The patient, whom you carefully and gently took from a productive initial consultation through surgery and the delicate postop recovery period, now slams her hand on your desk in anger. Her demeanor has gone from all smiles to all frowns. What happened?

Angry or difficult patients pose one of the biggest challenges for a plastic surgeon. When a patient is angry about a bad outcome, whether or not medical error was a possibility, there are many ways that plastic surgeons can rescue the situation. However, the best approaches to take are not always intuitive. How does one deal with the disgruntled patient and "reel them back in" and revive a good patient-physician relationship?

Julie Ann Woodward, MD, is service chief, oculoplastic and reconstructive surgery service, at Duke University in Durham, NC, and an expert on the nature of difficult or unhappy patients and how to successfully deal with them—with compassion and humanity without allowing them to "run you over" or manipulate a difficult situation into a potentially litigious one. PSP spoke with Woodward about this topic. We started with what is probably the most contentious issue for plastic surgeons in 2010.

PSP: Have patients written online reviews about you or your practice and your cosmetic surgery techniques? Any negative reviews?

Julie Ann Woodward, MD: A lot of doctors are having a hard time with this one because that can be so unfair. However, unfortunately, it’s here to stay. If you get one crazy patient going nuts on the Internet, it could be devastating. I think the problem is that happy patients tend to tell two friends and unhappy patients tend to tell the whole world. I have never personally checked any of mine. I don’t want to know. Actually, one of my patients came in the other day and told me that he had read good reviews about me online. I was happy about that because going online and writing reviews is where the unhappy patients go. They actually take the time to file complaints.

PSP: What do you do if or when you encounter an unhappy or angry patient?

Woodward: First, I think I have a really good rapport with my patients. I have never been sued. I have never had a complaint filed against the board. I think it’s important to have really good rapport, be very intuitive, and know how to relate to your patients.

However, I started thinking about the little things that I do when I run into small problems, and I think the biggest thing is to never disagree with the patient. If they see something is wrong, you agree with them right away because the last thing we want to do is feel like we are discrediting them. I’m on the faculty at Duke with the most prestigious physicians in the entire world, and even they have difficult patients just like everybody else. They have patients that file complaints and even lawsuits. I don’t think it is something that anybody can avoid. I think if you deal with a high volume of people, you are just going to have this problem somewhere along the line.

PSP: What do you suggest aesthetic practitioners should do to not turn patients into unhappy and difficult ones?

Woodward: Any physician can have an unhappy patient who is not difficult, and you can easily work with that person and make them happy and tell them exactly what you’re going to do. You can continue to walk on water, even though they are not thrilled at their situation. The problem is when you get somebody who is an unreasonable patient on top of being unhappy. That’s where your surgical skills don’t matter anymore—it’s all about your interpersonal skills.

UNHAPPY AND DIFFICULT PATIENTS CHECKLIST

We all have them—not even the very best physician can deny this. The most respectable and well-known physicians I know on the Duke University faculty have a tale to tell about a difficult patient.

I learned many of the tips described below from observation during my fellowship, from talking with colleagues, and from personal experiences.

PREOPERATIVE STAGE

  1. Slightly downplay expectations—eg, "Laser skin resurfacing will not get rid of every wrinkle. You may still need some fillers."
  2. Talk in numbers and give percentages whenever possible—eg, "Twenty percent of patients may need an adjustment with this procedure."
  3. Stress the time required to heal.
  4. Beware of a patient who abuses your staff’s time. If so, tell her, "I’m sorry, the staff and I can’t meet your expectations." You may want to refer them to another physician and then call that physician to apologize for the difficult patient referral.
  5. If a patient seems uneasy and difficult, encourage them not to do the surgery. The money you collect from a difficult patient will not be worth your time.

POSTOPERATIVE STAGE

  1. Never disagree with what a patient sees is wrong, even if you do not see it at all.
  2. Remind the patient that healing can take from 6 months to a year.
  3. Take action—If the patient does not like the look of their scar, inject a small amount of steroid or make an appointment 4 to 6 months out for a touch-up. In my experience, most patients will be happy by then and will not even want the touch-up.
  4. See the patient with increased frequency and show that you care. Call them frequently. Don’t be afraid to gently touch the patient’s arm or knee in a calming way. The worst thing a physician can do is to send the patient away for a month and hope that they will cool down. Even if it is stressful for you, ensure the patient will return frequently.
  5. A happy patient will tell two friends, and an unhappy patient will tell everyone on the planet via the Internet (at yelp.com or healthgrades.com, to name a few). As unethical and inaccurate as we know these Web sites can be, they are here to stay. If a disgruntled patient posts a negative comment on a Web site, contact five of your happy patients and encourage them to post positive comments to push the negative comment down on the Web page.
  6. Consider doing touch-ups either for free or for a nominal fee—but set limits. Do not give free Botox/Dysport touch-ups. These patients will want free touch-ups every time. They will "doctor shop" the entire medical community to locate the practices willing to give freebies.
  7. Maintain positive interactions with your colleagues so that you can refer patients for second opinions. Ask them in some cases to see patients with worrisome outcomes.

DEALING WITH ANOTHER PHYSICIAN’S UNHAPPY PATIENT

  1. Never say anything bad about another physician. The patient will naturally seek the physician with a higher level of self-confidence and who does not speak poorly about colleagues. Negative comments about colleagues will usually come back to bite you.
  2. Disgruntled patients who come to you from other practices will probably be unhappy with whoever treats them, even if you dramatically improve their situation. You may want to encourage that patient to return to the physician who did the original surgery.
  3. Consider giving a friendly call to the physician who did the original surgery to let them know you have seen the patient. Mention that you supported that physician’s original work. You might establish a new referral source from this call.
  4. Never return a patient’s money. Most lawyers will say that patients will view this as an admission of guilt, and it usually is an excuse for them to just go out and complain to more people.

—Julie Ann Woodward, MD

PSP: What are some of the techniques that you use?

Woodward: For preop, I slightly downplay the expectations to the patient. You never want to deliver false promises, and you don’t want to always speak in numbers. Never say a risk is small; always say the risk of something happening is 5% or 20% or 50%, because if you give them a number you can inflate the number a little bit. That way, at least they have something concrete to just conceptualize in their head instead of them coming back and saying, "Oh, you told me the risk was low."

Another good point: There is no way you can do a procedure without having some form of a scar, somewhere, except maybe for a transcongenital bufferplasty. So, I always counsel my patients ahead of time that a scar takes 6 months to a year to heal. You know the first thing they are going to do after surgery is say, "Why do I still have red lumps and bumps here?" I try to always let them know how long scars take to heal, and tell them prior to surgery.

Also, beware of patients who abuse chat time. Those are usually red flags. If they spend an hour-and-a-half, 2 hours on the phone with the staff before you have even seen them, it probably will not be a good thing to operate on that patient.

PSP: What if the patient is uneasy, unhappy, and difficult?

Woodward: You don’t want to say, "I think you’re going to be happy," or "I think you will be extremely happy," But you have to make sure that you don’t scare them away. However, it is better to scare away a patient or two than to end up operating on someone you know is going to be difficult to deal with because they didn’t hear your warnings. One thing I would do after skin resurfacing, for example, is I’ll show them a picture of a postoperative surfacing procedure at day 4—that will scare some patients away. But I don’t really care because if somebody is too anxious to handle it, I don’t want to operate on him or her anyway. Let them look at a picture of what the worst possible day of healing looks like.

If they are unhappy, don’t try to downplay it. Always see exactly what they are talking about. Tell them you have to come up with an action plan—what you are going to do to make it better. If they are complaining about a scar, inject it with a little bit of Kenalog or schedule them for a touch-up 4 to 6 months out. Then they just immediately calm down. You can just see it in their face. Even if you say, "I think it might get better over time," and go ahead and make the appointment, 80% of the time they will come back and say, "Oh, I think it is so much better. I don’t think you need to do anything."

The most painful thing to do when you have a difficult patient is to see them more often. However, the biggest mistake a plastic surgeon can make when a patient is slightly unhappy is to think that if they just go away and let it calm down and heal for a while they will come back and it will be better. If they are not happy, you need to see them in 2 days or 1 week.

When you see them very frequently it shows that you care, and it gives them less chance to stew. A patient who is stewing is the worst thing that can happen. They need to look forward to their appointment with you. They need to be able to vent. I think it gives them less of a chance to go see another physician. Therefore, if you maintain in contact whatever the little issue is, you can fix it. If they have started to heal, eventually you know you’ll be able to take care of them and get them through the situation.

Finally, consider doing touch-ups either for free or for a nominal fee in set limits. It depends on the patient. If I feel like I have a really good rapport with the patient, I might do it for free. If I don’t feel like the rapport is that good, that’s when I charge a small amount. If you do too much for free, they feel like you are exhibiting some kind of guilt and then they can actually become more difficult.

PSP: Do you think that it’s important to have good relationships with colleagues?

Woodward: Yes. It is important to be friends with your colleagues—people with whom you can refer for exchanging opinions. I just try to maintain a really good rapport with all the facial plastic surgeons in town, and it has ended up being just huge because they are great referral sources. For example, when they get complicated eyelids they send the patient my way, and if I have something that I think is a major difficult patient I may send them over there. They feel that you are confident enough to send them out of your office. I think that that is an important thing for patients to see sometimes.

PSP: It sounds tricky.

Woodward: It is part of the same thread we’re following here, because sometimes if patients aren’t happy with another physician, they are just unhappy in general and they are not going to be any happier with you. Therefore, I never say anything bad about another physician. I think patients naturally will try to seek the doctors that are more self-confident, that won’t talk bad about other doctors, and generally it is just going to come back to bite someone if they make negative comments. I think it’s just helpful to be professional even if you don’t particularly like the doctor. You don’t want to get stuck in the middle of a lawsuit with a patient that says, "Oh, doctor so-and-so said that this doctor did a bad job, and now I want you to testify in this case because you agreed that he messed me up." That puts you at odds with another doctor in the community, and that’s the last thing you want.

I have also seen unhappy patients from other physicians who have come to me for repair work. In those cases, I just call their original physician—maybe they don’t know that their patient is in my office. That doctor might appreciate the opportunity to be able to call that patient to talk about what the problems might be.

On The Web!

See also "The Biggest Threats Facing Your Practice" by Catherine Maley, MBA, in the October 2008 issue of PSP.

I called a physician one time, and I was telling him about an unhappy patient of his that was in my office. I told him, "Well, you may want to give this patient a call," and his comment to me was, "I’ll have the office put in a call." I thought that was so wrong. Physicians need to get on the telephone themselves and show patients that they care. If a patient is unhappy, don’t expect your staff to be calling that patient for you. Patients will pick up on that and say you’re very cold and uncaring.

PSP: What is the most challenging patient situation you’ve ever encountered?

Woodward: I think two of the most difficult patients I ever had were so much trouble in the preop phase, I never even operated on them. They were so difficult with the staff. They consumed 3 to 4 hours of our time before we even made it to the operating room. With those patients, you have to write a letter to them and say, "I am sorry, I don’t feel my staff and I could meet your needs."

Overall, I can’t say I’ve had many problems. I have never been sued. I’ve never had anyone file a complaint with the state. Two, maybe three patients have filed complaints at Duke. Honestly, I don’t think it was anything with my work. It was more just a case of dealing with a crazy patient. There is one man who filed a complaint at Duke over 2 years after his blepharoplasty, saying I did not take enough skin off of his upper lips. I responded that I would be happy to take a little more if he likes.

Fortunately, I have never had any bad complications, such as blindness or paralysis, or anything permanent that would have caused a serious problem. Usually, the things that patients are upset about are the ways that scars look, maybe needing a little bit more skin, perhaps a little more wrinkle tightening, or a little touch-up on the filler.

Rima Bedevian is a contributing writer for PSP. She can be reached at [email protected].