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KEY ISSUES IN PATIENT SELECTION FOR PLASTIC SURGEON

Avoiding potential problem patients in cosmetic surgery, it's a concern many of us face on a daily basis reminding us of the importance of patient selection and informed consent. How can we minimize the number of problem patients in our practice and how can we limit the impact of those who are already in our practice?

You are listening to ReachMD, The Channel for Medical Professionals. Welcome to The Clinicians Round Table. I am your host, Dr. Michael Epstein, Board Certified Plastic Surgeon. Our guest is Dr. Peter Adamson, Professor of Otolaryngology Head and Neck Surgery and Head of Facial Plastic and Reconstructive Surgery at the University of Toronto. Dr. Adamson is recognized as an international leader in facial plastic surgery.

DR. MICHAEL EPSTEIN:

Welcome Dr. Adamson.

DR. PETER ADAMSON:

Thank you Michael. It is a pleasure to be with you.

DR. MICHAEL EPSTEIN:

So, how often are seeing this particular type of patient walk in your office?

DR. PETER ADAMSON:

Well, I think patients who require some type of psychological support or at least further diagnostic assessment before proceeding, probably would come down to 1 in 5 or 1 in 6 patients that you see for elective surgery for one reason or another.

DR. MICHAEL EPSTEIN:

That's a fairly high number. So, this is a pretty significant problem. How often does the actual thought of turning the patient away come into play when you are seeing a patient?

DR. PETER ADAMSON:

It comes into play with every patient, in fact, as we try to determine whether they are going to be a good candidate or not. So, what I like to look at in each patient I ask myself this, first of all do they have a physical complaint that is real or objective from my perspective. Is there expectation then we have to talk about this course and review their images. Is there expectation from improvement objectively possible and is it possible within your hands, that is, you don't say well I know somebody else down the street or what I saw in a textbook can get that result, can I achieve that result, that's the first thing. And then you need to say to yourself if I can achieve that specific objective result for the patient, will that give them the subjective sense of satisfaction that they are seeking because after all nobody really wants surgery. They are only willing to go through the surgical experience, which they do not wish to do, but to achieve that result, which is going to give them an improved quality of life, decrease any sense of anxiety or concern about that body part, which they are not happy with. The next thing is that are they medically a good candidate, you know, no significant heart disease, diabetes, immune diseases, etc. So just as you would for any preoperative assessment, they must pass that hurdle and then the final hurdle is, are they psychologically, you know sound and stable. Now, the reality is that everybody has certain personality characteristics, many people have, you know, mild neurosis or what have you. These kinds of individuals of course can be managed quite satisfactorily as part of everyday medicine for all of us, but we really need to be aware of those patients who have a chronic history of psychological or psychiatric issues or very deep-seated issues, which you think you cannot manage. You know most patients certainly want to speak to a psychiatrist; if they are seeing one, to confirm they are all right or sometimes a way I can translate out of having to operate on, that is to say if we are going to achieve the best result for you it's important that I know that you are a good candidate psychologically, I would like you to see a psychologist or psychiatrist to make sure that that's the situation. If they turn me down on that, then I say I am not prepared to proceed without doing that. So, again, I think that probably 5% or 10% of patients we might turn down for true physical reasons, this is particularly in revision rhinoplasty. We just aren't going to achieve much more for them or may be 5%, 10 at the very outside, depending on the given day for psychological reasons, they are not going to be a good candidate.

DR. MICHAEL EPSTEIN:

So, you would say essentially the reverse of those or if they fulfill those requirements, they would be a good candidate for surgery?

DR. PETER ADAMSON:

Yes, in some better than others, that the ideal candidate has a very specific complaint, if bothered them for a longtime, it's quite easily correctable surgically. They have a very specific psychological result to expect. I just wanted a little bit better, they are not expecting perfection. They are willing to accept a little bit of risk and assume responsibility that it is a mutual decision. It's not all the surgeon's responsibility and they are physically healthy. In a patient like that you can make a decision very quickly, and of course the other end of spectrum is the patient who has none of those ideal features about their situation.

DR. MICHAEL EPSTEIN:

Just to be clear, you are not saying an absolute contraindication would be somebody that has a psychological history.

DR. PETER ADAMSON:

No, absolutely not. Because let's face it, many, many people in society today do. So, in fact, some patients who had a psychological history, let's say in particular for example depression or may be it's an anxiety neurosis. If they have a comprehension of it, may understand where they are coming from. You know what's the 2 plus 2 equals 4 doctor, but it bugs me, then as long as you review everything with them and they understand and perhaps they have their family doctor or psychiatrist support them, they can be a great patients, but it's more the person who is not reality based or substantial personality disorder, that’s where we get into more difficult issues and we really want to try to avoid them if we can.

DR. MICHAEL EPSTEIN:

Dr. Adamson, why don't we take this opportunity to just go through a couple of examples of problem patients?

DR. PETER ADAMSON:

Sure. Well, there is a couple of interesting ones we see. One we call, and these are just terms that we put together to help us understand these people, I call it the package of pictures syndrome and this is much more with women than with men, although with men occasionally too, and they all come in with cutouts from various magazines and they show a whole host of photographs of the kinds of nose for example they like or the kind of jaw line they would like to have and also they will sometimes bring in, especially when it's an aging face surgery, they will bring in a picture of the wedding day and they will show them on their wedding dress, and I don't know why, but it's just something that seems to happen and they would like to have that kind of look. So, I take a step back and say I know you would like to have that kind of look, but your facial features are different from the people in those magazines, so I obviously all of these are of course beautiful models and we really cannot achieve that for you or I will explain that yes, we can improve your facial appearance 5, 10, or 12 years what have you with facial rejuvenation surgery, but we can't get you back to your wedding picture. Now, some people are pretty good. Once you explain things so well I understand now, as we just may ideal and I accept that and if you can just make it, you know, a little bit better here or there, that's okay with me, those patients are okay and I will pass them and we can move forward to surgery, but once in a while, the patient will keep coming back to it. They will keep taking the picture later, say well, you know, why can't you get this or what's the problem with that, and if they don't get it, then they are not going to be a candidate for surgery. Another one, that's a little bit newer, I think, out of syndrome, is something I call, the my theory syndrome, and of course, today all of our patients have wonderful access to the web, which has of course become the medical library of last resort for many people and so I am sure if anyone is listening who does this kind of work, they will chuckle when they hear this because they have all had these patients who come in and they will say, well doctor, particularly for rhinoplasty, I would like to have this or that done, you know, I know that I need a spreader graft up here, and you know, are you going to use a columellar strut or how about a vertical division of the cartilages. I read that that's good and I think that's what I need. Now, if you take a step back and again you explain to these peoples why their nose is different or they come in for example they might have said the same kinds of things, but I need a mid facelift or I want a mini facelift and not a <_____> lift. They will use all these medical and surgical terms. If you take a step back and explain to them how they are little bit different and how you do at this way and this is what they can achieve, and if they can accept all that, may seem to come around and they are just, shall we say a little misguided, they may be a candidate, but if they keep coming back to it and sort of insisting that this is what they need and wrong on these photographs, then that's an absolute contraindication for me at least to move ahead with them. So, those are perhaps the more interesting ones we see today.

DR. MICHAEL EPSTEIN:

Sure, you have been aware of those. That brings me to sort of an interesting thing that I see and actually utilize in my patients who is wondering if you utilize digital imaging to help sort of decide for whether or not these patients can be problematic in anyway?

DR. PETER ADAMSON:

The answer to that is yes and no. What I actually prefer to do is we do use digital photographs, but I actually prefer to get the photographs out and perhaps I am a bit old fashioned in this, but I know some of my colleagues still to do this too, and I use a light box and then draw on the photographs and so you can do it with a mouse or I feel I can do it nicely with a pencil, which is perhaps little bit more artistic shall we say rather than mechanical, but I think it does help. Now, that brings up you know an interesting point of conversation. There certainly are some, you know, nice studies in the literature that say that, you know, computer imaging does help the patient determine whether they are going to like a certain result or not, and I think that in general that's true, but I would offer that in my experience I am concerned about a patient who feels that they must have a specific drawing or picture that shows an exactly what they are going to look like with their jowls improved or the puffy lips removed or you know what the nose is going to look like on profile with the bump removed. I think, we all recognize that our goal is to get as close as we can to an ideal result for that patient, but no surgeon, whether it's on a computer or drawing or whatever, can say this is exactly what your result is going to be like, and I think that if a patient is unable to accept certain degree of variability, if they are not able to accept that the goal is really a good improvement to lower the bump or refine the tip or good improvement to take away that baggy look under the eyes or the saggy eyelid skin of the jowls, if they can accept that just a good improvement is okay for them, they are gonna see that really specific result, I think that is a very substantial red flag that they may be too perfectionistic, obsessive-compulsive, narcissistic, depending upon several different personality types that can lead to that, but I think that they have a much higher incidence of patient's dissatisfaction postoperatively.

DR. MICHAEL EPSTEIN:

Absolutely. Let's pretend now that we have a difficult patient. Let's say you've identified one in the office before surgery and then may we will even get into how you would manage a patient that you've sort of missed on and they become difficult, you know, they don't see eye to eye with you after surgery.

DR. PETER ADAMSON:

Yes. If I do feel that the patient is not going to be a good candidate, then there are 2 situations that may arise here. The first one is you explain everything to the patient stressing that your goal is only to use the surgery or some other medical treatment, whether it's laser or whatever you are doing, to make them better and you don't feel you can achieve a good objective result for them, they accept that and they, you know, leave happily. Or may be it is a psychological issue when you explain why you feel that because of their depression or they expect so much that you won't be able to achieve that and again they are reasonably happy. Then, there is the other one, although you are trying to tell them that you don't think they are good candidate and they keep insisting that they want to go ahead, wellI am sure you can do it doctor or I am willing to take that risk, but you, the surgeon, are feeling very uncomfortable about proceeding. These patients can consume an incredible amount of time in your office and sometimes it's very difficult to even get them out the door, so I will listen to the talk and then my approach is to say, listen I would like to review your chart, I would like to review the photographs we talked about today in our discussion, and then I would get back to you and let you know whether or not I feel we can proceed or not. In that way, I can bring that consultation to a close and then I will send them a letter by registered mail, a very nice letter, saying I have reviewed everything, but in my hands, I don't feel that I can achieve what they wish and I am not willing to proceed and that's it. I will go further. I think we have an obligation if you truly believe that it's not in their best interests to have some other surgeon do it, we all know that anybody can knock on enough doors, any patient, and they will get some surgeon to do something, but if you are really convinced that it's not in their best interest to have further surgery, then we say that and I will say, I know you may elect to see someone else and they may recommend proceeding, but this would not be my recommendation or if you do proceed and have a satisfactory result, I will be very pleased for you, but I do believe that the potential for that occurring is much less than the potential for your being dissatisfied.

DR. MICHAEL EPSTEIN:

I would like to thank our guest, Dr. Peter Adamson.

We have discussing key issues in patient selection for plastic surgeon. I am Dr. Michael Epstein. You have been listening to The Clinician Roundtable on ReachMD, The Channel for Medical Professionals. Be sure to visit our website at www.reachmd.com featuring on-demand pod casts of our entire library and thank you for listening.

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