If you go through the exercise and expense of becoming properly trained in the administration of facial injectables, you probably aren’t thinking about all of the patients you won’t treat.
Most of us enter into this practice thinking of all the patients we will treat and how we will have a positive effect on their lives. And let’s face it, some practitioners join the ranks of injectors, motivated primarily by the presumed effect it can have on their bottom line.
Since facial injectables are mainly a want and not a need, patient management should be pretty straightforward, right? The patient walks in, receives some Botox and/or dermal fillers, pays on the way out, and everybody’s happy!
Well, not always.
The unfortunate reality is that difficult and unreasonable patients will always find their way to your office. And it goes beyond that. Some people just aren’t appropriate candidates for facial injectables for a variety of reasons. So how do you break the news to these people that you don’t want to or shouldn’t treat them?
Plus, what do you do about the one who slips through your invisible fence—the elusive malcontent? The one you’ve already treated who doesn’t “see any difference,” even when presented with before and after pictures?
Or how about the ones who could only afford one syringe? You told them they’d need 4 syringes, but they said they wanted to move slowly (so their friends wouldn’t notice!) and now they feel it wasn’t worth the money since there’s “really no difference.”
Saying no is hard. It’s uncomfortable for you, and it has the potential to make your patient angry or hurt. It’s so much easier to go ahead with treatment, hit the “silence” button on your neural dosimeter, and keep your fingers crossed in hopes that the patient or the results don’t come back to haunt you.
But, aside from being unethical, treating the wrong patient or treating the patient wrong can present you and your staff with a chronic headache or even a legal problem. It’s important to think about how you’ll handle these awkward situations before they happen, because if you’re open for business, these situations are inescapable.
Here are some of the reasons why you might not want to treat a patient:
- Unrealistic expectations
- Request for treatment beyond what would appear natural
- Bad vibes
- Medical history contraindications
- Mental health issues/Body Dysmorphic Disorder (BDD)
The most basic elements of the doctor-patient relationship are honesty and trust. Sometimes, being honest with patients about their needs (or lack thereof) doesn’t feel like a great short-term business decision. Telling patients they don’t need treatment may not be productive today, but the eventual yields can be enormous. These patients often become amazing referral sources and trust you when you do say that it’s time for any future treatments.
Conversely, patients who demand treatment where none is warranted may be angry or insulted when you decline to buy in to their requests. An obsession with “more” can morph into a preternatural look that appears obvious to everyone but the patient. People who become caricatures of themselves are not practice builders for you.
Trust me when I urge you to let them walk. Patients with unrealistic or warped views of their supposed needs are often incapable of seeing any improvement in those perceived defects after treatment. You might suggest that they find a practitioner who shares their “esthetic vision” and also their inevitable disappointments!
Typical patients usually know what they want, but they have no idea what they need. Popular media provides an endless source of misinformation, and many patients believe that Botox can do it all. For example, tear-troughs and under-eye circles are common areas for facial rejuvenation, but there are situations when surgery is the best (or only) modality of treatment that will address a patient’s presenting deformity.
Having a conversation with these patients and explaining in laymen’s terms why injectables won’t address their problem is the right course of action. Realize that, from the patients’ points of view, it’s pretty disappointing to hear what they thought would be cured by a few drops of Botox today actually requires surgery.
But patients who spend several hundred dollars on Botox and have no improvement of their chief complaint will be, justifiably, a lot more than disappointed. Moreover, any trust between you and these patients will quickly evaporate.
Popular media contributes to the unrealistic expectations some patients have. Evidence is building that social media, photo-filters, and perpetual celebrity Photoshopping and airbrushing are all having an effect on individuals’ body images.1 When patients show up with a picture of a celebrity and tell you they want lips or some other area just like so-and-so in the picture, that’s going to require some discussion.
If, for whatever reason, these patients cannot understand why you can’t fulfill their esthetic vision, it’s time to craft your refusal to treat. Rather than antagonize, you could offer something like this: “I’m probably not the right person for this kind of treatment. I don’t think I can deliver what you’re truly looking for. I don’t want to waste your time or money, so let’s have you see someone else for a second opinion.”
Studies report that between 7% and 12% of patients presenting for cosmetic surgery have BDD.2 Patients afflicted with BDD have a disabling preoccupation with a perceived body flaw. It affects men and women equally and can be socially crippling.
These individuals can be quite persistent in their efforts to receive cosmetic treatments and are rarely satisfied with treatment results. An excellent reference source for those who would like to learn more about BDD can be found online at the Rhode Island Hospital Body Dysmorphic Disorder website. The criteria used to identify these patients goes beyond the scope of this article, but these patients as well as those with other borderline personalities should not be treated.
Not only are these individuals incapable of seeing improvement after treatment, but they can often turn against you and threaten you physically and/or legally.4 These situations require a delicate and tactful approach because the correct course of action is a psychiatry referral. It’s helpful to avoid beginning the conversation with hot-button words like “psychiatrist” or “mental health.”
Unlike an endodontic or dermatologic referral, psychiatric referrals unfortunately have social stigma attached to them. You could try something like this: “Jane, I’d like you consider speaking with one of my colleagues who could help you sort out what you’d like to accomplish from this procedure. This could help clarify your esthetic desires, and afterward I’ll be happy to discuss it with you.”
Sometimes the chemistry just isn’t there. Other times it’s about patients you’ve been treating for years and you already know the complexities they represent—and that’s just for routine dental work! In these situations, go with your gut and don’t head down that slippery slope.
My personal strategy is to relieve the patient of the burden of responsibility and place the onus on me, as in this example: “David, I understand what you’re looking for, but I don’t think I’m the best one to deliver that for you. Let’s see if we can find an appropriate referral.”
If their response is something like: “But I know you did the same thing for my friend, so-and-so!” I’ll reply with, “David, HIIPA laws don’t allow me to discuss any other patients, but please remember, every cosmetic case is different and has its own unique challenges.”
What about the ones who slipped through undetected? You’ve already treated them and now, like clockwork, they call every week with some related issue. “I still see wrinkles… I still think I need more… Every time I do ‘this’ I can still see it… Are you sure you used Botox, because it didn’t work like the last time… Am I going to get charged again, because this should have been perfect…” We’ve all had them.
With the first call, I give everyone the benefit of the doubt and see them right away. Legitimate refinements are not unheard of and usually easy and pleasant to manage. Your employees on your phone staff are often the first to identify problem patients, with lots of eye rolling when they come to tell you that so-and-so is on the phone—again. Make it a concrete rule that after the 2-week follow-up visit, you stop tinkering with modifications at will.
Trust me when I tell you this is the classic dog-chasing-his-tail scheme. At some point along this maddening trajectory, you’ll realize you have to end it. Do it early and save yourself and your staff the aggravation. If it appears to be an unreasonable request, I apply the brakes and say, “Mary, it’s now beyond the 2-week mark. We really need to pause and re-evaluate at the next natural interval for treatment,” which is either 3 months for neurotoxin or 6 to 9 months for most dermal fillers.
If I feel I’m dealing with a patient who is potentially dysmorphic or just angling for something free, I’ll close the door more firmly, as in: “Alex, I believe we’ve reached a point where I don’t think there’s anything more I personally can do for you. Perhaps it’s time to find someone who more closely shares your esthetic vision.”
Dealing with difficult patients is, well, difficult. If you’ve been in practice long enough, you know that life with these patients rarely gets better with time. Once you’ve treated a patient, you’re responsible for follow-up care. Check your state laws and malpractice policy to see how long that period is.
My estimate is that probably 98% of the patients we treat with facial injectables are happy with their results, and so are we as practitioners. But that remaining 2%! Patients we probably should never have agreed to treat in the first place wind up occupying a disproportionate amount of time in our practices and in our heads.
These patients can be pushy, manipulative, abusive to your staff, and too busy to get proper pre-operative clearance by their doctor. They also are always angling for discounts, expecting perfection rather than improvement, and frequently presenting with special scheduling requirements. Resist the fantasy that you can please everyone. Be vigilant, be prepared, and always recognize and treat within the limits of your competence.
Facial injectables can be an incredibly rewarding and refreshing departure from the traditional dental procedures you perform daily. As the practitioner, you play a central role in the development of this segment of your practice.
Careful patient selection includes evaluation of subjective intangibles that fall well outside the injectable product capabilities. Identifying patients you shouldn’t treat and managing those individuals promptly and professionally will help you create an injectable practice you love.
Disclosure
This article is not intended to represent legal advice. Please consult with your attorney for definitive advice on how to legally decline cosmetic treatment for patients in your state or province.
References
- “New 2015 Stats: Face of Plastic Surgery Goes Younger Due to Growing Social Media and Reality TV Influence on Millennials,” American Academy of Facial Plastic and Reconstructive Surgery
- Sarwer, Wadden, Pertschuk, & Whitaker, 1998; Phillips, Dufresne, Wilkel, & Vittorio, 2000
- Sarwer, Wadden, Pertschuk, & Whitaker, 1998; Phillips, Dufresne, Wilkel, & Vittorio, 2000
- Sarwer, Wadden, Pertschuk, & Whitaker, 1998; Phillips, Dufresne, Wilkel, & Vittorio, 2000
Dr. Gigi Meinecke is the founder and principal of Facial Anatomy for Comprehensive Esthetic Seminars (FACES), the only facial injectable course to combine cadaver review workshops with live patient training. She has lectured nationally since 2010 on facial injectables and maintains a full-time private practice in Potomac, Md. She is the immediate past president of the Maryland Academy of General Dentistry and a Fellow in the International College of Dentists. She serves on the ADA Council on Communications and the AGD Legislative and Governmental Affairs Council, and she is a national spokesperson for the AGD.
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