In an age of makeover media, and with new categories of patients entering the market, there is a need for good patient-selection protocols more than ever. Strong patient management is the key to protecting your practice from the risk of claim and loss.

Among the major challenges facing aesthetic physicians today are safety, patient confidentiality, maintaining suit-proof medical records, telephone triage, documentation, informed consent, and regulatory compliance issues. (See also “Get Hip to HIPAA” by Glen Lubbert in this issue.) Developing formal patient-selection criteria and implementing protocols in your practice can safeguard you from litigious patients down the line.

Communication Skills

Communication between physician and patient is universally recognized as the best way to avoid a breakdown in the professional relationship, a loss of confidence, and potential lawsuits.

According to Peter Hilger, MD, president of the American Academy of Facial Plastic and Reconstructive Surgery, and an associate professor of otolaryngology and the director of the Division of Facial Plastic Surgery in the Department of Otolaryngology at the University of Minnesota in Minneapolis, “In our office, we strive to have a team approach to our goals of excellent, aesthetically pleasing natural results and happy patients.

“Our initial consults are conducted in a nonclinical environment before we move to a traditional exam room. This environment facilitates a true dialog between the patient and the physician, and allows us to better assess motivation and emotional stability suitable for surgery. We encourage family members to attend the initial consult, as social interaction provides valuable insights into desires and a favorable supportive perioperative environment.”

Patient-Selection Criteria

It is virtually impossible to deal with the issues of informed consent appropriately in one brief consultation visit today. A physician cannot really address all of the options—as well as the possible risks, complications, and alternatives for each—in less than 1 hour. Although it is not possible to weed out all patients who may be problematic, every effort should be made to spend a reasonable amount of time with each prospective patient before administering treatment.

The average aesthetic patient will present with a long list of questions about various procedures and products she has read about in a magazine or seen on a talk show, and preconceived notions of what she wants, needs, or is a good candidate for. Most plastic surgeons find themselves spending half of the consultation time re-educating patients about what they can and cannot do.

It is a rarity nowadays for patients to come into an aesthetic practice with just one thing in mind, such as correcting heavy upper eyelids or deep nasolabial folds. Rather, they are more likely to arrive armed with a legal pad full of questions ranging from those about face to body to skin procedures.

The overwhelming number of choices in terms of surgeons, devices, and treatments has contributed to this frustrating phenomenon, which adds time to the average preoperative visit. A second visit also gives the physician another opportunity to rule out problem patients and to reassess his or her initial treatment plan. The more face time the patient has in the office, the more comfortable the patient will feel and the more she will reveal herself to the physician and staff. By the patient’s second visit, the physician should have a fairly good idea of whether he or she wants to treat that individual.

Hilger adds, “Patients spend time with our experienced patient coordinator, and after each consult we review the patient and her desires. This provides valuable information, and if either of us has reservations about the patient, we defer surgery until concerns are resolved.”

To save yourself from the agony of accepting someone as a patient whose name, when it appears on your daily schedule, causes you to break out in a cold sweat, you may be well-advised to cut the patient loose. Whenever possible, the ideal time to do that is as early as possible into the relationship. Red-flagged patients should probably be screened out on the first visit to avoid a confrontation later on.

According to Foad Nahai, MD, of Paces Plastic Surgery in Atlanta and president of the American Society for Aesthetic Plastic Surgery, “Turning down a potentially difficult patient by explaining that you do not feel you can make her happy is acceptable and much preferable to dealing with an unhappy patient postoperatively. In this regard, I have found the input of our nurse and patient coordinator invaluable in recognizing and avoiding such patients.”

It is acceptable practice to inform a patient that you do not believe that you can achieve a favorable outcome in her case. Although you are not technically required to make a referral to another physician, the patient may appreciate that courtesy, and it may ease the sting of rejection.

Once you have decided not to treat a patient, it is critical to stand your ground. Inform the entire staff that the patient should not be given another appointment, dictate the appropriate note into the chart that indicates your decision not to offer services, and segregate the patient’s chart in a special file. If the patient adamantly insists to be seen again, consider contacting your malpractice carrier or attorney for the best language to use to formally discharge the patient in writing.

As Hilger explains, “Patients who are rude or unkind are flagged and may not be suitable for our practice. In particular, prospective patients who are condescending toward the receptionist and overly solicitous of the medical staff are likely, in the long run, to be a problem.

“On occasion, we find patients who we don’t think will be benefited by our care, and we send them a formal letter expressing our concerns and suggest that they seek care elsewhere.”

Managing Patient Expectations

Overpromising the results you can deliver is a surefire strategy for generating unhappy patients. It is important to determine the patient’s motivation for changing or improving her appearance and to understand her goals.

Showing before-and-after photographs of previous patients may be helpful, but you should always do this with caution. Photos can only be used with proper patient authorization. It is always advisable to show a range of results—from good to average—to provide a fair portrayal of results. Presenting only your best results is tantamount to an implied guarantee of the quality of what the patient can expect to achieve.

Patients who make comments on the order of, “I don’t see any difference,” or, “She looked better before,” should be examined more closely before proceeding. These may be signs that their expectations are unreasonable, or that they are looking for something more than surgery, injectables, or resurfacing can offer.

Computer imaging can be worthwhile, especially for rhinoplasty, chin augmentation, and breast-surgery cases. It is imperative to reiterate that each patient and case is different, and that a given person’s result may not be exactly like the image on the screen. Beware of any patients who want to take a copy of the image with them. This is not recommended because it represents an implied guarantee, even if you have added an appropriate disclaimer.

Similarly, patients who bring in photos, taken from the Web or from magazines, of the look they are hoping for often have misconceptions about aesthetic surgery and what procedures can and cannot do. Celebrities and supermodels embody the image of characteristics that are largely unattainable to the average person, and may present a setup for a disappointed patient.

Maintaining suit-proof medical records can be an ongoing challenge in busy aesthetic practices. Documentation of your discussion of risks, complications, alternatives, and specifics about the patient’s goals, desires, and expectations is mandatory. If the patient has brought in photos or other materials, you should include them in her chart for future reference, along with your notes of any conversation you had in response to these photos.

It is best to dictate or write your notes as soon as possible so that they are fresh in your mind. The more time that elapses from the office visit to the day that you record your notes, the less likely you are to recall all the precise details of what transpired between you and the patient.

The Unhappy Patient

Special attention should be paid to all patients who miss a postoperative appointment, or who have voiced a complaint and have not returned for several weeks or months since their last visit. Assign a staff member to follow up with these patients by phone. If attempts to reach them by phone are unsuccessful, it may be advisable to send a letter requesting that the patient return to the office to be seen by you.

If unhappy patients are allowed to slip through the cracks, their disappointment and anger may fester. This can ultimately become the root of potential litigation. A vocal, unhappy patient can attempt to poison your reputation in the community, and on Web bulletin boards or chat rooms as well.

“The management of a patient who is not satisfied with the results of her treatment requires considerable time, energy, and patience for both the physician and staff,” says Farzad Nahai, MD, also of Paces Plastic Surgery. “Although nurses can assist in addressing some of their concerns, the patient will look to the physician for definitive answers. Therefore, the physician needs to be involved in the process. Schedule a private appointment to see these patients when you are able to effectively address each of the issues at hand, rather than during the middle of busy office hours when you are most likely to be under time constraints.”

See also “Learn from Your Patients” by Wendy Lewis in the January 2007 issue of PSP.

It is common practice to bring such a patient back for repeat visits—at no charge—until her concerns settle down and the situation resolves on its own or with intervention. The worst thing you can do is minimize a patient’s concerns that are serious to her, or avoid dealing with her altogether.

“Patients with complex. nonurgent problems are asked to schedule a second consult after they have had an opportunity to reflect on the initial visit with us,” Hilger says. “We also encourage patients with complex problems to seek additional opinions. I am happy to suggest other competent surgeons in our area. Patients are appreciative of this approach, and it tends to foster patient confidence in our practice.”

Risk-Reduction Tips

Finally, Steven J. Pearlman, MD, FACS, a facial plastic surgeon in private practice in New York City, offers these risk-reduction tactics:

  • “Computer imaging is useful, not only to simulate the results of potential surgery for the patient, but as a screening tool. Patients should be told before and during the imaging that it is only a simulation. However, when the patient starts to point out minutiae or becomes hypercritical of the imaging, it may be a sign that this patient might do the same thing following surgery.”
  • “With most patients who have a major procedure, I prefer a second consultation. At that time, questions can be asked that the patient might otherwise not ask over the phone or to other staff members. Patients are encouraged to create a list of questions prior to the second consult to minimize the unknown, reduce preoperative concerns, and avoid last-minute phone calls.”
  • “Avoid getting into very detailed discussions about exactly how you will be performing a surgical procedure, especially in revision surgery. This is because the procedure cannot always be precisely predicted during the examination. For example, patients who come in with detailed questions about the size, shape, origin, and number of grafts are not academically qualified to differentiate between what one surgeon tells them and what another says. I suggest that the patient choose a surgeon based on appropriate credentials and the degree of comfort with the surgeon—and then let the physician exercise his or her expertise.”
  • “Patients who come in with negative comments about previous surgeons might pose potential problems. If everything does not go perfectly, you will be next on their list to trash.”
  • “Be wary of the patient who praises you too much—especially after denigrating the previous surgeon. Phrases like, ‘You are the only one to fix this problem,’ or, ‘You are the absolute best at this procedure,’ are warning signs.”

Wendy Lewis is a contributing writer for  Plastic Surgery Products; author of America’s Top Cosmetic Doctors (Castle Connolly); and the editorial director for, a medical marketing and publishing group. She can be reached via her Web site,