- Email: [email protected]
Essays on Patient Management and Elective Surgery
259
FACIAL PLASTIC SURGERY CLINICS OF NORTH AMERICA Facial Plast Surg Clin N Am 16 (2008) 259–265
Essays on Patient Management and Elective Surgery Donn R. Chatham, -
-
-
MD
Essay one: The five stages of postprocedural malaise Essay two: Do physicians create their own difficult patients? The Frankenstein theory ‘‘Speed kills’’ Risky business The desired procedure Personalities Labels ‘‘Today’s special’’ Ouch! Essay three: Top ten ways to stay out of patient trouble Listen to your gut during consultations
Essay one: The five stages of postprocedural malaise The surgeon enters the procedure room with expectations and hopes that a good outcome will be achieved; however, this ideal scenario is not always achieved. It has been said that when a patient undergoes an operative procedure that ends poorly or results in a complication, that patient experiences several emotional phases in a specific order. It is helpful for the surgeon to understand these phases or stages to help the patient navigate them and reduce unexpected surgeon frustration. Much has been written about the stages of grief. The stages, as articulated by Dr. Kubler-Ross, are denial, anger, bargaining, depression, and acceptance [1]. These stages may be thought of as shock and
-
Undersell and overdeliver Talk straight to the patient preoperatively Be like Paine Webber: when the patient talks, the doctor listens If a postoperative problem is likely fixable, then plan on doing it. If it is just 50:50, think twice A little help from your friends: ask for it when needed Sometimes it is the little things that count Be diligent the first week back to work after a surgical seminar Be real References
denial followed by anger, attempts to change course, then sadness/depression, and finally acceptance of the inevitable. Do grief and postoperative unhappiness share a common chord? There is a ‘‘loss’’ that comes from an imperfect or problematic surgery. The patient began with hopes of improvement, even transformation, and maybe increased happiness. When it seems that these hopes will not be achieved, then the negative and more difficult emotions emerge. The various stages are as follows [2]. The first stage is surprise. The patient may not have anticipated that things might not go splendidly, so this was unexpected. The second stage is disappointment. If one has expects a certain outcome and it is not there, who would not feel disappointed? Expectations were not met, regardless of
Chatham Facial Plastic Surgery, 4001 Kresge Way, Suite 310, Louisville, KY 40207, USA E-mail address: [email protected] 1064-7406/08/$ – see front matter ª 2008 Elsevier Inc. All rights reserved.
facialplastic.theclinics.com
doi:10.1016/j.fsc.2007.11.019
260
Chatham
whether they were realistic. The third stage involves resentment. After all, the patient met with the surgeon and told the surgeon what he or she wanted. Is it asking too much to expect that a well-trained and qualified surgeon could deliver the end result? Plus, the patient may have spent a lot of money, taken time out of life’s schedule, experienced the anxiety of surgery, and suffered postoperative pain in the process. Now what does he or she have to show for the toil? Wouldn’t most people feel betrayed? The fourth stage involves focused anger. It may manifest as verbal criticism of the surgeon and staff or it might be quietly emotional. It may include requests—or even demands—that something else be done. The patient may insist that another procedure be performed to correct or enhance the result; however, he or she may have lost confidence in the skills of the primary surgeon. If there has been no intervention or compromise, the final stage involves retribution. Retribution may come in the form of threats that can range from legal to physical. The patient sometimes feels that only by enlisting additional allies (ie, court system) can he or she achieve satisfaction. These patients should not be taken lightly. Clearly, it is easier to deal with a patient in the early stages of grief rather than the extreme part of the last stage. By anticipating these stages, it may be possible for the surgeon to build on the doctor-patient relationship that hopefully was positive at the time of the surgery. In my opinion, this relationship begins by listening to the patient and acknowledging that his or her feelings are legitimate. Do not dismiss them as unreasonable, crazy, or unworthy of your time. It is not unusual to reduce the intensity of a patient’s feelings simply by listening to his or her concerns. This is not a cure-all, but it is the first step. The surgeon needs to realistically evaluate what reasonable options might help the situation, which might entail another procedure if the technical aspects are within the surgeon’s armamentaria and if the patient seems truly realistic as to what is likely and what is not. There are cases, however, in which another surgery does not seem wise. Sometimes self-disclosure and candor may require saying to a patient that the current result may be as good as one can get. In some cases, the patient may be able to lower expectations and learn to appreciate what has been improved. It is in the surgeon’s best interest and likely everyone involved—except third party payers (eg, attorneys)—that the final stages of retribution not be reached. Should this happen, however, further ongoing contact with the patient seems futile and it may be time to ‘‘circle the wagons.’’ In any event, it is prudent to recognize preoperatively that not
all procedures turn out splendidly, and the alert surgeon anticipates and empathizes with the patient’s postoperative world. Parenthetically, surgeons may experience similar feelings after a postoperative result that was less than satisfactory. Not to say that the result was ‘‘bad’’ versus ‘‘good.’’ Rather, we surgeons are typically perfectionistic, and anything less than perfect may be perceived as undesirable. If a patient comes back with a less-than-wonderful result, it sometimes catches us off guard and we are surprised. Conversely, we may think that a result is fine, but the patient who seemed so pleasant, compliant, and reasonable preoperatively currently is behaving like a lover scorned, which this can be very surprising. Naturally, we are disappointed, perhaps in our technique, in what we did not do, or even in the behavior of the patient. This disappointment can lead to resentment toward the source of this aggravation. What doctor wants to spend time during a busy and challenging day listening to a patient whining or griping? It is understandable that negative feelings toward the patient develop. If the patient becomes truly adversarial, the surgeon likely will become defensive and harbor feelings of retribution, especially if the conflict escalates. All this seems to indicate that we all are people, whether highly trained specialty surgeons or ordinary lay people looking for a little help, and as human beings, we sometimes have to deal with disappointment and frustration. With respect to Garrison Keillor’s Lake Wobegon [3], ‘‘Where all the women are strong, the men good looking, and all the children above average,’’ few of us practice in a world in which surgical results are exemplary, all the patients look marvelous postoperatively, and patients shower us with effusive praise. The real world is usually just fine, but be prepared for the times that it is less so.
Essay two: Do physicians create their own difficult patients? The Frankenstein theory In Mary Shelley’s classic [4], Dr. Victor Frankenstein became obsessed with creating his version of life, hoping to become a god of a new race of man. Unfortunately, his genius spawned a nightmare as the new creature confronted the good doctor, consumed with feelings first of confusion, then rejection, then anger, and finally wanted revenge for what he was made into. Clearly, the doctor bore responsibility for the ‘‘creature’s’’ state. Is there an analogy to modern plastic surgeons and the disgruntled, unhappy, and difficult patients of our practices? Although most postoperative plastic surgery patients who undergo either cosmetic or
Essays on Patient Management and Elective Surgery
reconstructive procedures fare well and report satisfaction with their experience, clearly there are those who do not [5]. Who is to blame? The postmortem examination can reveal several factors, which have been discussed in other articles in this issue, such as (1) unrealistic expectations by the patient, (2) a lessthan-good surgical performance by the surgeon, (3) factors such as poor healing and poor patient compliance, (4) an actual complication as a result of the surgery, and (5) a malcontent reprobate patient who did not appreciate the benefits he or she received. There are situations in which the apparently benign, compliant, preoperative patient morphs into the nasty noncompliant patient from hell after surgery and there seems to be no rational explanation. What of the Dr. Frankenstein factor? Sometimes the application of science can lead to unintended consequences. Plastic surgeons are not ‘‘mad scientists’’ in search of immortality, but avoiding the fate of good Dr. Frankenstein would be a desirable goal with each patient we operate on. Do we sometimes bring on our own misery? If so, how so? A survey performed by the American Academy of Facial Plastic and Reconstructive Surgery several years ago asked the question ‘‘What was the primary reason for postoperative patient unhappiness?’’ The results may surprise you. Postoperative complications were listed as the primary factor only 4% of the time. Negligence was listed at only 5%. Poor patient selection was listed 6% of the time. One would think that a poor surgical result was likely the biggest reason, right? No, poor surgical results were listed in 14% of cases. That finding leaves unrealistic patient expectations, right? In 17% of cases, patient expectations were the primary culprit. The single most common reason listed for unhappiness in postoperative patients was lack of physician rapport. Coming in at 51%, finding clearly outweighed all the other factors put together. How is it possible that patients actually proceeded with surgery if there was poor rapport with the surgeon to begin with? Did the rapport fade away later? Was a less-than-satisfactory result the catalyst that sparked the loss of relationship? An article in the New York Times with the headline ‘‘When the doctor is in, but you wish he weren’t’’ [6] discussed a growing problem seen in modern medicine: the difficult doctor. Surveys revealed opinions such as this: ‘‘Patients say problems come in many guises. The arrogant or dismissive doctor. The impatient doctor with his hand on the doorknob. The patronizing doctor. Or, as one young woman experienced, the doctor who is callous and judgmental.’’ There are other
factors that also seem to reside more in the realm of the surgeon than with the patient.
‘‘Speed kills’’ This old adage is certainly true in our specialty. I do not mean speed in the operating room; I mean speed in the consultation room. After having the same conversation with many patients over a period of time, the prospect of sitting in a room with a novice patient discussing the same old material for the umpteenth time gets old. Answering a seemingly endless stream of questions and repeating the same old quotes time and again does get tedious. How else can a surgeon make an informed decision about this new particular patient without spending time and looking the patient in the eye while asking the most pertinent questions? Even with adequate time and preparation, it is not always easy to accurately evaluate the motivation and expectations of all people, much less establish a good healthy rapport with them. Trying to do so in 10 minutes seems foolish.
Risky business What about the patient who seems marginal but not really inappropriate or risky? The more experience we get as surgeons, the better our perception of taking on riskier cases. After all, our capabilities and skills are legendary, are they not? The temptation is to take on any reasonable request, which is how we make a living, not shy away from tough cases. Perhaps this bravado is one of the reasons that physician pilots have a reputation as ‘‘dangerous docs,’’ sometimes attempting to overcome the plane and nature itself by force of will. Dr. Frankenstein overestimated his abilities. Sometimes we do as well.
The desired procedure Another situation that all surgeons encounter involves a patient who seeks one procedure but has an even more obvious problem in the eyes of the surgeon or the staff. It takes considerable discernment to not bring up chin implant surgery to the patient who has asked you to help her with the bump on her nose. We are in the beauty business, so what is wrong with telling Mrs. Smith that although you agree that she does need her eyelids rejuvenated, she also needs a facelift and skin resurfacing? Many patients have complained that their surgeon did not really want to listen to what they wanted but instead was ready to tell them what the he or she wanted to do. Sometimes this strategy works fine; sometimes it can backfire badly. So keep the patient’s ‘‘main thing’’ the real ‘‘main thing.’’
261
262
Chatham
Personalities There are warning signs that even the least transparent patients may offer up. When preoperative patients praise you and denigrate a previous surgeon, bemoaning their fate of not finding you the first time, better get those antennae up. When they express anger at the previous surgeon, especially in the face of little evidence that any wrongdoing was committed, you are playing with fire. When patients state that they have a cadre of friends waiting to beeline to your office if the results are good, be skeptical. When patients consider themselves to be royalty or at least VIP-blooded, not only do they want their preoperative special needs met but also their postoperative expectations may be unattainable. Other warning signs exist, and willingly taking on these patients may qualify as extreme risk-taking behavior. At times this may be living life on the edge. And, sadly, from time to time, a surgeon pays with his life for the decision to operate on a patient who later targeted his benefactor.
Labels How we view patients is usually done in a dispassionate and healthy perspective. Are we guilty at times of denigrating the person with unhealthy labels? Consider the diagnosis of one plastic surgeon after evaluating a female patient who presented for possible cosmetic surgery: ‘‘.she was no beauty to begin with but now she exhibited the typical ‘turkey neck’ and her eyelids have become crepey and wrinkled, giving an untidy and withered appearance.’’ Patients who present for cosmetic procedures already know they possess a less-than-perfect feature. It seems cold-hearted to label them with terms that are at best insensitive and at worst disparaging. If a patient discovered either written or overheard words later, who could blame him or her for feeling angry and demeaned?
‘‘Today’s special’’ Surgeons are in the unique position of recommending a procedure/surgery and performing it; thus, we benefit financially. We also can benefit from the sale of consumable home products and supplements and the use of certain devices and injectibles. Doctors also practice in an era in which we are required at educational meetings and in publications to disclose whether we have financial ties to companies, devices, or drugs that we recommend. Although most doctors would agree that we should not make treatment decisions influenced by our relationships with a device or products (eg, a laser) or our ‘‘consultation’’ relationship to a company that markets a product or prescribe anything for reasons
other than efficacy, the lines of decision making can become blurred. Consider this quote: ‘‘Patients can be viewed as biological structures that yield future net cash flows’’ [7].
Ouch! The good life Do we do ourselves disfavor by sometimes living a life of blatant affluence? At the risk of fomenting controversy, I will just ask the question. Many people—in and out of the medical field—reap the fruits of their labors, and what is wrong with that? Driving a nice car, building a large house, and living the good life are all part of a surgeon’s typical life and any financially successful person’s life, aren’t they? There is nothing wrong with perks, but sometimes the public accoutrements reinforce the stereotype of the profiteering surgeon who benefits from the maladies of the less fortunate. Many surgeons take care of patients pro bono, waive fees, wipe out debt, accept Medicaid, donate their time and services, and travel to foreign lands (eg, Face-to-Face program, including the domestic violence program). These are wonderful decisions that demonstrate to all the benevolence of our kind. Sometimes, however, we seem to shoot ourselves in our public relations foot. I once read of a famous plastic surgeon who was featured in the society pages of a media publication. His house was grand, his collection of automobiles was impressive, and his wine cellar was second to none. He was quoted as saying that he has cigars and wine so expensive that he could pay for the college tuition of several students with their worth. This statement begged the question by some readers: ‘‘Why don’t you, doc?’’ It is not up to me or the public to decide whether he should part with a couple of cigars and a bottle of wine and send an unfortunate kid to school, but this kind of publicity seems to fan the fires of the class warfare proponents. Perhaps a more realistic image might be this: ‘‘My doctor is nice; every time I see him, I’m ashamed of what I think of doctors in general’’ [8]. I believe that most physicians entered medicine with altruistic reasons and, even after years of service, we welcome the opportunity and privilege of helping others. We need to make a living, however. There are not many Albert Schweitzers or Mother Teresas. Most of the time our judgment is sound and our priorities remain in healthy directions, as imperfect as we may be. I believe that not many of us are destined to mimic Dr. Frankenstein, however, motivated solely by self-importance and selfish grandeur. There are times when the application of science can lead to unintended consequences. Avoiding the fate of good Dr. Frankenstein would
Essays on Patient Management and Elective Surgery
be a desirable goal with patients who entrust us with their health and place their faces in our hands.
Essay three: Top ten ways to stay out of patient trouble Listen to your gut during consultations When patients present for consultation, it is easy to focus on things such as their facial anatomy, their requests for surgery, and even the income it can bring. Surgeons want ‘‘good candidates for surgery,’’ and we do not really want to disqualify potential patients if we do not have to. Some patients are not really suited for what they might be asking, however, and it is in the interest of all not to proceed at that time. There may not be a solid psychologic or medical reason not to proceed but rather a sense of unease or vague discomfort with that patient. Listen to this voice and heed its call. We get little training in intuition, which is not taught in medical school. It is taught by life itself. A second consultation may clarify this feeling. Alton Ochsner, MD, the famous New Orleans surgeon, once said: ‘‘All medicine is judgment. I can bring anybody in off the street and teach him how to cut and sew in three months. It is knowing when to operate and when not to operate that matters’’ [9]. Better to listen early than to say to yourself after a problem: ‘‘There was something that told me she/he may not be a good one to operate on.’’ Rarely will you regret the decision not to operate on a particular patient.
Undersell and overdeliver Some patients come to a surgeon with high hopes and expectations. Even realistic patients want ‘‘good results’’ and deserve ones that are performed safely and carefully. Although surgeons want to encourage patients and help them proceed to scheduling, we do not want to present an overly rosy picture or ignore the reality of surgery and its risks and imponderables. By emphasizing modest results and delivering better than expected ones, the likelihood of patients being satisfied increases. Although some patients may not schedule with a surgeon because the procedure was ‘‘underpromoted,’’ the ones who do will likely be pleased.
Talk straight to the patient preoperatively Do not shy away from dealing with possible realities. The old adage that ‘‘information given preoperatively is informed consent; delivered postoperatively it is an excuse’’ is still true. Few of us want to discuss possible complications or problems or even hear about them, and the management of less-than-perfect outcomes fits into this category.
What happens if a reoperative procedure is required? Who pays? Is the procedure not ‘‘guaranteed,’’ like so many goods sold in stores today? What if the patient is simply not ‘‘fully satisfied’’? Occasionally I have had to say to preoperative assertive patients: ‘‘I guarantee that I will do my absolute best to achieve the best result we can get. I cannot guarantee actual results, nor can any ethical surgeon.’’
Be like Paine Webber: when the patient talks, the doctor listens When patients talk, listen. When they tell you what they think they want, listen. When they complain, especially if you have been involved in their care, listen extra well. Maybe they have a point; do not dismiss their concerns. They are trying to tell us something, and sometimes their language may be nonverbal. Although reasonable doctors do not seek out problems, listening to patients often is good medicine. Let them express their feelings— good and bad—and accept them as real. If they need more than this ‘‘verbal tonic,’’ then let them know that you are willing to do what you can to help the situation and will try to come up with a good plan. As Richard Webster, MD, counseled me many years ago regarding a patient with whom I was having trouble: ‘‘Son, get to know her very well over the next few weeks. And listen to her.’’ It is wise to keep your happy patients close but your less-than-thrilled patients closer. Listen also to those around you, such as your staff. During a consultation with the surgeon, patients are likely on their best behavior. Why would they not be? They may or may not exhibit the same behavior with your staff. For example, perception of the staff as ‘‘underlings,’’ especially by the ‘‘VIP’’ patient, could be revealing. If the patient smiles at you but is rude or inappropriate with the staff, then you need to be aware of this before making the final decision about proceeding with treatment. Your staff will be more empowered, you will appreciate them helping keep you safe, and everyone will be happier.
If a postoperative problem is likely fixable, then plan on doing it. If it is just 50:50, think twice If you plan to operate on a patient and there is a physical issue that you believe has a high chance of being improved, tell the patient that. Then figure out a reasonable strategy about how to make it happen. If there may be a cost to the patient, such as a facility or anesthesia fee, hopefully this has been discussed preoperatively. On the other hand, if the problem exceeds your technical skills, the patient is overly expective, or other factors collude to
263
264
Chatham
make success a toss up, you may be best served by cutting your losses, being candid with the patient, and proceeding down an alternative path. Patients may appreciate being told that you do not want to put them through another surgery that does not have a high chance of success. If they wish, you may guide them to a (trustworthy) colleague who also can offer them an opinion. You do not want to operate again and then experience de´ja vu all over again.
A little help from your friends: ask for it when needed Surgeons are human, neither infallible nor omnipotent. Although medical school and residency programs propagate the message of almost superhuman skills, endurance, and knowledge, none of us can know or be everything in all situations. When we are challenged, confused, and perplexed and are not sure of the next best step to take, consider asking for a ‘‘lifeline’’ from one of your colleagues who can lend a dispassionate ear and share perspectives, experience, and advice with you. If they can use this on ‘‘Who Wants to Be a Millionaire,’’ maybe we can, too. This is not a sign of weakness or an indication of incompetence. Rather, it demonstrates a degree of realistic maturity.
Sometimes it is the little things that count When in doubt about patients’ suitability for a surgical procedure, especially if there are emotional or psychologic factors, steer away from surgery and redirect them to a lesser therapy. Administering a nonpermanent therapy, such as Botox or injectibles filler or a noninvasive laser, does carry a low risk and gives you and your staff time to observe the patient during this process. Even limited skin care plans or facials provide a glimpse of their personality. If they are not excited about this approach, remind them that many patients really do benefit from these, and the surgeon may be willing to partially defray the cost of any future surgery for patients who are cooperative and compliant during the ‘‘noninvasive’’ period. If they are unhappy with the little things, do you really think they will be much happier with the big ones?
Be diligent the first week back to work after a surgical seminar After several days hearing about the latest and greatest surgical techniques, advanced procedures, and digital gadgets, there is often an enthusiastic, even religious, desire to jump right in. First, remember that the first week after a medical or surgical meeting can be hazardous to the health of
your patients and you. Integrating a variation of a new technique into your already sound surgical armamentarium may be a natural step, but few of us can really bring a whole new technique to the operating room based on what we heard once or twice. If a new idea is sound and performs well, time will prove its worth. All surgeons like to think of themselves as up-to-date on the latest education and skills, but everyone cannot be the first in town with ‘‘the latest.’’ Some procedures prove to be passing fads; others may even be harmful. Think of some of the gadgets you purchased but rarely used. Do not be the last to adopt new skills. Just do it wisely.
Be real Remember that all of us—physician and patient alike—came into the world helpless, naked, and uneducated. Some people are more gifted, some more intelligent, and some perhaps luckier or unlucky. We are all trying to make sense of the world, whether as a surgeon or single mom. Patients discern when the doctor is ‘‘real,’’ takes time with them, can empathize, and treats them with dignity and respect. Most patients quickly pick up on disingenuousness, pomposity, and insincerity, and every patient has a story, however small or insignificant it may seem at first. Most patients appreciate what you try to do for them, as long as they know that you are doing your best. Even when things are not perfect, most patients accept that you and they both worked together on this and the world itself is an imperfect place to begin with. If they are sad or happy or disappointed, it is OK to let them know that you share their sadness and joy and disappointment, too. Care about your patients.they are entrusting their health and appearance to you. Leon Bernard stated: ‘‘Medicine should be practiced as a form of friendship’’ [10]. Some, but not all, of your patients will even become your good friends. Be real. Enjoy them and let them see that you are a person, not just the ‘‘surgeon.’’ Always, always, always put the welfare of your patients first [11].
References [1] Kubler- Ross E, Kessler D. On grief and grieving: finding the meaning of grief through the five stages of loss. New York: Scribner; 2005. [2] Gorney M. AAFPRS Fall meeting, New Orleans (LA), September 23–25, 1999. [3] Keillor G. News from Lake Wobegon. [4] Shelley M. Frankenstein, or the modern Prometheus; 1818. [5] Honigman R, Phillips K, Castle DJ. A review of psychosocial outcomes for patients seeking
Essays on Patient Management and Elective Surgery
cosmetic surgery. Plast Reconstr Surg 2004; 113(4):1229. [6] Kolata G. When the doctor is in, but you wish he weren’t. New York Times November 30, 2005; Available at: http://www nytimes.com/2005/11/ 30/health/30patient.html. [7] Reinhardt UE. Hippocrates and the securitization of patients. JAMA 1997;277:1850–1.
[8] McLaughlin M. The second neurotic’s notebook; 1966. [9] Ochsner A. Medical wit & wisdom: Jess Brallier. Philadelphia: Running Press; 1993. [10] Leon B. Medical wit & wisdom: Jess Brallier. Philadelphia: Running Press; 1993. [11] Conley J. Concepts of ethics in medicine. Otolaryngol Head Neck Surg 1993;109:973–4.
265
FACIAL PLASTIC SURGERY CLINICS OF NORTH AMERICA Facial Plast Surg Clin N Am 16 (2008) 259–265
Essays on Patient Management and Elective Surgery Donn R. Chatham, -
-
-
MD
Essay one: The five stages of postprocedural malaise Essay two: Do physicians create their own difficult patients? The Frankenstein theory ‘‘Speed kills’’ Risky business The desired procedure Personalities Labels ‘‘Today’s special’’ Ouch! Essay three: Top ten ways to stay out of patient trouble Listen to your gut during consultations
Essay one: The five stages of postprocedural malaise The surgeon enters the procedure room with expectations and hopes that a good outcome will be achieved; however, this ideal scenario is not always achieved. It has been said that when a patient undergoes an operative procedure that ends poorly or results in a complication, that patient experiences several emotional phases in a specific order. It is helpful for the surgeon to understand these phases or stages to help the patient navigate them and reduce unexpected surgeon frustration. Much has been written about the stages of grief. The stages, as articulated by Dr. Kubler-Ross, are denial, anger, bargaining, depression, and acceptance [1]. These stages may be thought of as shock and
-
Undersell and overdeliver Talk straight to the patient preoperatively Be like Paine Webber: when the patient talks, the doctor listens If a postoperative problem is likely fixable, then plan on doing it. If it is just 50:50, think twice A little help from your friends: ask for it when needed Sometimes it is the little things that count Be diligent the first week back to work after a surgical seminar Be real References
denial followed by anger, attempts to change course, then sadness/depression, and finally acceptance of the inevitable. Do grief and postoperative unhappiness share a common chord? There is a ‘‘loss’’ that comes from an imperfect or problematic surgery. The patient began with hopes of improvement, even transformation, and maybe increased happiness. When it seems that these hopes will not be achieved, then the negative and more difficult emotions emerge. The various stages are as follows [2]. The first stage is surprise. The patient may not have anticipated that things might not go splendidly, so this was unexpected. The second stage is disappointment. If one has expects a certain outcome and it is not there, who would not feel disappointed? Expectations were not met, regardless of
Chatham Facial Plastic Surgery, 4001 Kresge Way, Suite 310, Louisville, KY 40207, USA E-mail address: [email protected] 1064-7406/08/$ – see front matter ª 2008 Elsevier Inc. All rights reserved.
facialplastic.theclinics.com
doi:10.1016/j.fsc.2007.11.019
260
Chatham
whether they were realistic. The third stage involves resentment. After all, the patient met with the surgeon and told the surgeon what he or she wanted. Is it asking too much to expect that a well-trained and qualified surgeon could deliver the end result? Plus, the patient may have spent a lot of money, taken time out of life’s schedule, experienced the anxiety of surgery, and suffered postoperative pain in the process. Now what does he or she have to show for the toil? Wouldn’t most people feel betrayed? The fourth stage involves focused anger. It may manifest as verbal criticism of the surgeon and staff or it might be quietly emotional. It may include requests—or even demands—that something else be done. The patient may insist that another procedure be performed to correct or enhance the result; however, he or she may have lost confidence in the skills of the primary surgeon. If there has been no intervention or compromise, the final stage involves retribution. Retribution may come in the form of threats that can range from legal to physical. The patient sometimes feels that only by enlisting additional allies (ie, court system) can he or she achieve satisfaction. These patients should not be taken lightly. Clearly, it is easier to deal with a patient in the early stages of grief rather than the extreme part of the last stage. By anticipating these stages, it may be possible for the surgeon to build on the doctor-patient relationship that hopefully was positive at the time of the surgery. In my opinion, this relationship begins by listening to the patient and acknowledging that his or her feelings are legitimate. Do not dismiss them as unreasonable, crazy, or unworthy of your time. It is not unusual to reduce the intensity of a patient’s feelings simply by listening to his or her concerns. This is not a cure-all, but it is the first step. The surgeon needs to realistically evaluate what reasonable options might help the situation, which might entail another procedure if the technical aspects are within the surgeon’s armamentaria and if the patient seems truly realistic as to what is likely and what is not. There are cases, however, in which another surgery does not seem wise. Sometimes self-disclosure and candor may require saying to a patient that the current result may be as good as one can get. In some cases, the patient may be able to lower expectations and learn to appreciate what has been improved. It is in the surgeon’s best interest and likely everyone involved—except third party payers (eg, attorneys)—that the final stages of retribution not be reached. Should this happen, however, further ongoing contact with the patient seems futile and it may be time to ‘‘circle the wagons.’’ In any event, it is prudent to recognize preoperatively that not
all procedures turn out splendidly, and the alert surgeon anticipates and empathizes with the patient’s postoperative world. Parenthetically, surgeons may experience similar feelings after a postoperative result that was less than satisfactory. Not to say that the result was ‘‘bad’’ versus ‘‘good.’’ Rather, we surgeons are typically perfectionistic, and anything less than perfect may be perceived as undesirable. If a patient comes back with a less-than-wonderful result, it sometimes catches us off guard and we are surprised. Conversely, we may think that a result is fine, but the patient who seemed so pleasant, compliant, and reasonable preoperatively currently is behaving like a lover scorned, which this can be very surprising. Naturally, we are disappointed, perhaps in our technique, in what we did not do, or even in the behavior of the patient. This disappointment can lead to resentment toward the source of this aggravation. What doctor wants to spend time during a busy and challenging day listening to a patient whining or griping? It is understandable that negative feelings toward the patient develop. If the patient becomes truly adversarial, the surgeon likely will become defensive and harbor feelings of retribution, especially if the conflict escalates. All this seems to indicate that we all are people, whether highly trained specialty surgeons or ordinary lay people looking for a little help, and as human beings, we sometimes have to deal with disappointment and frustration. With respect to Garrison Keillor’s Lake Wobegon [3], ‘‘Where all the women are strong, the men good looking, and all the children above average,’’ few of us practice in a world in which surgical results are exemplary, all the patients look marvelous postoperatively, and patients shower us with effusive praise. The real world is usually just fine, but be prepared for the times that it is less so.
Essay two: Do physicians create their own difficult patients? The Frankenstein theory In Mary Shelley’s classic [4], Dr. Victor Frankenstein became obsessed with creating his version of life, hoping to become a god of a new race of man. Unfortunately, his genius spawned a nightmare as the new creature confronted the good doctor, consumed with feelings first of confusion, then rejection, then anger, and finally wanted revenge for what he was made into. Clearly, the doctor bore responsibility for the ‘‘creature’s’’ state. Is there an analogy to modern plastic surgeons and the disgruntled, unhappy, and difficult patients of our practices? Although most postoperative plastic surgery patients who undergo either cosmetic or
Essays on Patient Management and Elective Surgery
reconstructive procedures fare well and report satisfaction with their experience, clearly there are those who do not [5]. Who is to blame? The postmortem examination can reveal several factors, which have been discussed in other articles in this issue, such as (1) unrealistic expectations by the patient, (2) a lessthan-good surgical performance by the surgeon, (3) factors such as poor healing and poor patient compliance, (4) an actual complication as a result of the surgery, and (5) a malcontent reprobate patient who did not appreciate the benefits he or she received. There are situations in which the apparently benign, compliant, preoperative patient morphs into the nasty noncompliant patient from hell after surgery and there seems to be no rational explanation. What of the Dr. Frankenstein factor? Sometimes the application of science can lead to unintended consequences. Plastic surgeons are not ‘‘mad scientists’’ in search of immortality, but avoiding the fate of good Dr. Frankenstein would be a desirable goal with each patient we operate on. Do we sometimes bring on our own misery? If so, how so? A survey performed by the American Academy of Facial Plastic and Reconstructive Surgery several years ago asked the question ‘‘What was the primary reason for postoperative patient unhappiness?’’ The results may surprise you. Postoperative complications were listed as the primary factor only 4% of the time. Negligence was listed at only 5%. Poor patient selection was listed 6% of the time. One would think that a poor surgical result was likely the biggest reason, right? No, poor surgical results were listed in 14% of cases. That finding leaves unrealistic patient expectations, right? In 17% of cases, patient expectations were the primary culprit. The single most common reason listed for unhappiness in postoperative patients was lack of physician rapport. Coming in at 51%, finding clearly outweighed all the other factors put together. How is it possible that patients actually proceeded with surgery if there was poor rapport with the surgeon to begin with? Did the rapport fade away later? Was a less-than-satisfactory result the catalyst that sparked the loss of relationship? An article in the New York Times with the headline ‘‘When the doctor is in, but you wish he weren’t’’ [6] discussed a growing problem seen in modern medicine: the difficult doctor. Surveys revealed opinions such as this: ‘‘Patients say problems come in many guises. The arrogant or dismissive doctor. The impatient doctor with his hand on the doorknob. The patronizing doctor. Or, as one young woman experienced, the doctor who is callous and judgmental.’’ There are other
factors that also seem to reside more in the realm of the surgeon than with the patient.
‘‘Speed kills’’ This old adage is certainly true in our specialty. I do not mean speed in the operating room; I mean speed in the consultation room. After having the same conversation with many patients over a period of time, the prospect of sitting in a room with a novice patient discussing the same old material for the umpteenth time gets old. Answering a seemingly endless stream of questions and repeating the same old quotes time and again does get tedious. How else can a surgeon make an informed decision about this new particular patient without spending time and looking the patient in the eye while asking the most pertinent questions? Even with adequate time and preparation, it is not always easy to accurately evaluate the motivation and expectations of all people, much less establish a good healthy rapport with them. Trying to do so in 10 minutes seems foolish.
Risky business What about the patient who seems marginal but not really inappropriate or risky? The more experience we get as surgeons, the better our perception of taking on riskier cases. After all, our capabilities and skills are legendary, are they not? The temptation is to take on any reasonable request, which is how we make a living, not shy away from tough cases. Perhaps this bravado is one of the reasons that physician pilots have a reputation as ‘‘dangerous docs,’’ sometimes attempting to overcome the plane and nature itself by force of will. Dr. Frankenstein overestimated his abilities. Sometimes we do as well.
The desired procedure Another situation that all surgeons encounter involves a patient who seeks one procedure but has an even more obvious problem in the eyes of the surgeon or the staff. It takes considerable discernment to not bring up chin implant surgery to the patient who has asked you to help her with the bump on her nose. We are in the beauty business, so what is wrong with telling Mrs. Smith that although you agree that she does need her eyelids rejuvenated, she also needs a facelift and skin resurfacing? Many patients have complained that their surgeon did not really want to listen to what they wanted but instead was ready to tell them what the he or she wanted to do. Sometimes this strategy works fine; sometimes it can backfire badly. So keep the patient’s ‘‘main thing’’ the real ‘‘main thing.’’
261
262
Chatham
Personalities There are warning signs that even the least transparent patients may offer up. When preoperative patients praise you and denigrate a previous surgeon, bemoaning their fate of not finding you the first time, better get those antennae up. When they express anger at the previous surgeon, especially in the face of little evidence that any wrongdoing was committed, you are playing with fire. When patients state that they have a cadre of friends waiting to beeline to your office if the results are good, be skeptical. When patients consider themselves to be royalty or at least VIP-blooded, not only do they want their preoperative special needs met but also their postoperative expectations may be unattainable. Other warning signs exist, and willingly taking on these patients may qualify as extreme risk-taking behavior. At times this may be living life on the edge. And, sadly, from time to time, a surgeon pays with his life for the decision to operate on a patient who later targeted his benefactor.
Labels How we view patients is usually done in a dispassionate and healthy perspective. Are we guilty at times of denigrating the person with unhealthy labels? Consider the diagnosis of one plastic surgeon after evaluating a female patient who presented for possible cosmetic surgery: ‘‘.she was no beauty to begin with but now she exhibited the typical ‘turkey neck’ and her eyelids have become crepey and wrinkled, giving an untidy and withered appearance.’’ Patients who present for cosmetic procedures already know they possess a less-than-perfect feature. It seems cold-hearted to label them with terms that are at best insensitive and at worst disparaging. If a patient discovered either written or overheard words later, who could blame him or her for feeling angry and demeaned?
‘‘Today’s special’’ Surgeons are in the unique position of recommending a procedure/surgery and performing it; thus, we benefit financially. We also can benefit from the sale of consumable home products and supplements and the use of certain devices and injectibles. Doctors also practice in an era in which we are required at educational meetings and in publications to disclose whether we have financial ties to companies, devices, or drugs that we recommend. Although most doctors would agree that we should not make treatment decisions influenced by our relationships with a device or products (eg, a laser) or our ‘‘consultation’’ relationship to a company that markets a product or prescribe anything for reasons
other than efficacy, the lines of decision making can become blurred. Consider this quote: ‘‘Patients can be viewed as biological structures that yield future net cash flows’’ [7].
Ouch! The good life Do we do ourselves disfavor by sometimes living a life of blatant affluence? At the risk of fomenting controversy, I will just ask the question. Many people—in and out of the medical field—reap the fruits of their labors, and what is wrong with that? Driving a nice car, building a large house, and living the good life are all part of a surgeon’s typical life and any financially successful person’s life, aren’t they? There is nothing wrong with perks, but sometimes the public accoutrements reinforce the stereotype of the profiteering surgeon who benefits from the maladies of the less fortunate. Many surgeons take care of patients pro bono, waive fees, wipe out debt, accept Medicaid, donate their time and services, and travel to foreign lands (eg, Face-to-Face program, including the domestic violence program). These are wonderful decisions that demonstrate to all the benevolence of our kind. Sometimes, however, we seem to shoot ourselves in our public relations foot. I once read of a famous plastic surgeon who was featured in the society pages of a media publication. His house was grand, his collection of automobiles was impressive, and his wine cellar was second to none. He was quoted as saying that he has cigars and wine so expensive that he could pay for the college tuition of several students with their worth. This statement begged the question by some readers: ‘‘Why don’t you, doc?’’ It is not up to me or the public to decide whether he should part with a couple of cigars and a bottle of wine and send an unfortunate kid to school, but this kind of publicity seems to fan the fires of the class warfare proponents. Perhaps a more realistic image might be this: ‘‘My doctor is nice; every time I see him, I’m ashamed of what I think of doctors in general’’ [8]. I believe that most physicians entered medicine with altruistic reasons and, even after years of service, we welcome the opportunity and privilege of helping others. We need to make a living, however. There are not many Albert Schweitzers or Mother Teresas. Most of the time our judgment is sound and our priorities remain in healthy directions, as imperfect as we may be. I believe that not many of us are destined to mimic Dr. Frankenstein, however, motivated solely by self-importance and selfish grandeur. There are times when the application of science can lead to unintended consequences. Avoiding the fate of good Dr. Frankenstein would
Essays on Patient Management and Elective Surgery
be a desirable goal with patients who entrust us with their health and place their faces in our hands.
Essay three: Top ten ways to stay out of patient trouble Listen to your gut during consultations When patients present for consultation, it is easy to focus on things such as their facial anatomy, their requests for surgery, and even the income it can bring. Surgeons want ‘‘good candidates for surgery,’’ and we do not really want to disqualify potential patients if we do not have to. Some patients are not really suited for what they might be asking, however, and it is in the interest of all not to proceed at that time. There may not be a solid psychologic or medical reason not to proceed but rather a sense of unease or vague discomfort with that patient. Listen to this voice and heed its call. We get little training in intuition, which is not taught in medical school. It is taught by life itself. A second consultation may clarify this feeling. Alton Ochsner, MD, the famous New Orleans surgeon, once said: ‘‘All medicine is judgment. I can bring anybody in off the street and teach him how to cut and sew in three months. It is knowing when to operate and when not to operate that matters’’ [9]. Better to listen early than to say to yourself after a problem: ‘‘There was something that told me she/he may not be a good one to operate on.’’ Rarely will you regret the decision not to operate on a particular patient.
Undersell and overdeliver Some patients come to a surgeon with high hopes and expectations. Even realistic patients want ‘‘good results’’ and deserve ones that are performed safely and carefully. Although surgeons want to encourage patients and help them proceed to scheduling, we do not want to present an overly rosy picture or ignore the reality of surgery and its risks and imponderables. By emphasizing modest results and delivering better than expected ones, the likelihood of patients being satisfied increases. Although some patients may not schedule with a surgeon because the procedure was ‘‘underpromoted,’’ the ones who do will likely be pleased.
Talk straight to the patient preoperatively Do not shy away from dealing with possible realities. The old adage that ‘‘information given preoperatively is informed consent; delivered postoperatively it is an excuse’’ is still true. Few of us want to discuss possible complications or problems or even hear about them, and the management of less-than-perfect outcomes fits into this category.
What happens if a reoperative procedure is required? Who pays? Is the procedure not ‘‘guaranteed,’’ like so many goods sold in stores today? What if the patient is simply not ‘‘fully satisfied’’? Occasionally I have had to say to preoperative assertive patients: ‘‘I guarantee that I will do my absolute best to achieve the best result we can get. I cannot guarantee actual results, nor can any ethical surgeon.’’
Be like Paine Webber: when the patient talks, the doctor listens When patients talk, listen. When they tell you what they think they want, listen. When they complain, especially if you have been involved in their care, listen extra well. Maybe they have a point; do not dismiss their concerns. They are trying to tell us something, and sometimes their language may be nonverbal. Although reasonable doctors do not seek out problems, listening to patients often is good medicine. Let them express their feelings— good and bad—and accept them as real. If they need more than this ‘‘verbal tonic,’’ then let them know that you are willing to do what you can to help the situation and will try to come up with a good plan. As Richard Webster, MD, counseled me many years ago regarding a patient with whom I was having trouble: ‘‘Son, get to know her very well over the next few weeks. And listen to her.’’ It is wise to keep your happy patients close but your less-than-thrilled patients closer. Listen also to those around you, such as your staff. During a consultation with the surgeon, patients are likely on their best behavior. Why would they not be? They may or may not exhibit the same behavior with your staff. For example, perception of the staff as ‘‘underlings,’’ especially by the ‘‘VIP’’ patient, could be revealing. If the patient smiles at you but is rude or inappropriate with the staff, then you need to be aware of this before making the final decision about proceeding with treatment. Your staff will be more empowered, you will appreciate them helping keep you safe, and everyone will be happier.
If a postoperative problem is likely fixable, then plan on doing it. If it is just 50:50, think twice If you plan to operate on a patient and there is a physical issue that you believe has a high chance of being improved, tell the patient that. Then figure out a reasonable strategy about how to make it happen. If there may be a cost to the patient, such as a facility or anesthesia fee, hopefully this has been discussed preoperatively. On the other hand, if the problem exceeds your technical skills, the patient is overly expective, or other factors collude to
263
264
Chatham
make success a toss up, you may be best served by cutting your losses, being candid with the patient, and proceeding down an alternative path. Patients may appreciate being told that you do not want to put them through another surgery that does not have a high chance of success. If they wish, you may guide them to a (trustworthy) colleague who also can offer them an opinion. You do not want to operate again and then experience de´ja vu all over again.
A little help from your friends: ask for it when needed Surgeons are human, neither infallible nor omnipotent. Although medical school and residency programs propagate the message of almost superhuman skills, endurance, and knowledge, none of us can know or be everything in all situations. When we are challenged, confused, and perplexed and are not sure of the next best step to take, consider asking for a ‘‘lifeline’’ from one of your colleagues who can lend a dispassionate ear and share perspectives, experience, and advice with you. If they can use this on ‘‘Who Wants to Be a Millionaire,’’ maybe we can, too. This is not a sign of weakness or an indication of incompetence. Rather, it demonstrates a degree of realistic maturity.
Sometimes it is the little things that count When in doubt about patients’ suitability for a surgical procedure, especially if there are emotional or psychologic factors, steer away from surgery and redirect them to a lesser therapy. Administering a nonpermanent therapy, such as Botox or injectibles filler or a noninvasive laser, does carry a low risk and gives you and your staff time to observe the patient during this process. Even limited skin care plans or facials provide a glimpse of their personality. If they are not excited about this approach, remind them that many patients really do benefit from these, and the surgeon may be willing to partially defray the cost of any future surgery for patients who are cooperative and compliant during the ‘‘noninvasive’’ period. If they are unhappy with the little things, do you really think they will be much happier with the big ones?
Be diligent the first week back to work after a surgical seminar After several days hearing about the latest and greatest surgical techniques, advanced procedures, and digital gadgets, there is often an enthusiastic, even religious, desire to jump right in. First, remember that the first week after a medical or surgical meeting can be hazardous to the health of
your patients and you. Integrating a variation of a new technique into your already sound surgical armamentarium may be a natural step, but few of us can really bring a whole new technique to the operating room based on what we heard once or twice. If a new idea is sound and performs well, time will prove its worth. All surgeons like to think of themselves as up-to-date on the latest education and skills, but everyone cannot be the first in town with ‘‘the latest.’’ Some procedures prove to be passing fads; others may even be harmful. Think of some of the gadgets you purchased but rarely used. Do not be the last to adopt new skills. Just do it wisely.
Be real Remember that all of us—physician and patient alike—came into the world helpless, naked, and uneducated. Some people are more gifted, some more intelligent, and some perhaps luckier or unlucky. We are all trying to make sense of the world, whether as a surgeon or single mom. Patients discern when the doctor is ‘‘real,’’ takes time with them, can empathize, and treats them with dignity and respect. Most patients quickly pick up on disingenuousness, pomposity, and insincerity, and every patient has a story, however small or insignificant it may seem at first. Most patients appreciate what you try to do for them, as long as they know that you are doing your best. Even when things are not perfect, most patients accept that you and they both worked together on this and the world itself is an imperfect place to begin with. If they are sad or happy or disappointed, it is OK to let them know that you share their sadness and joy and disappointment, too. Care about your patients.they are entrusting their health and appearance to you. Leon Bernard stated: ‘‘Medicine should be practiced as a form of friendship’’ [10]. Some, but not all, of your patients will even become your good friends. Be real. Enjoy them and let them see that you are a person, not just the ‘‘surgeon.’’ Always, always, always put the welfare of your patients first [11].
References [1] Kubler- Ross E, Kessler D. On grief and grieving: finding the meaning of grief through the five stages of loss. New York: Scribner; 2005. [2] Gorney M. AAFPRS Fall meeting, New Orleans (LA), September 23–25, 1999. [3] Keillor G. News from Lake Wobegon. [4] Shelley M. Frankenstein, or the modern Prometheus; 1818. [5] Honigman R, Phillips K, Castle DJ. A review of psychosocial outcomes for patients seeking
Essays on Patient Management and Elective Surgery
cosmetic surgery. Plast Reconstr Surg 2004; 113(4):1229. [6] Kolata G. When the doctor is in, but you wish he weren’t. New York Times November 30, 2005; Available at: http://www nytimes.com/2005/11/ 30/health/30patient.html. [7] Reinhardt UE. Hippocrates and the securitization of patients. JAMA 1997;277:1850–1.
[8] McLaughlin M. The second neurotic’s notebook; 1966. [9] Ochsner A. Medical wit & wisdom: Jess Brallier. Philadelphia: Running Press; 1993. [10] Leon B. Medical wit & wisdom: Jess Brallier. Philadelphia: Running Press; 1993. [11] Conley J. Concepts of ethics in medicine. Otolaryngol Head Neck Surg 1993;109:973–4.
265