Cosmetic Medicine: The Unhappy Patient

How 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 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