Our patient safety risk management experts field questions from plastic surgeons around the country. The following questions are some of the most common we have answered.
- Can you suggest patient selection criteria for plastic surgery procedures?
- Yes. Begin by ascertaining the patient’s overall medical status and expectations of the procedure.
Proceed cautiously with any patient who:
- Has undergone repeated surgical procedures by other physicians.
- Sued another provider as a result of a plastic surgery outcome.
- Appears to be “doctor shopping” (i.e., visiting multiple physicians to obtain the medical opinion the patient wants to hear).
- Displays an exaggerated concern over a minor or nonexistent problem.
- Exhibits behavior that suggests possible fixations on particular physical features.
- Recently experienced a major life change, such as a failed relationship or a lost job.
- Suffers from depression, eating disorders, anxiety, poor self-esteem or who has an unhealthy motivation to have surgery.
- Is fixated on a prior surgical result or physical imperfection.
- Appears to be looking for a quick fix to a long-term problem.
Avoid 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.
Consider patients for plastic surgery who:
- Have realistic expectations about surgery.
- Comply with instructions and keep scheduled appointments.
- 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.
- Present with conditions or request procedures that you are experienced with and 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. Find suggestions for questions to ask in our article “Patient Selection for Elective Procedures.”
- Beware of making an implied warranty with the use of before and after images. 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 about 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.
- Document your discussions with the patient carefully. It is critical to include details of the patient’s expectations and the risks and benefits of the procedure.
- To save money, a patient is requesting that multiple plastic surgery procedures be performed during one session at an outpatient surgical center. What is the best way to proceed?
- Ask yourself the following questions:
- Is this patient a good surgical candidate overall?
- Is the patient an appropriate candidate to have surgery at the requested location?
- 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?
If you answer no to any of the questions, decline the request. Patient safety must take precedence over saving the patient money. The physician—not the patient—determines the standard of care for where to perform a procedure and the safety of performing multiple procedures during one session.
- 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 follow up. This becomes even more critical if the patient develops postoperative complications.
The second issue involves physicians who provide advice to patients in other states; providing advice to a patient who is physically out of the state could be viewed as practicing in the patient’s state without a license. A physician must take care when communicating by phone, email, or other electronic means with a patient in another state in which the physician is not licensed.
In addition, take care to avoid creating an expectation of a physician-patient relationship if you use social media or websites to provide literature or schedule appointments.
- A patient has presented for breast augmentation. She is a smoker who has promised to quit, but, at every appointment, the distinct odor of tobacco is 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 7 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 states 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; you are permitted to 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 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 description 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 plan for reconstruction?
- 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.
Understand that the husband may be afraid and angry about his wife’s diagnosis. His behavior may be an expression of loss and fear rather than a reaction to anything the office staff and physician have done. Empathize with them and acknowledge that it is difficult for the patient and for her husband as well. Remind them you are here to help and that all parties—including the spouse—must cooperate to achieve an optimal outcome. If the abusive behavior cannot be resolved, help 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 and may include complying with instructions, keeping all appointments both (pre- and postprocedure), taking all recommended medications, complying with financial arrangements, 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 raises HIPAA and confidentiality concerns if you are required to provide medical records to the credit card company.
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 execute an authorization to release medical records to the credit card company in the event there is a dispute in the future. For more information, read our article “Patient Billing Challenges, Frequently Asked Questions.”