We’ve all been there. The housewife who complains about having uneven brows, which she never had before you did her BOTOX®. The grandmother who thought all her wrinkles would go away with PRP and now points her finger at you angrily because she feels duped. The guy who beats you up every month because the discolouration on his cheek after laser resurfacing hasn’t faded yet, even though he spends his weekends in Spain and doesn’t wear sunscreen.

So what’s a doctor to do? Think damage control. It starts with practicing medicine defensively to weed out patients who are most likely to be unhappy and become litigious from the outset.

The best strategy to avoid having unhappy patients is careful screening, superior patient education, and competent pre- and post-procedure care. Yet, even if you follow this strategy religiously, it is no guarantee that some patients will not slip through the cracks. If you screen patients out too assertively, you will end up with no one to inject, resurface, or operate on. There was a time I can recall in my early years of managing a Park Avenue plastic surgery practice in New York City that a red flag was raised for any patients who presented with a psychiatric history, were taking medications for anxiety, depression, or mood disorders, consumed alcohol daily, and smokers if they were considering surgery. We frowned upon accepting patients who related that they had previous bad experiences and were down on doctors in general.

Aside from death and taxes, some things are inevitable: anyone who operates or treats cosmetic patients will have unforeseen complications some of the time, and some people are just wired to be dissatisfied most of the time.

Patients may be unhappy with surgery, lasers, injectables, or treatments through no fault of the practitioner. In the court of public opinion, however, the reasons, nuances, and details are irrelevant. Every unhappy cosmetic patient impacts negatively on your reputation within your community and has the potential to prejudice prospective patients against you.

Cosmetic patients, by their very nature, are often difficult to please and have become far more vocal about their displeasure. In the world in which we now practice, the Internet has given disgruntled patients a meeting ground to chat, exchange experiences, and offer advice to each other. They can form a type of bond that is comparable to a virtual support group.

Patient selection

No matter how god-like your skills as a physician are, how comforting your bedside manner is, and how many hoops you jump through to exceed patients’ expectations, the simple fact remains that no one can please all people, all of the time. The surest path to self-destruction in aesthetic medicine is an inadequate culture of patient screening. The practitioner whose sole criteria for accepting someone as a patient are the presence of a cheque or MasterCard, is destined for professional disaster.

If you don’t screen patients adequately, the grief you will inherit for the long term will far exceed the financial reward you may gain in the short term. One has to wonder sometimes how practitioners set aside good judgement and overlook the obvious signs. The tales unhappy cosmetic patients recount of their horrific experiences in a previous surgeon’s care can read like a Stephen King screenplay, and become more exaggerated with each telling. The memory of an unhappy patient is far more powerful than that of a satisfied one. They are convinced of their ability to recall even the most insignificant detail of their ordeal, although they rarely remember you having told them about possible risks and complications.

Patients also tend to present themselves differently in consultation. They may appear perfectly delightful and reasonable until something happens to dramatically change the relationship with the practitioner. Very often the trigger event is not a suboptimal outcome, but rather a miscommunication somewhere down the line. Therein lies a critical element of the physician–patient relationship: good communication.