Seth Matarasso, MD, Explains How to Respectfully Work With Frustrated Patients

Seth Matarasso, MD

At the 2023 American Academy of Dermatology (AAD) Annual Meeting, Seth Matarasso, MD, FAAD, clinical professor of dermatology at the University of California San Francisco School of Medicine and president-elect of the American Society for Dermatologic Surgery, discussed best practices for identifying frustrated patients and how to address their concerns.

Matarasso spoke with Dermatology Times® to discuss his difficult patient session presented during the “Dermatologic Surgery: Cosmetic Tips and Pearls” track at AAD, co-directed by Gary D. Monheit, MD, FAAD, and Rhoda S. Narins, MD, FAAD.

Dermatology Times: How do you identify a dissatisfied patient?

Seth Matarasso, MD: As physicians that provide cosmetic procedures it appears that we have evolved into a service industry and at some juncture inevitably one will encounter an unhappy patient. Successfully dealing with a frustrated patient is dependent on how they are managed. There are a few important considerations. First and foremost, try to identify potential problem patients and if there is a red warning flag, ultimately not preforming an elective procedure will save a lot of angst in the long run. After over 30 years in practice, my staff and I have developed a sense of who might not be content with their results and will encourage them not to proceed. One of the more recent concerns that has arisen is the advent of the “TikTok Doc.” With the popularity of these videos, many people consider themselves experts and will request procedures that they have seen online. These patients often do not have realistic expectations because the results that they have seen online is what they're hoping to recapitulate and often that does not translate well to their individual anatomy or what they are trying to address. The bottom line is if you or your staff perceive that the patients’ goals cannot be realized, it is in everybody’s best interest not to proceed.

Dermatology Times: What are your other tips for identifying a dissatisfied patient?

Matarasso: I think it is of paramount importance to establish a rapport. One of the most important tools in my practice is the stool that I have in each one of my treatment rooms. I will sit down and actively listen to patients' concerns. I engage in a dialogue with them and will listen to what they're trying to accomplish and if they have a timeframe in which to achieve these goals and in every initial consultation, I ensure that the patient is aware of all their treatment options. If a rapport has been established and the patient feels comfortable with you and your staff and a problem arises, they will be amenable to working it out. A friendship perse is not necessary, but make sure that there is an open and frank dialogue so that if something does go wrong, it can be amicably resolved. Furthermore, I always have a nurse or chaperone accompany me in the treatment room. That person can take notes to document the entire interaction and the focus is entirely on the patient. Photo documentation and signed consent forms can also help mitigate problems. Photographs taken from many angles is an important tool. Oftentimes after a patient has a procedure, they forget their baseline appearance. For instance, a patient who is concerned that their neurotoxin was ineffective, showing them their pretreatment pictures can demonstrate that their result was aesthetically appropriate and that will satisfy their expectations.

Dermatology Times: How do you tell a patient you aren’t going to perform their procedure?

Matarasso: Not charging a patient for their initial consultation and providing them with brochures and additional information so that they are well-informed and educated about what to expect can defray animosity. If they still want to proceed, they can return at a later date after they have considered all treatment options with the consequent potential adverse events, and a reasonable treatment plan can be formulated. Again, if the patient is simply not going to be satisfied, in the long run, it is not worth the angst that can occur. 

Dermatology Times: What is your process for addressing a patient that does come back unhappy?

Matarasso: Despite adequate photo documentation and a signed consent form, some patients may still express dissatisfaction. The most important first step is communication. Put yourself in that patient’s position. For example, if there is an unforeseen scar or pigment from a resurfacing procedure, ptosis following neurotoxin, asymmetry, or ecchymosis following a dermal filler how would you react and consider how you would like to be treated. Make sure that the patient can contact you and the office and that your staff can recognize if there's a problem, so that the patient can quickly return to the office to be evaluated. It is ill-advised to have a dissatisfied patient seek counsel elsewhere as their concerns can be taken out of context and the situation can escalate into potential hostility. Have the patient show you in a handheld mirror exactly what they are unhappy with or what they weren’t expecting. Then, you can formulate a treatment plan that will rectify it or make the patient more satisfied. Explain what can be done, what result can be expected, and initiate the protocol in a timely manner.

Similarly one of my tenets is if you are seeing a patient in consultation regarding a complication from another physician, be courteous and do not denigrate that doctor. Encourage the patient to go back and speak to their original physician to see what can be done and give that physician a chance to improve the outcome. If that is unsuccessful, l then I will endeavor to improve the complication.

Dermatology Times: Do you have to be careful when addressing a complication?

Matarasso: If there is a frank complication, I would suggest initially discussing it with your malpractice insurance carrier. When I counsel patients with complications or are dissatisfied, I try to be very precise with my communication so that there is no further misunderstanding. Offering an apology and/or refunding monetary funds can become a point of contention as it can be perceived as an admission of guilt and the patient can seek legal counsel citing malfeasance. That decision can be determined on an individual case-by-case basis. Much of the decision-making process will be contingent upon how correctable or the problem is and how unhappy the patient is. One of the most important things a physician can do upon completion of the interaction is acknowledging the patient's concerns, thank them for bringing it to your attention, that you appreciate their patience, and schedule a follow up in a reasonable time. This demonstrates an empathetic response and highlights that their best interests continue to be a priority.

Dermatology Times: Do you have an example of a difficult case that was escalated? 

Matarasso: Yes, unfortunately, I have had instances where a patient did not come back to me after a procedure or notify me that they were unhappy, and I learned about it via social media or they went to another physician. The worst-case scenario is to hear about a patient’s dissatisfaction via legal notification. One of the most egregious cases was a woman who was referred to me by her dermatologist. After placement of a total of 0.5cc of dermal filler in her nasolabial folds she felt that she was asymmetric. I requested that she come in to be evaluated at her convenience. One month later she returned, and I showed her the before and after photographs. She agreed that her result was acceptable and that there was no demonstrable asymmetry. I thanked her for returning to the office and asked if there was anything else that could help her with. She responded by saying that her lips were not large enough and that she had wrinkles around her eyes. I told her that I had not addressed these areas in the procedure, and we could re-address that at another time. The interaction became very contentious, and she got emotionally labile and claimed that I was the only physician that she would allow to treat her. I contacted my insurance company who advised me to refund her fees and discharge her.

One month later I received a letter from the Medical Board citing negligence and that the woman in question has gross facial asymmetry following the placement of 0.5 cc of a dermal filler. With legal counsel, a detailed letter was submitted with a copy of her signed consent form and copies of her clinical photographs. Ultimately, after a year and a half after the case was filed, it was dismissed. Ironically, I subsequently found out that this same woman had filed complaints against her prior two dermatologists before seeing me, and tried to sue an additional physician after our interaction. One of my other main points from my presentation is if you know that patient is already involved in litigation, if you are to proceed, proceed with great caution. The moral of this saga is even though the patient had a signed consent which details all potential complications (including asymmetry), and precise photo documentation, there will be a subset of patients who cannot be pleased.

Dermatology Times: What about patients who approach their dissatisfaction the right way?

Matarasso: In my presentation, I mention a patient who had a laser treatment that resulted in facial scarring. Fortunately, she had been a patient of mine for many years and had the confidence in me and my staff and allowed us to work through the compilation until there was complete resolution. Similarly, a patient returned with eyelid ptosis following neurotoxin. I acknowledged it, came up with a treatment plan, initiated it immediately, and was quickly able to restore the patient back to a baseline appearance. When I reviewed her original pretreatment photographs, which is a hallmark of any procedure, she had baseline ptosis. Both patients had every right to be dissatisfied. But because I had a longstanding relationship and rapport with them they came back, explained what happened, came up with a treatment plan, initiated it quickly, told them I was going to try to make it better, and saw them on a regular basis until there was resolution. The learning point was communication, establishing a rapport, and frequently, the patient will remain loyal.

Dermatology Times: In your presentation, you mentioned the depressed patient as a potentially unhappy patient. Have you had challenges with patients seeking cosmetic procedures that are not in the best mental state?

Matarasso: On occasion patients will come in for a consult and they are experiencing a crisis such as a divorce, death or another life-altering tragedy and they hope that a cosmetic procedure will improve their plight. As dermatologists we are not trained to provide psychological therapy however, if you discuss the cause of their concerns, the different treatment options and give them information and allow them time to think about the procedure and to return later to proceed with the procedure, they appreciate the compassion and will often return when they are better equipped for a procedure.

One of my favorite sayings is “primum non nocere.” First, do no harm. If you get the sense that the patient is not in the right frame of mind for a procedure, don’t do it. Reverse the roles. Be an empathetic physician. We all took the Hippocratic Oath or the oath of Maimonides: compassion always prevails.

Dermatology Times: How do you respectfully talk with a patient that you don’t feel is mentally prepared for a cosmetic procedure?

Matarasso: I learned the hard way. I had a patient referred to me by two sources. She came to the consultation with multiple bags of a myriad of skin care products and tretinoin. After a lengthy discussion, her skin care regimen was simplified. The patient subsequently returned a few months later and was pleased with her progress, however she still had some deep facial lines. She was informed that those lines/wrinkles would not be responsive to a topical regimen and that a more invasive procedure such as a laser or an injectable would be necessary to efface those rhytids.  The patient said she was ready to proceed with injectables. I sensed that there might be some red flag warning signs and told her that I was not sure I could meet her goals and expectations, however I would continue advice on her skin care. At neither of our encounters was the patient charged a fee and despite my attempt at honesty, she posted a blistering online review. This patient subsequently saw two dermatology colleagues. After treating her on multiple occasions also at no cost, they too had to discharge her. There are certain personalities that despite the best of intentions will remain discontent and will require you to proceed with care and caution. Those patients require careful conversations and ideally a nurse chaperone present in the room to document the consult. 

Dermatology Times: What closing remarks do you want fellow physicians to take away?

Matarasso: Put yourself in your patient’s position: they paid discretionary dollars, were expecting remarkable results and conversely they are seeing unexpected results or results that were not promised online or on Google. And now with the advent of social media, prior to trying to resolving the problem, patients may resort to venting their concerns on platforms which can be irreparably injurious to one's reputation: once in cyberspace-always in cyberspace. It takes ten happy patients to get one new patient, but conversely, it only takes one unhappy patient to make ten to leave the practice. Try to remember that you are not going to make every patient happy all the time and one of the many hats that we wear is to recognize those who will not be pleased and try to educate them.

Complications occur and dissatisfied patients exist. When this happens, be available, communicate, devise a treatment game plan, and follow up. And remember how would you feel if this happened to you or your family member? Just knowing that you're empathetic and compassionate makes the situation much more palatable for the patient.

My closing words are that physicians try to do what we were trained to do what is in our patients’ best interests, without ulterior motives and provide care that is therapeutically correct. Invariably the longer we are fortunate to practice dermatology, the greater the possibility that we will have a patient, who despite great effort, is dissatisfied. You're not going to be able to please all the people all the time, but in my experience if you are sympathetic, empathetic, and speak to them in good faith, the chances of having an unhappy patient can be greatly reduced.

[Transcript edited for clarity and space]