Strive to match 'expectation/performance'

February 1, 2005

Kissimmee, Fla. — In dermatology practices today, two basic types of procedures exist: "desire-based" cosmetic procedures and "disease-based" procedures, such as the removal of a skin cancer. Traditionally in medicine, physicians have employed a set of relatively objective criteria to define an acceptable outcome in the second type of procedure. It is the first category, elective and cosmetic procedures, where the physician must satisfy another, more subjective, set of criteria — one that is frequently the cause of disappointment, remorse, dissatisfaction, anger and, all too often, malpractice litigation.

Kissimmee, Fla. - In dermatology practices today, two basic types of procedures exist: "desire-based" cosmetic procedures and "disease-based" procedures, such as the removal of a skin cancer. Traditionally in medicine, physicians have employed a set of relatively objective criteria to define an acceptable outcome in the second type of procedure. It is the first category, elective and cosmetic procedures, where the physician must satisfy another, more subjective, set of criteria - one that is frequently the cause of disappointment, remorse, dissatisfaction, anger and, all too often, malpractice litigation.

According to William Philip Werschler, M.D., in this type of procedure it's the patient who holds the ultimate key to his or her satisfaction - and because of that, it's important for all aesthetic dermatologists to remember the definition of quality as applied to medicine: the meeting or exceeding of expectations and, as modified for cosmetic procedures, meeting or exceeding them at given price points.

Dr. Werschler, assistant clinical professor of medicine/dermatology at the University of Washington School of Medicine, spoke on the topic at the Orlando Dermatology & Cosmetic Conference here.

If a certain procedure is performed correctly and the result is achieved within defined parameters, he says, then it is successful from an objective viewpoint.

"But even the most artistically performed procedure that has the best possible outcome with no complications can be an abject failure from the patient's subjective viewpoint - depending on their expectations," Dr. Werschler says.

Because of the complex variability involved in achieving uniformity of opinion in evaluation of a successful cosmetic outcome, Dr. Werschler advises that dermatologists should strive to achieve what he calls an "expectation/ performance match" and, conversely, do everything they can to avoid an "expectation/performance mismatch."

Decrease 'mismatch' Dr. Werschler says dermatologists should take several key steps to help significantly decrease the risk of an expectation/performance mismatch leading to either objective or subjective patient disappointment:

1.Let the patient tell you what they want - "Always ask the patient what they would like to get from the procedure - in their own words. Carefully address their desires in the context of the least-effective outcome of the procedure."

2. Under-promise and over-deliver - "Never, ever over-promise on a cosmetic procedure. Always under-promise, and promise you will do your very best to achieve the desired outcome."

3. Make wise use of consent forms and photographs - "Use your consent forms as a teaching tool, being specific as to probable outcomes, including the negative ones. Insist on taking both pre and post-procedure photographs - no exceptions. Photos can be used to enhance the patient's perception of a good outcome; sometimes when patients are satisfied, but not overwhelmed, it does them - and you, the doctor - good to review the baseline photos. Document in the medical record that you thoroughly explained the procedure to the patient, that a consent form was signed, that pre- and post-procedure photos were taken, and that the patient had the opportunity to have all their questions answered. Remember this: ICG/BRE, which stands for 'informed consent given, benefits and risks explained.' "

Dr. Werschler says that in cosmetic procedures, the perfect outcome exists when physician and patient agree on and understand the patient's goals and desires, as well the risks and benefits. This kind of mutual understanding, he says, provides the best chance of leading to an expectation/performance match.