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    A novel tool to document patients' aesthetic complaints may help thwart litigation


    Dr. Blackburn
    Trinidad and Tobago-based plastic surgeon Victor Blackburn, M.A., M.B., B. Chir., F.R.C.S., was always somewhat perturbed, he says, when colleagues at plastic surgery conferences would pooh-pooh taking histories of their patients' cosmetic complaints.

    "To generalize, most surgeons had never heard of such a thing...some knew about it, but did not do it," Dr. Blackburn tells Cosmetic Surgery Times . "It is extraordinary that the very first thing we are taught to do at medical school is to take a history of the complaint from the patient. Yet when we become 'aesthetic surgeons,' we no longer 'need' to take a history. The patient just has to mention the feature of complaint, and, having studied aesthetic ideals, we have the surgical answer to improve the appearance of that feature — despite the fact that our ideals may not be the same as the patients'."

    THE ART OF HISTORY Dr. Blackburn says history-taking is vital for good patient rapport and better doctor-patient communication. The specific type of history, he advocates, should focus on the aesthetic distress caused by the feature of complaint.

    "Taking a pertinent history helps to establish rapport with the patient, and, obviously provides the surgeon with insight into the patient's personality and expectations of the outcome of surgery — all of which are recorded and are critical in both patient selection and surgical planning," he says.

    There might be dire consequences — starting with dissatisfied patients and escalating to lawsuits — for cosmetic practices that shun history-taking, according to Dr. Blackburn.

    ENTER SAGA Dr. Blackburn and his son Adam Blackburn, a plastic surgery registrar (the UK equivalent of a resident) training in Newcastle upon Tyne, England, coauthored a paper in the July 2008 Journal of Plastic Reconstructive and Aesthetic Surgery (JPRAS) on a history-taking guide which Adam had developed and aptly christened "SAGA." In recognition of the innovative nature of this tool, the journal subsequently awarded the paper its Mentor Prize in 2008, according to Dr. Blackburn.

    "...We do feel that SAGA should be the minimum data set that a surgeon records from every patient for aesthetic surgery," Dr. Blackburn advises.

    RECORD FOR REBUTTAL It is rewarding for doctors to review their SAGA records or patients' complaints with patients in the post-operative period and assess the degree of improvement in the quality of life, according to Dr. Blackburn.

    "Often the patient has forgotten the encumbrances of her pre-operative condition and she may be placated by recognizing the improvements in the complaints she had before surgery," he says. "These records are most useful in avoiding or defending litigation — particularly if it is understood, from the beginning, that improvement is expected, but perfection is impossible."

    THE OTHER GUY SAGA is also useful when dealing with a patient who is seeking a second opinion after unfavorable surgery elsewhere. The SAGA history can be recorded retrospectively, including improvements, if any, to the original complaint. This can defuse a potentially hostile situation, as it focuses the discussion on the patient and her problem, and away from the perceived errant surgeon. Based on the patient's expectations, it also allows the surgeon to assess whether or not any revisional surgery should be offered, according to the paper.

    "After using SAGA to establish a rapport, there is the beginning of a relationship on which to base an opinion, which is usually, 'Do I like/understand the patient?'" Dr. Blackburn says. "If you really do not like, trust or understand a prospective patient, it is best to refuse surgery."

    The authors start their paper's abstract with this quote, which summarizes the importance of using such a tool: "Most patient dissatisfaction in aesthetic surgery is based on failures of communication and patient selection criteria, and not on technical faults."

    REFERENCES

    Blackburn VF, Blackburn AV. Taking a history in aesthetic surgery: SAGA — the surgeon's tool for patient selection. J Plast Reconstr Aesthet Surg. 2008;61:723-729.

    Ward CM. Consenting and consulting for cosmetic surgery. Br J Plast Surg. 1998;51:547-550.

    Gorney M. Essentials of malpractice claims prevention for the plastic surgeon. eMedicine. Accessed: January 5, 2004.

    Lisette Hilton
    Lisette Hilton is a writer in Boca Raton, Fla., who heads up her company, Words Come Alive.

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