The Dissatisfied Patient

Robert M. Goldwyn

A dissatisfied patient is an unfortunate, stressful reality that can be prevented only by retiring from practice. Because this is an impractical alternative, surgeons must seek more practical and fulfilling ways to manage an unhappy patient after surgery. Although uncommon, an unsatisfied patient has an enormous negative emotional impact. It is thus important to address the management of dissatisfied patients in a discussion of unfavorable results.1

Background

Physicians seek to help others and to obtain their approbation. It is terribly distressing to have to deal with a person one has not only failed to help, but possibly has made worse; who, instead of being grateful, is hostile; and who, instead of applauding the surgeon’s motives and talents, openly accuses him or her of greed and incompetence and may actually seek legal redress.

A plastic surgical residency, like most other educational experiences, does not usually equip surgeons to manage the unpleasant side of the profession. Residents only address the results of somebody else’s efforts, and even when they advance to having their own patients, they are looking forward to the time when the rotation ends and they can begin their own practice. However, as practicing professionals, surgeons are ultimately responsible for results.

Plastic surgeons often practice in high population areas and are usually unknown to the patient before the initial consultation, have only brief contact with the patient, and project an image of wealth. Statistically, most plastic surgeons are at the upper end of the socioeconomic ladder and are portrayed by the media as delighting in displaying their wealth as well as their talents.

The average patient seeking aesthetic surgery comes with the belief that perfection is just around the corner. Some surgeons within the specialty, coupled with the media, have reinforced this false reality. Although it is true that most patients will be satisfied and that the surgical results will be exemplary, this obviously is not true for every patient and every outcome.

The Patient

As mentioned, some patients arrive with inflated expectations and unrealistic beliefs of the prowess of the plastic surgeon. However, many come distrustful of medicine in general and of any doctor in particular. A few patients are openly hostile and have the attitude “show me what you can do.” Unlike when I first began practice, patients today pointedly ask about the surgeon’s training, experience, capability, and even previous malpractice suits. The latter information is available online in many states.

Many patients have been referred by primary physicians whose incomes are generally less than those of plastic surgeons, especially those doing a preponderance of aesthetic operations. If something does go wrong, the family physician may not be the most understanding or helpful because of his or her resentment about the disparity in the financial rewards or personal views about aesthetic surgery in general.

Why Is the Patient Dissatisfied?

The first task of the surgeon is to determine why the patient is unhappy. Typically the patient allows no ambiguity by voicing a strong, unequivocal statement of the complaint, but if this is not forthcoming, the surgeon should be alert to veiled discontent—a sullenness, an irritability, or some form of passive-aggressive behavior, such as the patient not keeping appointments or not paying the bill if payment expectations were not clearly outlined before the operation. In some respects, it seems easier to let the patient leave the office, content to avoid the confrontation. Sooner or later, however, the unpleasantness will appear and must be faced. The surgeon must not become so unreceptive that the patient’s resentment festers and reaches the proportions of a lethal abscess. Before this occurs, a helpful comment might be, “You don’t seem too happy today. What is troubling you?”

Some patients seem more unhappy than they prove to be. Once they have expressed their concerns, sometimes after having been asked, they may respond more positively than anticipated. This becomes a good foundation on which to build the ensuing discussion and management. For many patients, dissatisfaction disappears with reassurance that circumstances are justified. For example, someone who is concerned about swelling 2 weeks after blepharoplasty can be told that the swelling will subside as healing progresses over the next several weeks or months. A patient may worry about the bulkiness of a recently turned flap. Here, too, reassurance about the progressive flattening will be comforting, particularly because it is true. Surgeons must keep in mind that one never reassures a patient if reality dictates otherwise.

Occasionally, postoperative unhappiness centers on minimal or nonexistent factors. In this situation, the surgeon must determine “why this now?” Is the person depressed and feeling guilty about having an elective operation or about something else? Has there been a recent loss, such as a divorce or death? I had a 35-year-old married woman as a patient who had a very good result after a rhinoplasty and chin implant but seemed depressed a few weeks later. She then told me her girlfriend next door had “kept away” and finally confessed to my patient that she feared rejection because she thought that my patient, now better looking, would need her less. Occasionally the culprit in postoperative depression of a mild sort is a primary care physician, who may have made a comment such as, “You went through all this to look like that?”—perhaps because the patient did not consult him or her about the surgery or because of resentment of what the physician considers an excessive fee for something that is not life-threatening.

Several patients have revealed after aesthetic surgery that female friends have rejected them because they believe that the patient is now a threat to them because their spouse might find the patient more attractive. A more insidious situation is a spouse or lover who may have enjoyed the personal dominance that resulted from the patient’s feelings of inferiority about a disliked feature. After surgical correction, the partner may become less secure about the leverage he or she formerly possessed. For example, after a breast reconstruction, a patient left her husband who was having affairs because he thought that, with her deformity, she would be lucky to have him and was not in a position to object to his other activities. One cannot save a marriage through plastic surgery, but sometimes the procedure may prompt a divorce.

A patient who complains legitimately about an undesirable result, for example, infection, asymmetry, or bad scarring, deserves prompt, appropriate attention. A valid complaint merits respect and empathy. A patient who has had aesthetic surgery may have sought it against the advice of family, friends, and other physicians and may have paid a large fee. When something goes wrong, he or she may feel foolish, ashamed, guilty, and, not unexpectedly, angry. The patient may believe that this complication is divine recompense for vanity that led him or her to risking his or her health for something “frivolous” that now has become a distinct liability.

Mismanaging a Dissatisfied Patient

The following comments from my patients emphasize the importance of properly managing dissatisfaction.

“He [another plastic surgeon] always tries to minimize the problem. He hasn’t really been honest with me. I don’t want to go back to him even though he said he would do it over for nothing. I don’t trust him. Suppose he makes a mistake again. But if I go to someone else, it will cost a lot of money and I can’t afford it. I already paid him $8,000 and for what [facelift]?”

“I am bringing my wife here to see you for a second opinion. It would have helped if Dr. [–] had suggested it. He never would. His ego could fill a ballroom.”

“He expects me to like him after all I have been through. He is lucky that I won’t sue him and I really might. I have trouble enough seeing him for this hole in my face [concavity after liposuction]. He avoids me like the plague. Maybe an attorney can get to him.”

“He was there for the money but he is not there for me now. All I get to talk to is his nurse [secretary]. He really doesn’t give a damn.”

“If I really thought this would have happened, I wouldn’t have had it done. Every time I see her, she tries to talk me into thinking that it [noticeable ectropion] will go away with time. It has already been 10 months. She won’t admit that she goofed. I can’t get a word in edgewise with her.”

“I thought that with your reputation, this wouldn’t have happened.”

“My boyfriend hasn’t come near me since the operation. I really can’t blame him. This big hole [skin loss after abdominoplasty] would disgust me, too.”

Aesthetic patients generally are well informed, often have sought more than one consultation, and, even though they have been informed about the possibility of a complication, have not been prepared emotionally to accept it.

A complication is even harder to accept if the patient went to a surgeon with a well-known reputation. However, regardless of who the surgeon is or how long he or she has been in practice, things can go wrong; the mighty also fail and fall.