Plastic surgery patients may be prone to lawsuits
They tend to have personality disorders, need help
This one may go in the "yeah, we could have guessed that" file, but new research suggests that patients seeking cosmetic surgery are much more prone to have personality disorders such as narcissism. The findings could have important implications for risk managers, however, because it also appears that cosmetic surgery patients with personality disorders are much more likely to sue for malpractice.
Such patients pose such an increased risk of unfounded malpractice claims that one of the researchers says cosmetic surgery patients should be screened carefully to rule out those with personality disorders. Those patients are unlikely to be satisfied with cosmetic surgery results no matter what, so it is better to avoid operating on them and instead steer them toward psychological help, says Henri Gaboriau, MD, a plastic surgeon in the department of otolaryngology/head and neck surgery, and facial plastic and reconstructive surgery at Tulane University in New Orleans.
"The doctor needs to triage the patient for personality disorders," he says. "Not everyone who crosses your door needs to have plastic surgery. We need to look at the whole patient, not just the face, the eyes, the nose. Can the patient handle the surgery, not just physically but also mentally?"
The tendency to personality disorders has a direct effect on the liability risk because it can exacerbate a risk already known to risk managers: the patient who is unhappy with the outcome of an apparently successful surgery and looking for someone to blame. Those patients can be found in nearly any medical or surgical specialty, but Gaboriau says his research indicated that plastic surgeons encounter those patients far more often.
He studied the problem with H. Devon Graham III, MD, FACS, a plastic surgeon with Ochsner Clinic and the Alton Ochsner Medical Foundation in New Orleans. They presented the findings at a meeting of the American Academy of Facial Plastic and Reconstructive Surgery in Palm Desert, CA. Their research will be published in a plastic surgery journal in the fall, but Gaboriau tells Healthcare Risk Management it should be a malpractice warning for plastic surgeons and hospital administrators.
Gaboriau says the problem occurs mostly with cosmetic surgery, not reconstructive plastic surgery. Many patients seeking cosmetic surgery are mentally disturbed, he says. "Those patients are mainly narcissistic. They’re very in love with themselves, so these people have a tendency to seek plastic surgery to reinforce that. They also can be very dependent and histrionic."
Patients also may be obsessive-compulsive, antisocial, difficult to satisfy, distrusting of authority, noncompliant, have unrealistic expectations, and have their own ideas of how the treatment should be done. Of 133 patients in the study, 71% suffered from at least one form of personality disorder. Twenty-five percent were narcissistic, 12% dependent, 10% histrionic, 9% borderline, and 4% obsessive-compulsive. Another 11% had other types of personality disorders. (See p. 84 for details on the research.)
All of those traits, especially in combination, can greatly increase the chance of being sued for malpractice, Gaboriau says. He does not advocate refusing care purely out of the fear of being sued, but he says patients with personality disorders usually are not well-served by cosmetic surgery.
Reconstructive surgery patients are another matter entirely. They can have personality disorders at the same rate as the general population, but the surgery is necessary and does not play into the patient’s misconceptions.
Look for warning signs of disturbed patients
Surgeons should avoid doing cosmetic procedures on disturbed patients, Gaboriau says. The patient is not served well by cosmetic surgery if the real motivation for the procedure is a lack of self-worth and other problems related to personality disorders, he says. For the patient’s own good, it is better to refuse the cosmetic procedure and refer the patient to another professional who can provide more appropriate help.
"Plastic surgery is not a treatment for psychiatric disorders. If the patient is not going to be helped by the surgery, it’s important to say so," he says. "But you can’t just say you’re sorry and you won’t do the surgery. You need to explain that you don’t think the plastic surgery will help and explain why you think that is the case."
Under the stress of surgery, patients may exhibit difficult behavior postoperatively and conflicts with the surgeon may arise, Gaboriau says. Patients with personality disorders are especially prone to that type of difficult behavior, "which may end in litigation over what is perceived by the patient as a poor surgical outcome."
Gaboriau recommends advising plastic surgeons about the risk of malpractice lawsuits from patients with personality disorders and urging them to screen carefully for those patients. Some plastic surgeons routinely obtain a psychological assessment of patients, but he says most just rely on their own abilities to spot trouble.
Referring the patient for a psychological assessment is a good idea if the doctor feels uneasy, but Gaboriau says doctors often resist that option because the patient usually is reluctant to comply because 1) the patient may think you’re saying he or she is crazy, and 2) the fee for the psychological assessment usually must be paid by the patient. A full-scale assessment may not be practical for each patient, but a simpler inventory may be useful.
"For risk managers, I’d say there is a tremendous benefit in having a homemade questionnaire to give to patients," he says. "Ask someone in your psych department to help you devise a simple questionnaire that can alert you to someone with personality disorders, and then you promise to refer those patients on for help in that department when the plastic surgeon can’t do anything for them."
Surgeons can lower their risk substantially by watching out for common warning signs, Gaboriau says. He recommends advising plastic surgeons to take these steps:
• Read the patient’s chart closely and look for red flags. Look to see if the patient has undergone psych iatric interviews in the past and whether the patient has been on psychiatric medications. "A lot of people take Zoloft [an antidepressant], but if the patient is taking five other drugs and seeing a psychiatrist once a week, that’s different," he says.
• See if the patient communicates well. Good communication often is the key to avoiding disappointment after plastic surgery. The doctor must understand what the patient wants, and the patient must understand what is reasonable to expect. Vague complaints, such as "I want my nose done" instead of "I want the bridge reduced and reshaped," are reason to worry.
"If you’ve seen the patient a couple of times and still don’t know what they want, one of you is not communicating well," he says. "Proceed with that patient and I can almost guarantee he won’t like the results."
• Avoid patients who have been "surgeon shopping." Watch out for patients who have seen a number of surgeons seeking treatment and then end up in your office. While it is possible that the patient is just a very careful consumer who is exploring options, the patient may have been turned down by the other doctors or found some reason to be dissatisfied with each one.
• Look for previous involvement in malpractice suits. This is difficult to determine, because the surgeon does not want to blatantly ask about this topic. But if the issue arises, be wary of any patient who has been involved in previous malpractice cases. The patient may be prone to litigation.
"No one wants to operate on someone who has a record of being dissatisfied and suing," he says. "It’s difficult for a malpractice attorney to get a nose job if we know ahead of time."
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