What do you do when a facelift goes bad? How do you handle the unhappy patients? Welcome to The Clinicians Roundtable, I am your host Dr. Larry Kaskel,joining me today is Dr. Richard Goode, Professor of Otolaryngology at Stanford School of Medicine and Chief of Otolaryngology at the Veterans Affairs Palo Alto Healthcare System and author of a recent article about dealing with the unhappy patient, which was published in the May issue of the Journal of Facial Plastic Surgery Clinics of North America.
DR. LARRY KASKEL:
Dr. Goode, welcome to the show.
DR. GOODE:
I'm happy be here.
DR. LARRY KASKEL:
Well, I guess my first question is what inspired you to write this article? I hope you don't have that many unhappy patients.
DR. GOODE:
This particular issue was put together by asking several older facial plastic surgeons to discuss this particular problem of the unhappy patient in facial plastic surgery from many aspects and how to avoid picking someone who might be a problem patient, what do you do afterwards in dealing with this, some of the medicolegal issues. So, because I've been doing this for a while, I was asked if I could contribute to this issue and, that's how I got picked that I had experienced which had been in some incidences painfully acquired.
DR. LARRY KASKEL:
Let's dive into some of those questions, you just ask and how do you damp in a patient's expectations, the patient that has a really unrealistic expectation, I mean you're not a psychologist or a psychiatrist, you are a surgeon.
DR. GOODE:
Well, some of these we brought on ourselves with a modern marketing that we do now in the field of plastic surgery and I just do facial, but the same thing is true for body surgery, appraised course, a number of other things that you will get this very, very positive or we can help you. I am special, you are special kind of thing and showing even results on your web page and that usually are spectacular, you are not going to put one.
DR. LARRY KASKEL:
Turned out not so good.
DR. GOODE:
No, I don't know if anybody who has done that. So what happens is, is that the person looks at this, sees this and comes in with very high expectations, so some of this, we have brought on ourselves but that is the way it is, so it is not going to change and that will be the way we acquire patient to used to be, we did good work, word of mouth, Dr. Goode's does a nice nose, you go see him, now it's more than that, they may just check out to web page if they like you and come see you and also word of mouth, so I don't want to minimize that. But you have that group that you develop just by the way you advertise and then you have those people whose expectations are unrealistic. The person who brings in a picture of Paris Hilton and right now, she looks something like the wicked witch and Snow White and once this transformation that is obvious, so that's not the appropriate and those people you can pick up easily. So, there is certain people that are pretty easy to say I don't like this situation that which you want, I don't think I can do, either you want to make them feel bad, you want to just say, I can't help you and try and to divert them and may be even send them to a colleague if you think that person.
DR. LARRY KASKEL:
Well, just a kind of putting the problem in someone else's lap?
DR. GOODE:
Ha, haa
DR. LARRY KASKEL:
It's kind of passing the buck.
DR. GOODE:
Well, the joke is, you send them to your worst enemy.
DR. LARRY KASKEL:
Right.
DR. GOODE:
And those patients that you don't see are good candidates at all. So, you're not giving up anything good you're right.
DR. LARRY KASKEL:
Have you been able to kind of stratify or put patients' personalities in certain types of buckets?
DR. GOODE:
Yes, I have, and these are generalities. So, that if you say, someone who is the perfectionist, obsessive, compulsive type person, what that I describe a lot of my surgeon friends, and so, I don't say that they're realistic, but some people who are, they come in and the hair is absolutely perfect and their makeup absolutely perfect and their dress is absolutely perfect and they have, you know again a real deformity, not they have some thing I can't see much or I can't help that. It is pretty easy as you said, it can't help you, but if they have something you can help, you still have to be careful because they want it perfect. So, if you miss by a little bit, but we then, you know, we then, what is reasonably thought to be, hey; that nose looks better, she looks better. That person I am saying, she but that is because most of the patients are women but it could be a man, there is not a gender issue here so it better be perfect. They are used to perfection and you know, they go and get their hair done and if Mr. Bruce doesn't do it quite right, they're unhappy.
DR. LARRY KASKEL:
I'm Dr. Larry Kaskel, and I'm talking with Dr. Richard Goode, who recently wrote an article appearing in the Journal, Facial Plastic Surgery Clinic of North America and that article is called, What do you do when a facelift goes bad?
What if you have a facelift, Dr. Goode that goes well? but is obviously perceived as bad.
DR. GOODE:
That is something that I did discuss in the article. I had that happen on more in one occasion and it is extremely difficult because the patient sees something that either such a minor deformity, if you wouldn't in fact you may not want to call it a deformity, such a minor thing, that should not going to go after it, what you need to do is, hey, look that's really not worth, the opportunity to try and fix that, that's not anything. Then you have the one, where you're really pleased with a result and they are unhappy and because what they had anticipated was slightly different that what you did, may be the thought on the facelift that be tighter may be on a nose, they thought that tip would be narrower, may be on, whatever on the neck, they thought that would be tighter on and on and so what you have to do is do everything you can to keep them happy, even though you may deep down feel that this is just inappropriate and you kind of keep them come in back talking, because one is, as time goes by, usually the plastic surgery results on the face get better, they don't get worse and so the hope is if there is a miniature damp there, that it might disappear overtime as the scar matures, so first thing is that you want to keep them happy and by that I mean that you are still interested in them, that you are going to work, we're going to work through this, we're going to try and make everything fine. I'm not going to operate on you. We'll keep you looking at you and since what we don't want is for them to walk out and get mad and then either go to other doctors certain complain or complain about to, to all of their friends and that's not good for your practice and the other thing that they can do with the internet.
DR. LARRY KASKEL:
Blog about you.
DR. GOODE:
Yeah, and in California they can make an anonymous call to the Medical Board, which has to followup on it, saying that this doctor I am worried about the skills that he did this and this and this and follow to go anywhere, they have to then become not anonymous basically they can do a number of things to make it difficult for you to be a have a happy day.
DR. LARRY KASKEL:
Historically unhappy customers of anything tell more people than happy customers.
DR. GOODE:
Absolutely, and you know you're going to have them, and what the idea is to try and eliminate as many potential ones before you do them but as a young doctor, young surgeon, you absolutely want a dome, that I'll tell you, you want a dome and you tend to over look some of these slags that you've have heard about but now there is nothing, I think we can do it and if we do have a defect that you feel you can fix, then obviously then that's even more so.
DR. LARRY KASKEL:
Dr. Goode, did you ever have the chance to see that TV show Nip/Tuck?
DR. GOODE:
I just thought one of them, I've heard a lot about it.
DR. LARRY KASKEL:
Everything you can think, what happens to these plastic surgeons including doctorates'? I'm wondering if you or one of your colleagues has had their car destroyed or some sort of really horrific thing happen?
DR. GOODE:
We've heard about these and they have happened. There're had been plastic surgeons killed by unhappy patient is quite rare. I don't know of any recent ones again, but that doesn't mean that they haven't happened or as you point out injury to either person or car or office. No I've have not had in plastic surgery that side, facial plastic surgery haven't had a death threat. I have had death threat from other patients. So, I do know what a death threat is and then I have had a patient who I did a procedure on, which also entail some nasal surgery inside the nose and afterwards he was very unhappy, thought I had definitely done him worse than he had imagined and I would find in my home, I would find on the front porch a bloody handkerchief with the note that said something like thinking of you and that was a little scary because you didn't quite know if this was a serious thing and when you talk to psychiatrist about that, again without interviewing the patient you don't know, they say for the most part these are gestures but then all of us know that they're intolerable and the gesture was certainly was, and got my attention and it continued for later time. I got little notes often with bloody handkerchiefs.
DR. LARRY KASKEL:
Can you extrapolate to the rest of medicine from plastic surgery for a moment and think what we, as let's say general practitioners, internists, primary care docs? When we have a patient and we walk in the room and we immediately have a transference or we don't like that patient or intend to go up in, we kind of sense that this is going to be a difficult patient, what is our ethical responsibility as physicians to treat that patient?
DR. GOODE:
When you got a patient who comes to see you with a medical problem and you realize that you don't like them for whatever reason, that they just start not your kind of person. You are placed in this situation where you are a physician, you have this abandonment problem, you know when once come in, have you accepted them as a patient but you can't tell them, you know, I think someone else would be better for your problem. You can do the same thing I do with the static surgery. I don't think, I can help you and see if you can not take them on as a patient, but here again you may when you are starting out, want to build your practice and if turn in but in a way. But you're trying to do it nicely and not imply that you don't like them, when you have the people as HIV folks or people with something like that, that you may be do not want to deal with, that is a different problem because they may say well, I'm being discriminated against and I suppose you can have it with minorities too, if you are not careful that they'll say he doesn't like this particular race, because he won't take him and I can see how you get a problem with that. So, you have to be careful but I think if you get that vibe and whatever it is, and sometimes that is your staff that will tell you this, because when they come to see you they are just oh!! everything is wonderful. Ho, doctor, I've heard so much about you and then talk to your front desk person or the nurse, they say ho, this guy was a really problem out there. Oh he was raising a heck, fussing at everybody insulted Jenny. So, I think that you need to check and at the point you hear of that I think you try and say again, here we go, who you want to send him to? You don't want to send me your partner because your partner is your partner. So and they want to come to you, it is difficult. But I think having been doing this for a while I would try and disassociate myself from them.
DR. LARRY KASKEL:
Dr. Richard Goode, of Stanford School of Medicine, thank very much for talking with me today.
DR. GOODE:
Thank you very much.
DR. LARRY KASKEL:
I am Dr. Larry Kaskel and you have been listening to the Clinicians Roundtable on ReachMD, to comment or listen to our whole library of on demand podcasts, please visit us at reachmd.com
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