In dealing with complications, experts advise being responsive and accessible to affected patients – and remembering to take care of oneself in the event of a lawsuit.
Avoiding patients who report complications is perhaps the quickest path to litigation, said panelists at the annual Cosmetic Surgery Forum (Las Vegas, 2015). Instead, they advised setting personal feelings aside and lavishing such patients with TLC. Should a lawsuit arise, they added, addressing the accompanying stress may well save one's sanity and practice.
Any dermatologic or aesthetic surgeon who says they've never had a side effect is either lying or denying - or else the affected patient never returned, according to Heidi Waldorf, M.D., director of laser and cosmetic dermatology and associate clinical professor of dermatology, Mount Sinai.
Every dermatologist has seen patients who present with complications created elsewhere, she says. When you ask the patient if she returned to the doctor, the patient says, "No, I never want to see that doctor again."
"When something bad happens, make sure that you and your staff provide a comfortable setting for your patients to return," she says. In fact, Dr. Waldorf says, some of her "complication" patients become her most loyal patients because of the way her practice treats them.
Suneel Chilukuri, M.D., said that when a patient reports a problem, his strategy is to see that patient every day.
"You want to make that patient get tired of seeing you," he says. Once the complication is under control, he gradually increases the between-visit interval to one day, two days and so on. "Work with them. They will be your best patient and your best referral source after that." He is a Houston-based cosmetic and Mohs surgeon in private practice.
Julie Woodward, M.D., adds that when a complaint surfaces, "Try not to take it personally." If you know the patient's identity, "Do whatever you can to make these patients happy." Rather than avoid them, she says, you have them return immediately, and continue to see them every week until they're satisfied. She is chief of the Oculofacial and Reconstructive Surgery Service in the Duke University Health System.
It's also important to ensure that your staff knows which patients require urgent handling. For example, Dr. Waldorf says, overly polite patients in pain may be willing to wait two weeks to be seen - unless a receptionist asks if they're concerned about a medical issue. If they are, "I want to get that call to the nurses," who perform triage using specific questions designed to uncover potential problems such as vascular necrosis. "And if you're worried that someone's angry," she adds, "have the patient come in before hours, or during lunch break, so they're not sitting in the waiting room getting angrier."
In one case presented, Dr. Chilukuri learned that six weeks had passed between the time a patient injected with hyaluronic acid (HA) by a nurse at another practice began complaining of pain, and the time the patient reached his office. By then, the patient had rock-hard subcutaneous nodules in both cheeks, with an abscess that required drainage of 6.4 cc of purulent fluid.
Some complaints seemingly come from nowhere. For example, Dr. Woodward received a letter from Ipsen in late 2014 because a patient had complained to the Food and Drug Administration about lumps in the lip following a Dysport (abobotulinum toxin A, Ipsen) injection. The patient was an 86-year-old female who had undergone Dysport and Juvederm (HA, Allergan) injections on the same day.
However, Dr. Woodward says, her staff found no record of phone calls from the woman, except a complaint about her bill two months before the letter arrived.
"I remember the conversation, and we adored (the patient)," she says. "Nothing went off on our radar" suggesting she should not undergo treatment.
Nevertheless, Dr. Woodward says this patient slipped through her filter.
"I didn't do a good job of counseling her," she says.
Armed with the particulars of the case, Dr. Woodward called her Allergan representative, who provided hyaluronidase to treat the woman promptly.
In another case, a female patient returned to Dr. Waldorf with a hard white nodule above the left corner of her upper lip six weeks after undergoing calcium hydroxylapatite injection above the lip.
Originally, she says, "I'd put a little strut in the cutaneous lip across the nasolabial fold. This was the early days, when I would tell patients when they got home that if something feels bumpy, massage it down."
The patient initially loved her results. But when Dr. Waldorf asked her about any problems, she showed her the bump, a result of repeated massages the week after treatment.
"As she was massaging the swelling, she shoved this material down," she explains.
Dr. Waldorf removed the bump with a punch excision under local anesthesia.
Additionally, "I tell patients now for all fillers except Sculptra (poly-L-lactic acid, Merz/BioForm): No manipulation for one to two weeks. No facials, no rubbing - nothing."
Another patient developed biofilm after multiple HA injections performed by other physicians. "This patient had seen multiple doctors. She had had HAs without a problem, then after two years suddenly started getting draining cysts and deeper cysts and abscesses across her face," Dr. Waldorf says.
Other physicians had tried steroid injections to treat these problems, resulting only in skin atrophy. Dr. Waldorf performed a punch biopsy and confirmed it was a granuloma. Routine cultures were negative, she says.
"As we know, with biofilms, you don't necessarily see organisms" under the microscope, she explains.
Accordingly, "We injected her with triamcinolone and 5-fluorouracil, in the same ratio (1:9) I use for keloids. If you don't use 5-FU, get some," she says. "It's fantastic, inexpensive and bactericidal. Plus it reduces inflammation."
Dr. Waldorf says she also gave the patient three (sequential) courses of Zithromax (azithromycin, Pfizer) and Avelox (moxifloxacin, Bayer), followed by intralesional hyaluronidase, injected with a needle because the lesions were too hard to break up with a cannula. "Ultimately, she got better," she says.
To avoid biofilms, Dr. Waldorf says, "I cleanse the heck out of people. I have my staff cleanse them," using makeup remover pads, because regular cleansers are no match for today's long-lasting makeups and tinted moisturizers.
Next, "I cleanse them with chlorhexidine, then alcohol - in that order because I don't want the chlorhexidine dripping by their eyes. Even though I'm wiping it off, it has a longer-lasting effect than alcohol." Drs. Waldorf and Chilukuri also tell patients to avoid the dentist two weeks before and two weeks after injectable treatments out of concern for bacteremia. Additionally, Dr. Waldorf says, "I now ask people about chronic periodontal disease." If someone has this problem or similar issues, "I consider giving them some doxycycline."
If complaints come anonymously online, Dr. Woodward suggests hiring a reputation management firm. "Sadly, there are many of these companies popping up to deal with this repeated issue."
Should a complication spawn a lawsuit, you must take care of yourself she says. The stress can lead to a condition called medical malpractice distress syndrome. Doctors facing lawsuits can feel humiliated, embarrassed, and you're angry. And although the suit is often frivolous, and there is no negligence, she says, a significant amount of time and money are still required to deal with the situation. In any given year, she says, one in 20 dermatologists gets sued. Even if the suit is dismissed or withdrawn, it can be emotionally devestating.
Amy Forman Taub, M.D., says that the first time she was sued by a patient, it was devastating.
"I actually thought about changing professions," she says.
One thing she found helpful was a one-day malpractice seminar offered by her insurance company. The retreat featured talks by attorneys. It helped her understand the legal process and take the lawsuit less personally, she says.
"You can't win the case by reviewing the chart 5,000 times," Dr. Taub says. "You have to continue to provide the best care possible to the patients you see each day, and this can't be done if you are second-guessing yourself. It's important to turn to your family for reassurance and focus on the good outcomes."
Disclosures: Dr. Waldorf is a speaker and consultant for Allergan, Merz, Valeant and Galderma. Dr. Chilukuri is a speaker and consultant for Allergan, Galderma and Cynosure Lasers and a consultant for Theravant Lasers. Dr. Woodward is a speaker for SkinCeuticals, NeoCutis, Lutronic and Merz. Dr. Taub reports no relevant financial interests.
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