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The WayI See It

The Way I See It columns reect the opinions of the authors and are independent of Medical Economics. Do you have an experience youwould like to share with readers? Submit your writing for consideration to medec@advanstar.com.

want to

from you!hear

We

In some cases, when a primary care physician (PCP)

involves the services of a plastic surgeon such as me, is

it risk management? In some trauma cases, we are not

there to treat the wound so much as prevent liability. When

do the services of a plastic surgeon rise above the cosmeticand into the medically necessary? The answer is debatable.

Let me share a real case. A 50-year-old woman who ap-

peared 10 years younger than her age went to an urgent care

facility after falling in the shower on a holiday. The internist

on duty found a burst injury along her eyebrow. He was

comfortable closing the wound and told her that it shouldnt

scar much, although she requested a plastic surgeon.

The doctor on duty

sutured the wound,

and the patient left the

facility. The discharge

paperwork indicated

that a scar would

result, so she frantically

searched for a local

plastic surgeon. She

called my o ce and paged on the stat line, then unloaded for

30 minutes about the doctor who promised her no scar.

Many plastic surgeons would not have oered an appoint-

ment to this anxious woman. With some reservation, I of-

fered to see her the following day. No one can guarantee that

a wound will not scar, especially a traumatic wound, and of

course I emphasized this point to her from our first contact,

adding that usually I dont revise surgical wounds early in

the postoperative process. Most dont end up needing it. Sheseemed pleasant and agreeable by the end of our conversa-

tion. If she had not appeared so, I wouldnt even have evalu-

ated her. Unreasonable expectations invite disaster.

When I saw her the next day, the patient said: I havent

slept all night. Will it scar?

Most traumatic wounds will form a visible scar, I

answered, looking at an inch-long closed wound along the

margin of her eyebrow moving toward the side of the eyelid,

but I am not crazy about nylon sutures in

such a wound. They can leave train tracks.

The sutures were well-placed but were sim-

ple and external, leading me to infer that nothing supported

the wound underneath. This is good general medicine, but it

is a plastic surgery no-no.

The doctor used the wrong stitches? I knew it! she said.

Now hold on a minute. I didnt say that, I replied.Much of what plastic surgeons do is looked at by other

specialists as being excessive. To an emergency department

doctor, this is a beautiful closure.

And to you? she asked.

It is OK, but if you ask me whether I can oer improved

scarring, the answer is, probably, I answered.

I ended up revising a portion of the wound, removing

the external nylon

sutures and burying

some absorbable sutures

underneath the por-

tion of the wound not

covered by her eyebrow.

I saw no other support

underneath, as I had

suspected.

Who is wrong in this case? Should the internist have re-

ferred the patient to a plastic surgeon? Should I have refused

to see her? Should she have just left alone what the urgent

care doctor did? No one right answer exists.

Plastic surgeons who do cosmetic work are accustomed

to the challenge of emotionally fragile patients who likely

have been more than just attentive to their appearance over

the years, and we charge such patients cash for the increased

wear and tear. PCPs can manage the actions and expecta-tions of such patients by not promising that a wound will not

form a scar, by stressing to them that a PCP is not a plastic

surgeon, by telling them that plastic surgeons likely will

charge them cash, and by indicating that plastic surgeons are

not always immediately available.

I always tell patients I can only do my best. I constantly

re-assess them for signs of having unrealistic expectations.

Turning away an unreasonable patient can save you a world

of headaches well worth the small loss in revenue. Be sure to

carefully document what you say so that any post-procedure

accusations can be contested properly.

KNOWING WHAT TO SAY, WHEN TO

TREAT, WHEN TO REFER CAN HELP

Managing patientexpectations

By JOHN DI SAIA, MD

San Clemente, California

TURNING AWAY

THE UNREASONABLE PATIENT

CAN SAVE YOUA WORLD OF HEADACHES.

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