Web Log – July 2018 – Declining to Operate

I completed a full five year General Surgery Residency and became Board Certified in General Surgery.  I do not take out colons or thyroid glands as a Plastic Surgeon, of course, but I and all surgeons learn valuable concepts in General Surgery.  These concepts include taking personal responsibility for your patient, providing your best care no matter the circumstances,  and putting the needs of the patient above your own.  There are many, many more lessons that I learned, but one that has particular application to elective Plastic Surgery is when not to operate.

A good General Surgery example is the patient who presents to the Emergency Room with right lower quadrant abdominal pain.  Survey says… appendicitis and a quick trip to the operating room!  But this type of pain is not always appendicitis.  The differential is long.  What if the pain is due to  a urinary tract infection, kidney stone, pancreatitis, or pelvic inflammatory disease, etc (all conditions that do not require an operation)?  Then you have subjected your patient to an unnecessary operation to open the abdomen and all that entails.  Now, a negative laparotomy of 15% when operating for appendicitis is considered acceptable.  If the general surgeon waited around until the diagnosis was 100% clear, you would have a lot of patients with ruptured appendixes and that’s not good.  So, what about elective (mostly cosmetic) Plastic Surgery?  What rate should we be aiming for?

I have near daily consultations with patients seeking elective surgeries like rhinoplasty, breast reduction, and abdominoplasty.  For these examples, as well as for almost everything else I do, the patient does not have undergo an operation.  He or she wants an operation.  The operation is considered a success if the patient is happy with the result, the value (result versus fee) and has had no problems before, during, or after the procedure.  I am expected to be as close to perfect as possible and I am certainly trying.  Alternatively, the patient is not harmed if I decline to operate.  That is entirely different than someone who has a lip laceration and needs it closed.  There is significant harm in not operating on a cut lip and a good chance that the patient will be improved, and hopefully happier, once we are though the operation and recovery period.

Now, back to the concept of putting the needs of the patient above your own.  I like to operate.  I have a staff who likes it when I operate because then they have a job.  As you might guess, my family likes it when I operate too (and not just because I am out of their business for awhile).  So, if I decline to operate on a patient who is seeking an elective procedure, I have a good reason.  And the reason is given the totality of evidence (my exam, my perception of the patient’s expectations, the patient’s health, and my experience), I feel the risks of operation outweigh the potential benefit.  Remember the old adage, do no harm?

Most patients who I assess and decline for operation understand and accept this thought process once I have explained myself.  I also point out that a consultation is merely my opinion and the next Plastic Surgeon may have a different opinion.  Unfortunately, a small minority of patients are offended and even angry.  This, truly makes me feel bad, but it does not change my decision.  I can only apologize for the perceived insult (insulting a patient is one of the last things you want to do) and hope the patient will eventually respect my good intent.


Mark D. Wigod, MD, FACS, providing Cosmetic and Reconstructive Plastic Surgery to Boise, Meridian, Treasure Valley and Southeastern Idaho.

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