What makes perfectly happy patients seek treatment elsewhere?
I must say that I am fortunate to have very loyal patients who keep coming back to me year after year, but having said that I must admit that once in a while I am surprised to see that a patient has had a treatment done elsewhere. Most of the time this is a filler or a Botox treatment that the patient was offered by their dermatologist while they were being treated for something else and the patient decided to have that treatment done at that location as a matter of convenience. What concerns me more is when I find out that the patient has had a surgery done by another plastic surgeon after having had very successful surgery done by me in the past. The reason I find out about these sorts of things is that the patients are often not happy with the results and come back to me very apologetic for having gone elsewhere. I recently saw a patient on whom I had performed cheek implants with a stunning results about twenty years ago and a facelift a few years later. About two years ago, when she needed another facelift, she followed her daughter’s advice and went to another plastic surgeon. Her daughter had had some spider veins treated by that doctor and was very infatuated by him, so she insisted that the mother goes to that surgeon for her facelift. The patient had that surgery done by this doctor under general anesthesia. The operation took six hours and the surgical fees where 50% higher than my fees. She had a difficult recovery and was completely paralyzed on the left side of her face. She recovered partially and has weakness of the muscles on the left side of her mouth as a permanent deficit. What is ironic is that she was never satisfied with her cosmetic results.
She came back to me two years after that unhappy event, very embarrassed to have gone elsewhere and asking me if I wood take her back as a patient and correct the problem. I asked her to bring me all her records from the other doctor and carefully examined her. She had suffered a facial nerve injury, which had recovered, but had left her with some permanent deficit on the left side of her mouth that could not be corrected. The thing that bothered her the most is that the skin of her neck had these unsightly folds vertically going behind her ears because the skin was not properly redistributed after her facelift and the incisions were not properly placed to correct her excess skin. I took her back to the operating room repeated the facelift under local anesthesia and corrected the problem with the proper incision. She was extremely happy and promised that she would never go elsewhere. So what happened in this case? Why did she decide to go elsewhere?
These are some of the possible reasons:
1) When I spoke with her daughter, she told me that her mother had difficulty with the numbness of her cheeks after my initial facelift. This is a normal consequence of a facelift operation. It is due to the fact that the skin is lifted. The nerve endings grow back into the skin within six months to a year and the numbness totally disappears. Despite the fact that we mention this side effect in the preoperative discussion, it is possible that the patient perceived this as an avoidable complication. Maybe I could have done a better job of explaining this issue to this patient.
2) The patient’s daughter is in the medical field and apparently had a great rapport with this other plastic surgeon who is a charming guy. The parents are often influenced by their young adult children, especially in this internet era when the younger people have an edge over their parents.
3) The internet presence and the degree of visibility online is often perceived as a sign of authority in the field of plastic surgery. The omnipresence of a name on multiple Google pages is often perceived as an indication that the doctor is an expert in the field. This other plastic surgeon who operated on my patient is indeed more visible than me on the internet and has a fancier website. I have been in practice for twenty-eight years and I had ignored my internet presence as over ninety percent of my patients come by word of mouth, referred by other patients. Lately I am paying more attention to my internet presence and try to optimize my site so that I am visible to the patients seeking plastic surgery treatment and to my existing patient who might see the internet presence as a sign of authority in the field of plastic surgery. There is no question that there are many doctors with good visibility that I would recommend as accomplished surgeons, but I must say that there are many who lack the talent needed to be a good plastic surgeon and wouldn’t have a practice if it wasn’t for their heavy marketing efforts, including their internet presence. Even though I have started to pay more attention to marketing and my visibility on the internet as well as on some local print media, I believe that the doctors should have never been allowed to advertise. I think this has diminished us in the eye of the public and commoditized our services. It is also more difficult for the average patient to decide who is really good to use. It took years of work and great results to establish a excellent reputation in the past, but now, one can look like a great expert with a fancy web site and great visibility on Google.
4) Many other practitioners like internists and gynecologists make use of their office traffic and their patient’s confidence to have patients accept cosmetic injections like Botox and fillers.
5) Plastic surgeons schooling and exceptional credentials are very important. There is no question that it takes a very smart and studious person to get to an Ivy league college and medical school, but remember that the surgical talent has less to do with how smart and studious one is and more to do with common sense, artistic ability and most of all how creative one is. This is most obvious in the plastic surgery specialty where the most important innovations have come from talented and creative surgeons who are in private practice. Some of the greatest and most important innovations like liposuction were not even started in this country.
6) Seeking a younger newly graduated plastic surgeon who one might think may have a more up to date knowledge is another reason why a patient may want to ere from an established relationship. Here again one has to remember that information is shared freely and is available to all. Plastic surgeons get trained in reconstructive and cosmetic surgery. During this training, there is a bigger emphasis in reconstructive aspects of plastic surgery, which today is centered over microsurgery. This is the technique that allows tissue to be transferred from one part of the body to another hooking up the blood supply under a microscope. The skills required to do this kind of surgery are very different than what is required to do cosmetic surgery. Reconstructive surgery has served us well and has allowed refinement of cosmetic surgery procedures. There is constant cross-fertilization between reconstructive and cosmetic surgery. The knowledge acquired during a two years plastics surgery residency, as important and necessary as it may be, is a first step towards maturity in cosmetic surgery. The degree of skills developed in this area is going to be dependent on the talent of the individual surgeon. Some may reach this level after five to ten years of practice and some may never reach it. There is no question however that a plastic surgeon will always have an edge over any other specialists in doing cosmetic surgery, because of the nature of his or her training which is intended to deal with form and function.
The challenge is to make sure the patients understand that services can be obtained at different levels, provided by doctors from many different specialties. Even among board certified plastic surgeons there is a big difference in the talent levels. Mistake in choosing the right doctor could be very costly both monetarily and as far as safety and results. The patients need to understand that if they have a good result with a plastic surgeon, they should not take that for granted and they should stay with him or her for any future surgery. They also need to understand what the doctor is capable of doing. Just because someone gives a cosmetic injection doesn’t mean that they can do surgery. There are also well credentialed and well trained plastic surgeons who keep busy in the emergency rooms doing trauma cases and hand surgery. They may not be the most experienced to do a facelift.