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Tuesday
Nov142006

Cosmetic Medicine: The Unhappy Patient

4Untitled-1.jpgHow to ask the patient to stop seeing you.

 
I shouldn't have even said "unhappy patient." I should have said the forever unsatisfied patient. Thankfully this is a very infrequent situation in our practice, but it happens every once in a while. And it leaves such a mark, that I thought I'd ask how other physicians handle these scenarios in their own practice.

Last year I saw a patient (56 year old woman) and treated her with a little Botox between her brows and some Restylane in her nasolabial folds and the lines above her lip. She came back to see me 2 weeks later and fell into tears in my office. In fact, I was moved to tears since it truly seemed like I had ruined her life (there's where I should have seen the first red flag, but I missed it). She felt like she had all sorts of new wrinkles, her brows had fallen, etc. Unfortunately (and let this be a lesson that some of you might learn from my mistake) I hadn't taken "before" photos of her. And that was unusual since I really do take pictures of almost everything I do. Especially the first time I treat a patient. And now I absolutely do! Anyway, I couldn't see any "lowering of her lids" from the Botox. In fact, the Botox did exactly what I had expected and had informed her beforehand that it would do. I assumed she just didn't like the effect. But in terms of the Restylane, she saw all sorts of new lumps, new horizontal wrinkles and changes to her original appearance.  In her defense, I did seem some minor areas I could fix and so I did so at no charge to her. And this time I took photos. I also added some Botox to her lateral brows hoping we would see a little lift there to alleviate what she saw as "drooping."  But there was no ptosis or any of the potential complications that could occur from Botox.

She returned to see me again in another two weeks and again was still unhappy. I had ruined her "girl's weekend" in Vegas because she couldn't leave her hotel room looking so "horrible." Again more tears. But I managed to take some more photos and compare them to the ones we had taken on the last visit. Her brows were elevated a bit and her lip lines and nasolabial folds looked great. We even zoomed in to take the closest look possible. But she was not swayed.  She was convinced she still looked horrendous and that I was to blame. So now I'm starting to notice a little bit of the flag. But it's still in my peripheral vision  I really listen and try my best to understand where she's coming from, but honestly I think she looks pretty good. Course it doesn't matter what I think, I still have a dissatisfied patient sitting in front of me. But I didn't think adding any more filler or Botox was going to improve the situation. So I ask her what she thinks can be done. And she comes right back, in a very matter of fact tone, and says that she feels the most appropriate next step would be for me to perform a thread lift on her at no charge. So right about now the red flag is waving frantically in front of my face....hopefully hiding the look of shock.  My mind is filling with all sorts of questions...like why would she want something more invasive, more long term? And if I'm the one who has ruined her life, why does she want me to do another procedure on her? 

Right about then I realized that she wanted more procedures done, but she just didn't want to have to pay for them. So in the nicest way I knew how, I simply said that I didn't think that I was going to be able to satisfy her needs.  I was concerned that there was little, including a thread lift, that I thought I could do to meet her expectations. And I wasn't sure whether she had unrealistic expectations or if I had promised the sun, stars, and the moon. But somewhere between what she wanted and what I could deliver, there was a great divide. But knowing that all our office offers are minimally invasive or noninvasive procedures, I routinely spend a great deal of time in the initial consultation. If a patient comes in to see me and has complaints that cannot be adequately treated with the procedures I offer, then I usually refer them to one of the plastic surgeons in the area. I try hard to communicate the strengths and weaknesses of what I can do in my office verses what a surgeon can do in the OR.  So I doubt I had given her the impression that a little Botox and filler were going to make her look like she was 22 again.

And I certainly didn't think it was going to be a good idea for me to be performing any more procedures on her given she already didn't like what I had done. Did I mention she had already spoken to her attorney? I think I forgot to tell you that part of the visit. At the end of my previous visit with her, she told me that her attorney had advised her to stop payment on the check that she had originally written for her initial services. I wasn't sure if that was even legal or not, but needless to say, that put a damper on our relationship. And then when I said I didn't feel it was in either of our best interests to do the thread lift, her tearful eyes quickly changed to scowling ones and she let me have it. I asked my office manager to step into the office with me since I wanted somebody else to witness the exchange. But now she turned from a weepy patient to an angry woman who was yelling and screaming at me.  Since it quickly became apparent that we could no longer communicate in a constructive manner, I let my office manager (who is extremely proficient in all situations) try to diffuse the tension. 

Cosmetic medicine is still medicine and needs to adhere to the regulations governing any practice. But are the terms somewhat different when it comes to patient "abandonment" and how to notify a patient that you no longer wish to be their provider? What happens when a patient wants you to do something that you don't feel comfortable doing? What if it gets ugly? Please share your stories or thoughts on these situations.

To learn more about how to end the Doctor-Patient relationship and the legal aspects or ethics involved, click here

Reader Comments (17)

Patients. We love them. We hate them.

What happened to the check?
11.14 | Unregistered CommenterLockstepMD
I think everyone has horror stories of irate patients. The worst thing I ever saw was a physician who was slapped (HARD) by a patient. I've also seen a bunch of threats, cursing and abuse of the staff. On the other hand I've seen and heard patients being ridiculed and dismissed. Doctors are people. Patients are people. People aren't perfect.
11.14 | Unregistered CommenterFLRN
She stopped payment and was sent to our collections agency. That's the last I heard of the situation.
Did we see the same client? I had a client that did almost the exact same thing - "lids drooping, lips are blown up" and I did one better - I ruined her only daughter's wedding day/photos! Honestly this woman looked just like I had expected her to after her treatment. When I look back the only thing I would have done different is that I would not have injected her. We two consultations prior to her injections which were done 3 weeks before the wedding, there was not even the smallest of red flags prior to her treatment. She came back to the office crying, no family to support her because "her husband, the attorney, would not be seen in public with her" because she looked so "hideous". She came back to the office in large Jackie-O glasses and a scarf. I did take before and after pics (thankfully). She stopped complaining and still comes in for other services in the spa but I will politely refuse to do any further treatments on her. It is hard to sniff out these clients, it would be nice if we could legally have some sort of tracking system so that they come with a warning. Keep your head up and duck when a client like this comes through your door every once in a while.
11.15 | Unregistered Commenterkaren
It's the 'clingers' you really have to watch out for.
11.16 | Unregistered CommenterMaxDerm

Hi:
re: Unhappy patient- I'm FURIOUS because she costs us all $, makes patients look bad, and potentially causes docs to misread other patients.

I read the article with an analytical eye and agree she was conning you.

Re: FLRN
What a balanced attitude you have! Nice. Thank you for pointing out that as patients, we are vulnerable to being dismissed - my experience with a nightmare tummy tuck AND correction, resulting in near deformity (my belly button was left one inch above my pubic hair line after the revision), massive scarring and lymphatic drainage problem. This doc told me to go away, basically. Hey after all, he DID a revision!!!

MaxDern: I worry what you mean about "clingers." I'm a frequent flyer in your business. It stands to reason that "tweaking" will result from some procedures and visits. As a patient, I need to understand that. As a doc, so do you.
For example: My face is slightly flatter on my right side. I returned to my dermatologist today to ask her to touch up my Radiesse cheek filler because it was still looking flat. She was happy to. Is it still as well defined as my left cheek? No. But I'm not looking for perfection. I expect my complaints to be taken as I deliver them: Kindly and graciously. She gets that.

Diana

08.22 | Unregistered CommenterDiana

I was in a situation where my staff had to ask a patient to leave. this patient came to our office through spa week special and claimed the ipl made her brown spots worse. she never paid a full time service. every time would come in the office spending at least 45min in free consultations about potential treatments she never took. she got very upset when we asked her to leave and started to harasses my office and myself with phone calls to offer her more free treatments to offset her unhappiness about being thrown out of the office.
I would like to know if such difficult patients can be "red flagged" in the medical spa community?

I dont know about USA but not here in Oz. Patient confidentiality - cannot give patient identifiers to a third party for any reason.
Of course the ones that should be flagged are the habitual default payers (I'll just get my credit card from the car - I'll leave my handbag with you". Dont come back - hand bag empty - you know the ones!)
If it makes you feel better everyone gets some patients like yours. Most patients of course are very nice and reasonable folk

12.13 | Unregistered CommenterTopher

Does anyone give refunds? I had a patient, ok it partly my fault to inject her... Anyways she wanted dermal fillers for her nasolabial folds which she felt was deeper on one side. Firt time I did it, she didn't seem all that happy but then she came back the following year wanting a repeat stating that her cheeks was puffier on one side and her nasolabial fold was deeper. I don't think it was that much of a difference. I injected her (only one syringe) and she comes back 2 months later stating that her fold is deeper and she is more "puffy" and people noticed and have been asking her about it and she is too embarassed to tell anyone she had any dermal fillers. She states that people know anyways. She states that the other side looks good. Honestly, I do not see what she was seeing and even ask a staff member to come in and look at it for me and she honestly did not see what the patient was talking about. She wanted me to "dissolve" the filler then reinject her for free. I told her if she wants me to try haluronidase to dissolve it, I will but I will not inject her again. She was upset and states she will file a complaint. I think what she was probably wants is a full refund. She gave the analogy that in her line of business (nail technician), if a customer was unhappy, she would give her a refund.
What do you do in these situations? Do you ever refund for cosmetic procedures such as these? Thanks.

This sounds like a clear case of poor patient selection. Sometimes it's difficult to catch personality types the first time a patient comes to the office. Do you have a patient care coordinator or someone to can spend a bit more time with the patient asking him/her what their expectations are and getting a feel for the patient's personality type before the procedure? It's also very important to notice a patient's demeanor when they come in. Are they going through a divorce or another difficult time in their life? Are they mean to your staff? Were they unhappy with the last few Physicians they went to? I used to think that the people unhappy with the other doctors would absolutely love my husband's skills because the other doctors were not as good. Isn't that funny? Now I know to be very cautious!

When my husband and I first started our own business (he used to work for a hospital) I made the mistake of not asking the right questions and I let two individuals move forward with procedures. We realized after we did the procedures, they were the wrong candidates and unfortunately I didn't spend enough time with them in the beginning to come to this conclusion ahead of time. With one, we did a surgery re-do and a few months of free aftercare and lymphatic massages. The other we gave her money back because we couldn't manage her expectations with another surgery. Also, our lawyer drafted a letter basically stating that in order to collect her money back, she would be unable to talk badly of our practice either verbally or through the internet. Come to find out she went to another Surgeon who accepted her money and he had the same problem!

So long story short, cut your losses and give the money back. If you keep it, she will most likely talk bad about you on every internet site she can find and cause you 20 times more money than she paid you.

06.7 | Unregistered Commenterwendyh

What are the protocol that you have implemented to deal with dissatisfied clients? Treatment was done recently, service was good but my client wants her money back. What to do?

When you have a dissatisfied client you must listen to her concerns and resolve the problem immediately. It'is cheaper to make an unhappy patient than to replace them. How about giving free or dicsounted services?

Giving refund will not hurt you. Negative reviews, may. Overall, that great satisfaction rate is the best indicator of your practice; it should also mean that you will do your best to satisfy those few dissatisfied clients. It pays off to develop a trusting relationship with your clients with both sides accepting that none is perfect.

07.24 | Unregistered CommenterP. Warner

Sometimes it is just a matter of managing your patient's expectations. If the client is reasonable, you can usually smooth the waters by negotiating another service or a discount, without giving a refund. But for irate, unrealistic or chronically unhappy patients, I'm in total agreement. Issue the refund and get them out. (nicely of course)

09.20 | Unregistered Commentershepard

There are some dissatisfied patients that have no objective reason to be satisfied. There are many expensive services that may render very poor or no results, yet frequently patients are not fully informed about the chances of disappointing outcome. If they were, most would not take the risk of wasting money. So, if patient is disappointed, we should be very objective and fair before labeling patient as someone with "unrealistic expectations".

10.6 | Unregistered Commenternate t

Sometimes it doesn't matter how clear you state the results, the patron wants to hear what they want to hear. We deal with services that are giving questionable results, not because we want to but because we are required to, and I am painfully honest with my patients...sometimes to the point of trying to talk them out of something and they still insist. Then when they don't see the result THEY envisioned, we get the "you said". Managing expectations isn't as easy as stating the obvious.

10.18 | Unregistered CommenterLS

Listen, Fix, Forget. Value the relationship above the transaction. The lifetime value of that relationship is amazing if you actually calculate it. It may be a car, a few mortgage payments, and most importantly, your reputation, which you can't buy, because it is earned.

11.8 | Unregistered Commenterbruno

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