Commentary: Treating patients in the information age

August 1, 2008

When I enrolled in medical school - what seems like a lifetime ago - I wanted to be akin to the sage and compassionate Marcus Welby, M.D. I wanted to be a pediatrician who takes care of and cures sick children.

Key Points

When I enrolled in medical school - what seems like a lifetime ago - I wanted to be akin to the sage and compassionate Marcus Welby, M.D. I wanted to be a pediatrician who takes care of, and cures, sick children.

I am, however, forever grateful that I discovered the diverse world of dermatology and dermatologic surgery - a specialty that allows a physician to take care of sick children as well as their ailing parents, and offers the unique opportunity to diagnose, as well as operate on that patient.

What a truly astounding field!

For the most part, it has been almost an intoxicating experience. In an ambulatory setting, with minimal patient discomfort, one can help improve a patient's appearance and, hopefully, his or her self-confidence.

The real trick - the art behind the science - is to recognize when enough is enough.

Mistake No. 1

With that introduction, let me relate one rather frustrating experience.

One recent morning, a young woman, approximately 35 years old, came in for an initial consultation. She wanted to augment her lips.

In hindsight, her very vocal displeasure about the "interminable" wait should have been a red flag, and proceeding was mistake No. 1.

As is the usual custom, with a nurse present, we nevertheless discussed the various FDA-approved filling agents, the technique of injection, the duration and the risk/benefit profile.

After the discussion, the decision was made to use a hyaluronic acid filler.

Sensing her animosity, I tried to say "no," and encouraged her to consider other options: getting second opinions, or, at the very least, returning another time - anything to avoid treating her at that moment.

But, nothing doing - she was determined to have the procedure right there and right then, especially after "that inexcusable wait."

Prior to application of a topical anesthetic, with the aid of a handheld mirror, subtle facial asymmetries were pointed out to her, and a consent form was signed.

Mistake No. 2

Mistake No. 2 - the most grave of errors - was the omission of taking pre-injection photographs.

When suitable anesthesia was achieved after about 20 minutes, the patient was treated.

The right perioral area was treated, and the patient was shown the result. She was very pleased, and ice was applied.

The contralateral side was similarly treated, and ice was then placed on that side.

This sequence was repeated until the patient voiced her satisfaction with the final appearance.

It was - to say the least - shocking when she reappeared in the waiting room two hours later, audibly and angrily complaining for all to hear of her complete facial disfigurement: "My lips are too small and uneven."

Attempting to calm myself, the patient, the remaining patients and the staff - in that order - I made sure that she was ushered back into a treatment room. She was evaluated by a nurse, and then by me.

With mirrors, pointers, variations in both light and facial angles, and, yes, finally even photographs, we scrutinized her lips.

Truly, for the life of me, no discrepancy seemed apparent; she looked symmetric, and the lips looked well-proportioned.

In fact, her appearance was remarkable in that despite the innate hydrophilic nature of injectable hyaluronic acid, there was little edema, no ecchymosis and, overall, it was what would otherwise have been considered a very successful aesthetic result.

Nevertheless, at no further cost to the patient, an additional 0.4 cc of the same filler was injected with painstaking accuracy - completely at the patient's guidance.

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