How to Gracefully Exit When You Don’t Want to Operate on an Elective Patient

7 thoughts on “How to Gracefully Exit When You Don’t Want to Operate on an Elective Patient”

1. Very succinct and well done. Are you ever interested in coming back to Palm Beach to talk to our group of Plastic Surgeons about Medical Justice and scenarios related to cosmetic surgery? I am the County President.

2. Excellent discussion and plan! It applies to many areas across elective surgeries, including orthopedic procedures or hand surgery problems. Psychosomatic issues are always tricky to navigate and your suggestion about consulting a knowledgeable professional in that area is excellent advice.

3. Wow. I would be afraid that telling a person that he/she has a mental disorder would create even more scathing comments and reaction. Probably the same scathing comments and reaction if you just said no, I am not doing the surgery for my own personal reasons. Which is worse? Tough question to answer.

4. You are brave to take on this such conversation with this particularly difficult type of patient. Still, what could the patient complain on line? “This doctor said I was crazy and refused to operate on me even though I paid them good money!!!!!” Many readers would assume, “wow, if they said that then you must be!”

   I’d be interested to know how you would frame the conversation if the elective surgery was NOT aesthetic. Say for example the patient ℅ back pain and the MRI showed apparent signficant stenoses in an appropriate distribution. But you then access a much older MRI that appeared the same, and the records from the prior surgeon implied he felt the patient had an unrelated cause of pain or less pain than they professed, or was seeking disability. The patient is demanding/persistent. But they may have been in pain/subjected to discrimination for years now and finally found someone who listened to them and was willing to try to help, before you had second thoughts. To whom/or what could you defer the ultimate decision? At least in this setting you presumably haven’t accepted a deposit…

5. Points one and two are valid. Everything after that should be omitted as it will trigger a lawsuit, malpractice or otherwise. Everything after point two will lead to the scorched earth result that you are seeking to avoid. As in a deposition, the shortest script or answer is the best. A simple I don’t think that I can fulfill your needs or expectations, is what is required. Also have a check in hand to return the client’s deposit. Then offer to refer the patient to another plastic surgeon, perhaps at a university hospital, who might be better able to help the patient.
   Any mention of psychiatric illness will trigger the adverse event of a scorched earth campaign.

   Offering to do surgery in the future if they are cleared by a mental health professional, keeps the client dangling. The only person that can clear a patient for surgery from a surgical perspective is you. They will still expect you to do the surgery. Will this patient get better from mental health treatment? Perhaps. Do you want this patient in your practice at any point? No.
   Keeping their check and keeping them dangling, keeps them bound to you. It also makes it seem like you are greedy by hanging on to their money. A clean dismissal of the patient is what is called for with a referral so that the patient is not abandoned.

6. Never regret surgeries not performed. 13% of patients who request rhinoplasty have BDD. A negative review about refusing to operate may be good for your online reputation. Rants about a “butcher” composed by the BDD patient postop, are painful and often costly.

7. Great article and topic.
   Being able to say no in such a way that the patient who may be unreasonable doesn’t go bonkers. I once had (in my opinion) a patient who had reflex sympathetic dystrophy. He continue to complain of severe pain of the thumb after a minor injury. I recommended a course of medication, therapy, desensitization,, and observation. He was adamant that I cut off his thumb. I sent him to University Hospital hand service. They sent him back to me with a letter, saying to go ahead and cut off his thumb! Psychiatrist don’t always know or agree with what the surgeon’s assessment is. Sometimes other practitioners don’t have your back and don’t always see what may be a mistake and can actually make things go sideways further by reinforcing the patient’s beliefs. Sometimes referring them to a specialist may risk putting you in an awkward position that doubles down on things you don’t want to do. I’ve defaulted to ann opinion over the years of simply saying that the patient needs somebody who’s better at their unique problems that than I am. I’ve also gotten away from referring him to other plastic surgeons for fear of being named as referring him to somebody who may actually do them harm. Just let them do their own research and find their own solution.

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