FAQs for Plastic Surgery

by Laura A. Dixon, B.S., J.D., R.N., Regional Patient Safety/Risk Manager

In this issue of The Doctor’s Advocate, we continue our series of articles featuring questions that are answered frequently by our regional patient safety/risk managers.
 
This quarter’s guest author is Laura Dixon, patient safety/risk manager in our Rocky Mountain and Northwest Regional Offices. For this article, Laura addresses plastic surgery questions.

Remember that your Department of Patient Safety is here to help. If you have any questions, please feel free to call us at (800) 421-2368, extension 1243.

—Robin Diamond, J.D., R.N.; A.H.A. Fellow–Patient Safety Leadership; Vice President, Patient Safety

Q: Are there suggested criteria to consider for patient selection for procedures?
A: Yes. Begin by ascertaining the patient’s overall medical status and expectations from the procedure. Proceed with caution with any patient 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

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 noncompliance or poor relationships with other physicians
• Request repeat procedures on the same site without adequate reasons

Candidates to consider for plastic surgery
include patients who:

• Have realistic expectations from surgery.
• Are compliant with instructions.
• Have a spouse or family member who is aware of the planned procedure and agrees with the plan.
• Can handle 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.

Q: How can I be sure that a patient’s expectations of plastic surgery are realistic?
A: We recommend that you:

• Utilize patient information questionnaires, such as The Doctors Company’s Assessment Tool for Patient Selection.
• Carefully use “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.

Q: 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?
A: Ask yourself the following three questions:

1. Is this patient a good surgical candidate overall?
2. Do accepted and sound medical practices indicate that the requested procedures can be completed safely in one session?
3. Would you recommend this to a member of your family?

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.

Q: 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?
A: 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.

Q: A patient has presented for 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?
A: 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 extensive education as to the risks and complications with smoking, it is best to decline doing surgery on this patient.

Q: 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?
A: 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 education as to what will be done. Avoid vague or subjective terms such as “to the patient’s satisfaction” in the consent form.

Q: 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?
A: 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 utilizing the following steps:

• Have a pathologist examine the implants and issue a report, similar to when any item is removed from a patient. The report will provide additional support to your surgical report as to the condition of the implants at their time of removal.
• Photograph the implants to show their condition at the time the patient assumed control 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 items released, the date of release, and that the patient assumed all responsibility for the released items.
• Retain a copy of the release in the patient’s medical record, and document what items were released and when.

Q: 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?
A: 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.

Clarification

Subsequent to publishing the “FAQs for Plastic Surgery” in the third quarter 2006 issue of The Doctor’s Advocate, we received comments from several physicians regarding our recommendations on two of the questions: care of an out-of-state patient and a patient with a history of smoking who requests a breast augmentation. We hope that the following information clarifies our recommendations.

The recommendation regarding advice provided to an out-of-state patient was intended to address those situations in which a physician provides medical advice by telephone or e-mail to a patient in a state where the physician may not be licensed. The question was not intended to include those situations where the patient comes to the physician’s clinic for treatment (or is treated at a hospital) in the state where the physician is licensed or has privileges.

Our recommendation on the smoker requesting breast augmentation is based on The Doctors Company’s loss experience with claims in plastic surgery. It is the company’s policy to never interfere with the medical judgment of our insured physicians as to the choice of treatment. Nonetheless, we feel obligated to share our claims experiences with you. Breast surgery represents over 80 percent of all of our aesthetic claims, and a significant number of those claims involve complications in augmentations performed on smokers.

We welcome all comments from our insured physicians and appreciate your input. If you would like to make additional comments, please contact the Department of Patient Safety at (800) 421-2368, extension 1243.

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