Recognition of the patient unsuitable for aesthetic surgery.

Mark Gorney, MD, is a senior consultant at The Doctors Company, a physician-owned medical malpractice carrier in Napa, CA. T here are definable risk-benefit ratios in every surgical procedure, and assessment of a patient's risk-benefit is a particularly important and complex responsibility of the aesthetic surgeon. If someone seeks an aesthetic operation and the surgeon carefully determines that everything about the patient's circumstances warrants the procedure and that the patient is properly motivated and understands the risks, a positive risk/benefit ratio then exists. There is a high probability that the end result will be successful. On the other hand, if the surgeon determines that the patient does not meet either the physical or psychological criteria for the procedure , or if there is simply a " gut feeling " that says, " No, " then the safest course is to decline treatment. If the physician proceeds with surgery regardless of indications to the contrary, no matter the quality of the final result in the surgeon's eyes, the situation is likely to produce an unhappy, troublesome patient. 1 There is little disagreement between aesthetic surgeons and mental health professionals that patients who exhibit even mild signs of a variety of psychiatric disorders are dubious candidates for aesthetic surgery. Unfortunately, most of those patients appear in the consultation suite in various " shades of gray " without labels on their lapels. Many surgeons, after their arduous climb to clinical excellence, tend to be focused more intensely on maintaining their surgical skills and knowledge than on the variable human equations that motivate their patients. Thus they often fail to distinguish between those who will be ecstatic over their surgical results and those who will prove to be unhappy regardless of the excellence of the improvement, a dilemma that can lead to serious consequences for the surgeon. Aesthetic surgeons expose themselves to risks that no other practicing physician assumes. They are not treating sick or injured patients to make them well, but are treating generally healthy people by making them temporarily unwell to ultimately make them feel better. This situation becomes even more complex when one realizes that the degree of improvement achieved, and the inevitable effect that the change has on the patient's self-image, is only in the eye of the beholder. Patient and surgeon may perceive the final result entirely differently. Regrettably, most training programs pay scant attention to the dilemma of …