The Psychology of Rhinoplasty: Lessons Learned from Fellowship

What Makes Patients Unhappy

Treatises on the subject of patient unhappiness usually focus on patient factors that may contribute to this unfortunate situation and tend to deemphasize the discussion on surgeon-related factors as a possible cause. Since surgeon factors are the only ones we can really influence, it makes sense to explore these more in depth. You may find it hard to admit that, more often than not, patients are justifiably unhappy because you failed to meet their expectations. With any luck, this happens very infrequently but, as the saying goes, if you do not have any surgical problems, you are probably not operating enough. Even the most meticulous and accomplished among us has a measurable revision rate. Having a very low revision rate, however, does not by itself declare you a great surgeon. Your unhappy patients may simply be taking your revisions elsewhere.

Patient expectations may have been unfulfilled for several reasons that may or may not fall within your control. The surgical outcome may have been truly subpar. The patient may be the inauspicious recipient of a complication despite your best efforts at avoiding one. You may have unwittingly misled the patient as to what you could accomplish with the proposed procedure. You may not have given the patient the time and attention he or she deserved. You may have talked the patient into having a chin implant because you thought it would improve her rhinoplasty result, even though she expressed no interest in this procedure. You may have been insensitive when she was airing her postoperative concerns. You may have accepted a patient who was a decidedly poor candidate for rhinoplasty. Most of these factors are avoidable. A patient's happiness with the procedure is arguably as much dependent on your attitude and conduct toward the patient as it is on the technical result itself and on the patient's personality features.

To be sure, many patient factors play a role in this interaction, and these will be examined. Yet, a survey by the American Academy of Facial Plastic and Reconstructive Surgery showed that the most common reason for patient unhappiness, more than all others combined, was a breakdown of rapport (51% of cases). The rapport developed preoperatively is most indicative of the direction of the postoperative dynamic. A strong preoperative bond will usually be reinforced under difficult circumstances when both the surgeon and patient are working toward a common goal of improvement. Likewise, a deficient relationship will usually decay under duress, sometimes beyond recovery. To fully understand and prevent problems pertaining to the surgeon–patient relationship, the microscope must be turned inward.

Avoiding and Preventing Unhappy Patients

There is a kernel of truth in the old adage that the secret to a successful practice is first Affability, followed by Availability and, finally, by Ability. Yet, there is no getting around an undeniably flawed technical result. No amount of kindness on the part of the surgeon can fully compensate for this failure. Jack Anderson, M.D., was known to teach that it is not essential that you operate brilliantly; rather, you should strive to never operate badly. The best defense against unhappiness, then, is to consistently do good work. But, what of the majority of patients who encounter an “adequate” result, one that most people would describe as at least good, if not perfect? This result has the potential to produce an overjoyed patient, a mostly satisfied albeit mildly disappointed patient, or a hopelessly discontent one. This difference has mostly to do with perception. A patient who was given realistic expectations and who is treated with true caring will be inclined to overlook the minor imperfections associated with this outcome. A similar patient with the identical result will be given to chronic unhappiness if she was led to anticipate a far superior outcome or if she or he was treated unjustly. The following section takes a practical, rather than theoretical, approach to the discussion of what a surgeon may do to increase the chances for having patients fall into the former category. These truisms are not meant to be patronizing but, rather, to act as a gentle reminder that the surgeon very often controls the direction of the physician–patient dynamic. The fact that they are generally simplistic and even patently obvious does not diminish their value as good principles of patient management.

If you do not like the patient, do not operate. This seems self-evident, but you should follow the principle of performing surgery on happy patients that you like. This is probably the single most important tenet of patient selection. A small percentage of people have a negative outlook on virtually every aspect of their lives and there is no reason to expect that your surgery will be any different. These are pessimists who exaggerate the negative impact of a majority of their life circumstances. Many harbor a general mistrust of physicians. As a result, they are unlikely to be fully satisfied with even an excellent outcome. Thankfully, these patients are relatively easy to identify during the preoperative consultation. Happy people, in general, are more likely to remain happy with their results, to accept imperfection, and to refer their like-minded friends and colleagues. This way, you will continue to attract happy people to your practice.

Take yourself out of the equation. Understand, first and foremost, that you do not matter as much as you might think. We call what we do preoperatively “patient selection” when, in fact, the truth is that you do not choose the patient; the patient chooses you. You are the gatekeeper of your practice. At best, you can refuse a patient. It matters not what you think of your surgical results. It matters only what your patients think; theirs is the measure of your success.

Work at keeping your patients happy. When patients agree to have you perform surgery, they are excited and optimistic. They want to enjoy a fulfilling and productive relationship with you. Contrary to popular belief, most cosmetic surgery patients are usually happy, well-adjusted, and committed people who are interested in self-improvement. Testing has repeatedly shown that cosmetic surgery patients are in the normal range for self-esteem, although most have a low self-image for the particular feature of concern. They are not typically unreasonable, discontent, disordered, experiencing chronic health concerns, or seeking secondary gain. Furthermore, most do not expect perfection. When they cease to be happy, it is usually because we have contributed to their displeasure by the way in which we have responded to them. A cosmetic practice is a little like a marriage in that happiness does not appear out of thin air. With that in mind, you should undertake every interaction with the philosophy that your foremost purpose is in helping your patients to achieve happiness.

Explore patients’ motivations. If you have concerns that a patient may have a generalized low self-image or is undertaking the procedure for some reason other than his or her personal satisfaction, you should consider not doing the surgery. A patient responding to external motivators is far more likely to be discontent even with an outstanding result. Unhealthy motivation and poor self-image often combine to increase the chances of psychological instability and dissatisfaction after surgery. By the time you agree to schedule surgery, you should be absolutely sure of the patient's sincere motives for self-betterment. Occasionally, surgery is not the answer and patients deserve to know that at the outset. Otherwise, you will discover a patient who continues to be dissatisfied despite obtaining a good technical result.

Listen more. It can be tempting during your consultation to launch into a discourse on what patients need and how fortunate they will be to benefit from your formidable talents. Spend more time listening than speaking during the consultation. A patient's questions can be as revealing as can their omissions. If the consultation becomes more about you than about the patient, you will have missed your chance to truly evaluate his or her suitability.

Be honest about your own motivations. External motivators play a complicating role when deciding on whether to operate on a potentially problematic patient. Experienced surgeons have the benefit of a more finely tuned “sixth sense” coupled with a motivation to avoid accepting patients who are at higher risk for being dissatisfied. A younger surgeon is more driven to accept every patient early in his career because he or she can ill-afford to lose a case. He or she wants every potential patient to choose him or her and will often ignore the little voice of unease that says this patient may not be right for him or her. Good judgment can easily be obscured by needs pertaining to the ego or to the pocketbook. An unselfish commitment to the patient's best interests in every situation may necessitate some short-term sacrifice, in the form of refusing surgery where appropriate, but will undoubtedly have the long-term rewarding effect of growing your practice.

Recognize and respect your limitations. It is more important to tell the patient what you cannot do rather than what you can. Check your ego at the door. You cannot be an expert at everything. The most respected giants in our field often do no more than four or five operations most of the time. They accumulate mastery of a technique. That is not to say that all learning should cease after training; quite the opposite is true. But, be cognizant of your place on the learning curve. If you are incorporating an emerging technology that you just discovered at a recent meeting, tell the patient that the potential benefits are not entirely clear. Ask yourself if this new technology is really likely to make your patient happier with the result. If a patient would most benefit from a rib graft, which you perform once a year, consider referring him or her to a trusted colleague who has more experience if you believe that to be the best procedure for that particular patient. A fourth time revision is perhaps not one you wish to include among your first 50 rhinoplasties. In general, a spirit of conservatism and prudence should prevail if you wish to minimize the number of unhappy patients you inherit. This is especially true early in your career where a single unhappy patient can wreak havoc on your budding practice.

Undersell the benefits. When you give your patients an expectation of the result preoperatively, whether by computer imaging or by other means, underpromise so that you can overdeliver, exceeding patient expectations. The authors make a habit of imaging a less than ideal result. We tell our patients that surgery is imperfect but we know that if they can be happy with the imaged “average” result, then we can almost assuredly do better for them. Be cautious of the rhinoplasty patient who also needs a chin implant. Do not push the patient to have a procedure that you think would be more beneficial. The level of unhappiness with a less than perfect result is far greater when the procedure was suggested by you rather than by the patient. Instead, be honest in your appraisal and dissuade patients from pursuing a procedure if they would not benefit optimally. Your integrity will be most welcome and will often result in a successful relationship in the future.

Do not let your head overrule your gut. Your gut instincts are not always right, but they often are. Your impression of the patient in the first 5 minutes of your interaction is usually an accurate preview of how this interaction will play out postoperatively. In the book Blink , the author Malcolm Gladwell describes that subcognitive perception enables us to make rapid assessments that have greater precision than those judgments that result from extensive analysis. The patient you initially think might present a problem after surgery often does live up to those expectations. Most physicians are often influenced by their urge to “do good.” The hope that your technically good procedure will engender a joyful disposition in a patient who is psychologically unsuitable for surgery is rarely realized. If you are unsure about a patient's suitability, spend more time with him or her. If your doubts are reinforced, you will have made better use of your time in deciding not to proceed with surgery than in spending countless hours with an unsatisfied patient after surgery. Remember, though, that the more time spent with some personality types, the more psychologically healthy they may appear.

Inform your patients properly. There is a saying among experienced surgeons, “What you tell patients before surgery is an explanation … what you tell them afterwards is an excuse.” It is true that patients hear only a small fraction of what you tell them during the consultation. So, make a habit of eliciting questions, speaking slowly, repeating often, and imparting information in more than one format. The authors routinely see patients for a second visit prior to surgery, partly to further gauge their fitness for our practice but also to convey information at a time when they are more relaxed and more likely to be receptive. The authors ask patients to sign a document stating that they have received, read, understood, and agreed to abide by all of the preoperative and postoperative instructions. By doing so, patients grasp that they are partners in this endeavor.

Tell a patient about the possibility of a revision. It is easy to gloss over possible complications because this discussion is uncomfortable and many patients do not even wish to have it. This temptation should be avoided. Patients should be given information along with an explanation of the surgical consent both verbally and in writing. The authors send patients home with a sheaf of literature that is more inclusive rather than exclusive of instructions on preoperative and postoperative care in addition to potential risks of the proposed procedures. Patients should be given time to review this information so they have a chance to digest it quietly at home within their comfort zone. That way, you are not springing something new on them in the follow-up period at a time when they will view new information with suspicion.

Respect your patients . Be likable and courteous. Do not keep patients waiting and apologize when you do. Schedule enough time to answer their questions. Patients are more inclined to be happy with you if you show them you actually care about them personally. Although you cannot forge a successful practice just by being nice, a cordial nature can produce inestimable dividends. If you come off as distant, dismissive, or arrogant, your patient is likely to form the impression that you treat every aspect of his care or her with the same lack of concern, inclusive of the surgery. You are more likely to end up with a practice full of patients who point out your minor failings rather than be accepting of the minor imperfections they encounter.

Save your patients added expense, time commitment, and inconvenience. Do not put them through unnecessary tests. If there will be added expense in the event of a revision, spell these out for them ahead of time. Sometimes a patient is justified in being unhappy with the result. Consider what you are willing to do for them in that event.

Warning Signs of Potential Patient Dissatisfaction

The patients described earlier in this chapter are those we seek for our practices. These are patients who have clear and sensible motivations and reasonable expectations. They understand the risks entailed by surgery and accept that there is no guarantee of a perfect result or of absolute satisfaction. They have divergent features of real concern but they are not excessively preoccupied with them. Their goals are reachable in our hands. They are courteous, pleasant, earnest, and dependable. They accept their share of the responsibility for their actions and decisions. They are not looking for nor expecting a radical, life-altering change. They desire an outstanding result but would be pleased with a good one. In short, these are generous, happy, and well-balanced people who constitute the majority of cosmetic surgery candidates.

We would all like to believe that every patient fits this description, but not all prospective patients do. These are not terrible people but they possess personality and psychodynamic traits and coping mechanisms that place them at an unhealthy risk for dysfunction following aesthetic surgery. They are more likely to be unhappy with any result. We owe it to our patients to remember our oaths and to make recommendations that will most benefit them. For some of these patients, surgery is not the appropriate recommendation and we should make every effort to save them and us the hardship of dealing with an unhappy outcome. Unfortunately, poor candidates for cosmetic surgery do not wear warning signs on their chests. Some of these maladaptive traits take time to become apparent and still others masquerade as wolves in sheep's clothing, only to surface after the procedure. What follows is an accounting of the common warning signs to which surgeons should be attuned in the preoperative period that will allow them to appropriately counsel patients not to proceed with surgery. These have been previously published in detail by the senior author (P.A.A.) under the moniker “The Dangerous Dozen” and can be further subcategorized as extrinsic or intrinsic factors.