Managing patient expectations

January 25, 2012

Unreasonable expectations invite disaster, but turning away a patient can cost you revenue. Where do you draw the line? Every doctor answers differently.

Let me share a real case. A 50-year-old woman who appeared 10 years younger than her age went to an urgent care facility after falling in the shower on a holiday. The internist on duty found a burst injury along her eyebrow. He was comfortable closing the wound and told her that it shouldn't scar much, although she requested a plastic surgeon.

The doctor on duty sutured the wound, and the patient left the facility. The discharge paperwork indicated that a scar would result, so she frantically searched for a local plastic surgeon. She called my office and paged on the stat line, then unloaded for 30 minutes about the doctor who promised her no scar.

When I saw her the next day, the patient said: "I haven't slept all night. Will it scar?"

"Most traumatic wounds will form a visible scar," I answered, looking at an inch-long closed wound along the margin of her eyebrow moving toward the side of the eyelid, "but I am not crazy about nylon sutures in such a wound. They can leave train tracks." The sutures were well-placed but were simple and external, leading me to infer that nothing supported the wound underneath. This is good general medicine, but it is a plastic surgery "no-no."

"The doctor used the wrong stitches? I knew it!" she said.

"Now hold on a minute. I didn't say that," I replied. "Much of what plastic surgeons do is looked at by other specialists as being excessive. To an emergency department doctor, this is a beautiful closure."

"And to you?" she asked.

"It is OK, but if you ask me whether I can offer improved scarring, the answer is, probably," I answered.

I ended up revising a portion of the wound, removing the external nylon sutures and burying some absorbable sutures underneath the portion of the wound not covered by her eyebrow. I saw no other support underneath, as I had suspected.

Who is wrong in this case? Should the internist have referred the patient to a plastic surgeon? Should I have refused to see her? Should she have just left alone what the urgent care doctor did? No one right answer exists.

Plastic surgeons who do cosmetic work are accustomed to the challenge of emotionally fragile patients who likely have been more than just attentive to their appearance over the years, and we charge such patients cash for the increased "wear and tear." PCPs can manage the actions and expectations of such patients by not promising that a wound will not form a scar, by stressing to them that a PCP is not a plastic surgeon, by telling them that plastic surgeons likely will charge them cash, and by indicating that plastic surgeons are not always immediately available.

I always tell patients I can only do my best. I constantly re-assess them for signs of having unrealistic expectations. Turning away an unreasonable patient can save you a world of headaches well worth the small loss in revenue. Be sure to carefully document what you say so that any post-procedure accusations can be contested properly.

The author practices in San Clemente, California. The Way I See It columns reflect the opinions of the authors and are independent of Medical Economics. Do you have an experience you would like to share with readers? Submit your writing for consideration to medec@advanstar.com