Managing Patient Expectations with Cosmetic/Plastic Interventions
Patients and doctors often have different expectations regarding the outcome of treatment. Managing patient expectations and providing clear and accurate information about treatment and care is an essential risk management strategy for healthcare providers. The need to manage patient expectations is particularly important when patients seek elective cosmetic/plastic interventions.
Doctors specialising in providing cosmetic/plastic services need to ensure their patients have a realistic understanding of the procedure involved and the anticipated treatment outcomes. Failure to manage expectations and suboptimal communication may increase the risk of patient complaints, requests for refunds, disciplinary action and ultimately litigation.
PMP claims experience
In a review of clinically coded cases* (n=695), notified to PMP between 2014 — 2020, 16% (n=112) related to cosmetic/plastic surgery.
*Clinically coded cases: included the identification of the allegation, clinical severity, claimant type, location, contributing risk factors and any involved procedures/medications/diagnoses.
The most common cosmetic/plastic procedure types are detailed in chart 1.
Of the 112 claims, 63% identified suboptimal communications with patients as a contributing risk factor**, which impacted patient expectations and/or patient outcomes, illustrated in chart 2.
**Contributing risk factors are failures in the process of care that appear to have contributed to the patient outcome and/or to the initiation of the case, or had a significant impact on case resolution.
The following are examples from the cases where communication was a contributing factor:
- A patient complained that a surgeon was unable to offer a follow-up appointment at short notice. This was followed by an intimation from the patient that they were dissatisfied with the original surgery.
- The patient was unhappy that their surgeon was unavailable for post-operative appointments.
- Following arm lift surgery, the patient alleged that the procedure had not been successful, as there was no improved movement. The patient alleged she had not been informed that ‘no improvement’ was a potential outcome.
- A surgeon performed an upper and lower blepharoplasty. The patient was unhappy with the result and alleged the surgery had not met her expectations.
Case example: post-operative scarring
- A female patient, in her late 60s, requested a lower face lift procedure.
- This patient stated that she had consented to an “S” facelift, but that in fact, a rhytidectomy with platysmaplatsy was performed, involving fat harvesting from hips and buttocks.
- The patient was dissatisfied with the results, including the visible scarring around her ears.
- She maintained that she was not given appropriate information, and therefore had not fully consented to the procedure.
- No patient information leaflet had been provided to confirm the extent of the pre-operative discussion. In addition, the patient had not been provided with a copy of the consent form.
The outcome of the case
The surgeon apologised to the patient admitting he had not adequately explained the procedure. He recommended the patient consider steroid injections ‘to help with the scarring’. No further action was taken by the patient.
Learning points from the case
It is evident from this case that the doctor had not ensured during pre-operative discussions, that the patient had a clear understanding of the procedure she was consenting to.
- The surgeon should have had a meaningful discussion with the patient prior to the surgical procedure, ensuring the patient was fully informed of the proposed surgery, including potential risks and benefits. The patient should have been given sufficient information to ‘make an informed choice’. Without adequate information, she was unable to make a properly informed choice. This resulted in the patient being dissatisfied and upset with the final outcome of the surgery.
- Doctors should be aware of their professional obligations and the principle of informed consent. For consent to be valid:
- the patient must have the capacity to make a decision regarding the proposed surgery/treatment
- the patient must have sufficient knowledge and information on which to base a decision
- the information being provided should be in a format they understand and include:
- aims of procedure/treatment
- risks and benefits
- alternatives, which could include doing nothing, if appropriate
- an accurate description of what the procedure entails.
- the doctor should also ascertain if the patient understands the information provided and if they have any questions or concerns.
- The doctor must record a summary of the discussion in the patient’s medical record. In addition, key information should be documented on the consent form. It is important to remember that filling in a consent form is not a substitute for a meaningful dialogue tailored to the patient’s needs.
- It is important to note that consent for cosmetic interventions must only be undertaken by the doctor who will be carrying out the procedure. It must not be delegated to another healthcare professional. Please refer to para 16 of the GMC Guidance for doctors who offer cosmetic interventions.
- In this case, the patient could have been provided with a patient information leaflet. The provision of information leaflets may be an invaluable means of reinforcing a detailed discussion of the risks and benefits associated with a particular procedure. However, they should not be regarded as a substitute for such discussions. If explanatory literature is given to a patient, this should be recorded in the patient’s records, in conjunction with details of the literature given (including version numbers).
Clinicians must follow GMC guidance Decision making and consent, which states in paras 8 and 9:
“The exchange of information between doctor and patient is central to good decision making. It’s during this process that you can find out what’s important to a patient, so you can identify the information they need to make a decision.
The purpose of the dialogue is:
- to help the patient understand their role in the process, and their right to choose whether or not to have the treatment or care
- to make sure the patient has the opportunity to consider relevant information that might influence their choice between the available options
- to try and reach a shared understanding of the expectations and limitations of the available options.”
Clinicians need to be mindful of the possibility that patients may recall promises and optimistic predictions rather than discussions about risks and limitations. Therefore, the importance of informed consent and detailed record-keeping, in accordance with GMC, Good medical practice, when providing cosmetic/plastic interventions, cannot be overstated.
GMC guidance, Decision making and consent, states in para 50: “Keeping patients’ medical records up to date with key information is important for continuity of care. Keeping an accurate record of the exchange of information leading to a decision in a patient’s record will inform their future care and help you to explain and justify your decisions and actions.”
Patient educational material
Practitioners who provide cosmetic services should be careful to distinguish between marketing and educational materials, eg, patient information literature. Educational materials should offer patients objective, clear information about the risks and benefits of proposed treatments.
The Royal College of Surgeons for England, Professional Standards for Cosmetic Surgery recommends that doctors performing cosmetic surgery should:
- “Recognise and respect the varying needs of patients for information and explanation and give them the information they need, using appropriate language in a way that they can understand.
- Signpost to patients written or visual information resources that will help them make an informed decision about the procedure they are considering, as well as feel confident about their choice of surgeon and hospital.
- Encourage patients to discuss the suggested procedure with their supporters.”
Educational materials are an important component of informed consent. They can assist patients in negotiating the sometimes difficult process of formulating relevant questions and allow clinicians the opportunity to clarify and respond to patients’ concerns.
Liability exposure increases when educational materials are written in such a way that they focus, almost exclusively, on the most successful treatment outcomes, whilst glossing over or ignoring the recognised risks associated with a procedure.
Honigman R J et al, reported in a paper, A Review of Psychosocial Outcomes for Patients Seeking Cosmetic Surgery that “the majority of people seeking cosmetic surgery procedures appear psychologically healthy; however, some are not, and for these individuals cosmetic procedures may have a negative outcome, creating problems for both patient and surgeon.”
Honigman states that problems encountered by the patient can lead to requests for repeat procedures, depression, adjustment problems, social isolation, familial dysfunction, self-destructive behaviours and anger toward the surgeon and staff.
“The challenge that surgeons face is how to identify, before surgical intervention, those patients who may have a poor outcome in terms of psychological adjustment and psychosocial functioning despite a technically satisfactory result.”
Similar findings were identified in a 2019 literature review by Sarwer D, Body image, cosmetic surgery, and minimally invasive treatments. Sarwer found that studies from around the world suggested that “between 5–15% of patients who present for cosmetic procedures meet diagnostic criteria for body dysmorphic disorder (BDD)”. He highlights that “extreme body image dissatisfaction may contraindicate cosmetic procedure”.
Honigman advises that a doctor should question a patient about previous cosmetic/plastic surgery and perceived outcomes. Literature suggests that “previous surgery with which the patient was dissatisfied, is a risk factor for yet another poor outcome. One should be most concerned about people who have had numerous procedures by many practitioners, most or all of which the patient has considered unsatisfactory.”
The GMC states in Guidance for doctors who offer cosmetic interventions:
“17. If a patient requests an intervention, you must follow the guidance in Consent, including consideration of the patient’s medical history. You must ask the patient why they would like to have the intervention and the outcome they hope for, before assessing whether the intervention is appropriate and likely to meet their needs.
18. If you believe the intervention is unlikely to deliver the desired outcome or to be of overall benefit to the patient, you must discuss this with the patient and explain your reasoning. If, after discussion, you still believe the intervention will not be of benefit to the patient, you must not provide it. You should discuss other options available to the patient and respect their right to seek a second opinion.”
It is important that, before obtaining consent, the doctor ensures patients are fully informed of the fees and costs of interventions, including any additional costs for follow-up treatment, potential complications and revisions. Information provided to patients should clearly outline those costs, such as medication and dressings, which are not included in the standard fee for the intervention.
Advertising and marketing liability
Doctors who provide cosmetic services should carefully assess all prospective advertisements, signs and brochures designed to sell their services in accordance with GMC Guidance for doctors who offer cosmetic interventions paras 47-54.
When reviewing these materials, doctors and staff should ask the following questions:
- Will this advertisement attract patients who have unrealistic expectations?
- Will this advertisement require practitioners to achieve impossibly high standards of care?
- Does the language use superlatives, make unrealistic promises, urge patients to judge the results by emotional rather than clinical standards? Does the language promise or imply absolute satisfaction?
- Do advertisements make critical statements about how competitors approach a procedure/treatment being offered? Do these comments hold the practitioner to an unrealistic standard by comparison?
In addition, doctors must follow the regulatory codes and guidelines set by the Committee of Advertising Practice, Cosmetic surgery.
- Surgeons may only claim they are “qualified”, “highly qualified”, or “fully qualified” if they are on the GMC Specialist Register, related to the relevant surgical specialty. If a doctor was practising cosmetic surgery independently before 1 April 2002, they should hold a Certificate of Specialist Training (CCST) in plastic surgery or an equivalent qualification.
- Marketing material should not include claims such as “leading clinic” or “gold standard” without providing evidence to substantiate the claim.
- Marketing material should not portray procedures as “safe”, “easy” or “risk-free” because all surgery carries some element of risk, including seemingly minor interventions.
While advertising motivates a potential client to take action, for example, to buy a particular product or service, marketing strategies are generally designed to trigger initial interest and help individuals identify wants or needs. Marketing materials may also provide reassurance to a client that they have made a wise decision, thereby preventing the post-decision guilt known as ‘buyers’ remorse.’
Promises are risky
Doctors who promote themselves as cosmetic specialists must be cautious that their advertising and marketing strategies do not promise more than they can deliver. When in the market for ‘self-improvement’, some prospective patients hear only what they want to hear. For this reason, marketing strategies are often designed to promise emotional rather than physical results.
Examples of slogans that perpetuate emotional promises include:
- ‘Get the body of your dreams by swimsuit season!’
- ‘A whole new smile – a whole new outlook on life!’
- ‘Get the appearance you’ve always wanted!’
- ‘Take off years with a simple, painless procedure!’
None of these slogans offers a physical result; rather, they promise an idealised ‘happy ever after.’ This type of advertising will most likely draw in potential clients. However, it may well attract people whose vision of change is impossible for even the most talented practitioner to achieve.
Informed clinic staff
In their eagerness to contribute to the practice’s success, the staff at a cosmetic surgery clinic might inadvertently mislead patients by referring to the practitioners’ skills or past outcomes in glowing terms. This may lead to unrealistic patient expectations, regardless of the specific circumstances of individual patients. All staff should be appropriately trained to ensure they communicate the correct messaging to patients when discussing or marketing the clinic’s services.
It is clear from the PMP claims analysis and literature review that managing patient expectations and addressing unrealistic expectations is crucial in reducing the risk of claims, particularly in the cosmetic/plastic specialties.
A meaningful consent discussion, ascertaining from a patient what a ‘good outcome’ would be if the intervention took place, can help the clinician determine whether a patient’s expectations are realistic or clinically achievable.
If a patient experiences an adverse outcome following surgery, they are less likely to make a claim or complaint, alleging negligence, if a shared decision-making approach has been adopted from the outset. This approach should be clearly evidenced in the patient’s medical record. Finally, it is essential, following an adverse outcome, to investigate, explain and apologise appropriately to the patient. Please refer to the GMC’s Openness and honesty when things go wrong: The professional duty of candour.
If you receive a complaint from a patient, or a patient suffers an adverse event, please notify PMP as soon as possible, in line with the terms of your policy. PMP can assist customers in preparing an appropriate response.
Please refer to PMP risk tips: Ten Tips to Managing Patient Expectations with Cosmetic/Plastic Surgical Procedures.
If you have any queries or concerns surrounding the issues raised in this article, please do not hesitate to call the PMP medicolegal helpline. The medicolegal helpline is provided by our legal partners Clyde & Co. The helpline is open 24/7, contact details can be found on your policy documents or customer card.