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In many elective surgical practices, patients are scheduled weeks to months out. I’ll use plastic surgery for my example here. But the principle applies more broadly.
Imagine that a patient presents for a facelift. Or rhinoplasty. Or tummy tuck. Doesn’t matter.
You know you can do the job. It’s obvious what the patient needs. And it is squarely within your skill set. The patient agrees. You set a date. The patient puts down a deposit.
Then, things change.
You’re bombarded by scores of text messages at all hours of the day and night.
This patient is demanding. There’s no room for error. If you are off by a millimeter, you expect to be on the receiving end of an onslaught.
You start to wonder if this patient has a mental illness.
Perhaps, Body Dysmorphic Disorder (BDD).
But you’re not a psychologist or psychiatrist. You believe that if you tell this patient to part ways, they will double down with an online scorched earth campaign.
You start to fantasize about another career choice.
What to do?
First, remember, the customer is always right. But not everyone has to be YOUR customer.
Here’s a script that might help dial down the temperature.
1. On our initial interaction, I believed, based on your presentation, I could perform a surgery that would make you satisfied.
2. Based on our evolving back-and-forth correspondence, I do not believe, at this point, I can meet your expectations.
3. More importantly, I am concerned you MAY have a mental health condition called BDD. I say “MAY” because I am not a mental health professional. I just screen for such conditions. Because if you actually do have that condition, aesthetic surgery is contraindicated. I generally refer such patients to a specialist to determine if indeed that is the case. If cleared, I will perform the surgery. If I learn the patient has BDD, then I wait until the professional says surgery can be performed.
4. So, I am not saying “No, because.” I am saying “Yes, if.”
5. This is no different than if a patient has a cardiac condition. I refer to a cardiologist for medical clearance first. Or if the patient has a possible history of seizures. I refer to a neurologist first. Regardless, we want to optimize for a potential surgical outcome and meet expectations.
Importantly, surgery is contraindicated in a patient with BDD. BDD is a mental health condition. And each additional cosmetic procedure just adds to the accumulating problem. Regardless of how objectively good the patient’s outcome might look post-op, the patient will not subjectively perceive it that way. In other words, using a scalpel to treat a mental health condition will not get either the patient or doctor to an optimal outcome.
How will such a patient react to this discussion?
It depends. Certainly, better over the long term than if you performed surgery and they become progressively more dissatisfied.
Interestingly enough, many such patients are relieved to learn there may be an explanation for the constellation of symptoms they have experienced and that someone took the time to dig deeper into root causes. This patient may not be happy today, or even tomorrow. But in the long term you may have truly helped them.
Finally, having a seasoned professional ready to accept this challenging patient in referral is key. That person should have the skill set to manage the acute conversation. They can assist with “damage control.”
Knowing when to operate, and when not to operate is part of our lifelong learning curve. Even when there is no perfect decision to be made, you should be able to mitigate the worst possible outcomes.
What do you think?
"Can Medical Justice solve my problem?" Click here to review recent consultations...
- Former employee stole patient list. Now a competitor…
- Patient suing doctor in small claims court…
- Just received board complaint…
- Allegations of sexual harassment by employee…
- Patient filed police complaint doctor inappropriately touched her…
- DEA showed up to my office…
- Patient “extorting” me. “Pay me or I’ll slam you online.”
- My carrier wants me to settle. My case is fully defensible…
- My patient is demanding an unwarranted refund…
- How do I safely terminate doctor-patient relationship?
- How to avoid reporting to Data Bank…
- I want my day in court. But don’t want to risk my nest egg…
- Hospital wants to fire me…
- Sham peer review inappropriately limiting privileges…
- Can I safely use stem cells in my practice?
- Patient’s results are not what was expected…
- Just received request for medical records from an attorney…
- Just received notice of intent to sue…
- Just received summons for meritless case…
- Safely responding to negative online reviews…
We challenge you to supply us with a medico-legal obstacle we haven’t seen before. Know you are in good hands. Schedule your consultation below – or click here to visit our booking page.
Jeffrey Segal, MD, JD
Chief Executive Officer and Founder
Dr. Jeffrey Segal, Chief Executive Officer and Founder of Medical Justice, is a board-certified neurosurgeon. Dr. Segal is a Fellow of the American College of Surgeons; the American College of Legal Medicine; and the American Association of Neurological Surgeons. He is also a member of the North American Spine Society. In the process of conceiving, funding, developing, and growing Medical Justice, Dr. Segal has established himself as one of the country’s leading authorities on medical malpractice issues, counterclaims, and internet-based assaults on reputation.
Dr. Segal was a practicing neurosurgeon for approximately ten years, during which time he also played an active role as a participant on various state-sanctioned medical review panels designed to decrease the incidence of meritless medical malpractice cases.
Dr. Segal holds a M.D. from Baylor College of Medicine, where he also completed a neurosurgical residency. Dr. Segal served as a Spinal Surgery Fellow at The University of South Florida Medical School. He is a member of Phi Beta Kappa as well as the AOA Medical Honor Society. Dr. Segal received his B.A. from the University of Texas and graduated with a J.D. from Concord Law School with highest honors.
In 2000, he co-founded and served as CEO of DarPharma, Inc, a biotechnology company in Chapel Hill, NC, focused on the discovery and development of first-of-class pharmaceuticals for neuropsychiatric disorders.
Dr. Segal is also a partner at Byrd Adatto, a national business and health care law firm. Byrd Adatto was selected as a Best Law Firm in the 2023 edition of the “Best Law Firms” list by U.S. News – Best Lawyers. With over 50 combined years of experience in serving doctors, dentists, and other providers, Byrd Adatto has a national pedigree to address most legal issues that arise in the business and practice of medicine.
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.
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.
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.
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…
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.
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.
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.