Patient selection may well be the most important factor in building a practice as doctors market themselves to a particular prospective patient group. Additionally, patient selection is also the most important factor in mitigating your risk of dissatisfied patients and legal liability. Patients have certainly raised their expectations with regard to the outcomes that they demand, and the procedures that they seek.
At the same time, patients accept less responsibility for being accountable in their own pre-operative and post-operative care. Plastic surgeons face claims and lawsuits by patients that acknowledged known risks of various outcomes, as well as from patients that failed to comply with even the most basic aspects of their own care. The public has come to see physicians and the practice of medicine as being capable of providing perfect outcomes, and when those outcomes are not achieved, patients (and their family and friends) assume that something went wrong in the delivery of their care.
Your most effective tool in reducing these risks is appropriate and honest patient selection: choosing patients with whom you feel that you have mutually agreeable expectations, patients for whom you feel that your skill and experience can meet those expectations, and patients with which you feel that you have a good and trusting relationship. Develop a habit and routine of seeing your patients more than once to develop your relationship with that patient and to be clear about assessing their goals and expectations.
It can sometimes be difficult to decline a patient’s requests and demands, but deciding not to perform a procedure you are not comfortable with, or providing care to a patient that has unreasonable expectations or does not comply with your preoperative care instructions is far better than defending a malpractice suit later. You must also be vigilant when you are obtaining a patient’s medical history as to whether the patient has had adverse experiences that the patient blames on a former physician. And current literature on patient care and medical conventions that you can attend offer important information on how to identify patients with body dysmorphic disorder or those who will never be satisfied with a surgical outcome.
It is important to be realistic in presenting the patient with the choices of procedures, and in reaching a decision on which procedure to undergo. Patients are becoming more insistent about obtaining specific medical procedures and treatments, rather than simply asking for your help in resolving their medical issues and concerns. Internet research has made patients more familiar with various procedures and medical treatment options, but consumers do not have the medical training to diagnose their condition, take into consideration various complicating factors, and decide on the proper procedure for their condition. The internet is not the ideal forum in which to obtain reliable information. An important part of your medical care is educating your patient.
Health care providers must keep in the forefront of their minds that they, and not the patient, are responsible for the health care choices made. Part of the physician’s role is to protect and guide the patient, even if sometimes that means protecting them from themselves. It is not appropriate to grant the patient’s desires unless those requests are appropriate for their condition and achievable by your delivery of the procedure requested. In a malpractice suit, judges and juries are rarely persuaded by a defense that the patient insisted on a procedure and signed all of the consent forms documenting the potential risks. Patients cannot “consent” to an inappropriate procedure, and the responsibility for approving the procedure belongs to the doctor, not the patient. It is the physician’s obligation to suggest an appropriate procedure or to decline providing medical care to that patient.
Think of the risk profile as an inverse set of criteria: treatment is most appropriate and has the least legal risk when the patient has little concern for the desired outcome and the procedure is fairly easy for you or your staff to administer. You need to be more careful when either the amount of patient concern increases or the procedure becomes more difficult and challenging. This calculation also involves an honest evaluation of your experience and skill in performing the patient’s desired procedure. In the high risk category are patients with a high level of concern over the perceived deformity, their unrealistic expectation for the outcome of the procedure or the impact of the deformity upon their daily activities combined with the difficulty of the procedure. That last category should raise significant red flags before you perform the procedure.
The more attention that you pay in your practice to screening for appropriate patients, the less risk you expose yourself to from problem patients or in performing challenging procedures.