Mrs. Jones, this is a significant procedure we are discussing today, and this is the first time I have had the pleasure of meeting you. I would like you to consider the various goals, risks, and outcomes we discussed today, then let’s get back together in a few weeks to confirm the plan. I can also answer any additional questions you might have. Furthermore, I will also be giving additional thought to the plan and make sure I feel this is the best approach to address your concerns. This way, when we meet the morning of surgery, we will both feel that all issues have been addressed.”

For a discussion of elective procedure concerns related to the pandemic, see our article, “Resources for Elective Procedures During COVID-19.” For additional questions, please contact The Doctors Company Patient Safety and Risk Management Department at (800) 421-2368 or by email.

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