Editorial Board Forum: How Do You Manage Expectations?

WHY IS IT IMPORTANT TO MANAGE PATIENT EXPECTATIONS?

Jason Pozner, MD: It is very, very important; At its simplest, the key is to not oversell. The older I get the blunter I get with patients. Tell it to them straight; risks and benefits and when surgery is the right option. Don't be afraid to say no to people when they want the wrong thing.

Joel Schlessinger, MD: Expectation management isn't important - it is everything when it comes to aesthetics. If you don't do this right, you can pretty much forget having a successful practice. Sure, some folks will come in and use your services once or twice, but they won't trust you after they see results unless you explain in detail what they can expect and temper their enthusiasm if necessary.

Steven Pearlman, MD: Expectations and outcomes are the only way we can truly measure the results of aesthetic procedures and surgery. We aren't curing diseases or removing cancers. Eradication of such entities and cure rates, survival rates are easier to track and compare. From a scientific point of view, applying evidenced based medicine to aesthetic procedures is far more difficult than similar measures for illness based treatments.

For surgical procedures such as rhinoplasty I use computer imaging. I try to “under-do” the results; under promise and over deliver.

Julie Woodward, MD: Expectation management is an investment of the physician's time that increases the chances of having a satisfied patient. The amount of the investment is dependent on both the patient's personality and the type of procedure. Approximately nine percent of the population is on the spectrum of some personality disorder such as borderline/narcissism, bipolar, or anxiety. These patients often require more time and can cause the physician more grief postoperatively.

Some procedures have more BPB (Bang Per Buck) than others. Blepharoplasty has high BPB (dramatic results) while Ultherapy may have lower BPB (subtle results). Both can yield very happy patients but the blepharoplasty consult will have more time invested to explain post op care while Ultherapy will require more time to explain possibility of results and perhaps even a suggestion to have a facelift instead.

Vivian Bucay, MD: Managing expectations means being honest with the patient and with myself. As physicians, we often suffer from “the disease to please,” which can lead to not saying “no” to a patient…It's best to go with one's gut feeling. If that inner voice says to steer clear of trouble, listen to it.

Gregory Buford, MD: Our patients are being bombarded with unrealistic expectations regarding outcomes from products and procedures, and these unrealistic expectations are coming from a variety of sources. Some are from television shows hyping “zero downtime” rejuvenation or simply promising results that we could never expect to attain with the average client.

Another source is our non-core competition who use dramatic language and one-in-a-million result photos to try to sell their way into the aesthetic marketplace. And the other source is, sadly enough, our own patients. Some patients simply don't absorb what we say during the consultation and expect far more than we can ever deliver.

Randolph Waldman, MD: Expectations of a patient are so important in all of our decision making. False expectations are probably the most common cause of patient dissatisfaction and we simply do not want patients who are dissatisfied.

Joe Niamtu, DMD: Most leading cosmetic surgery practices are pretty savvy at providing concierge care. When patients know they will be treated special, sometimes they expect too much. Basically happiness means meeting someone's expectations. So, if you have a normal patient with normal expectations and they have a positive experience with a good outcome, everything comes together. However, many patients have unrealistic expectations and no one can make them happy. Or a patient can have normal expectations but experience a complication.

Paul Carniol, MD: Before performing a procedure we routinely give patients an explanation as to the likely outcome, variability of results, the risks, alternatives and the associated costs. This enables a patient to make the decision as to whether they want to have a procedure. After this, the vast majority of patients will be happy with the outcome (98+ percent). However, there can still be a minority of patients (one to two percent) who may not be happy, regardless of the explanation or the outcome. If you can identify these patients in advance (not always possible) it is better not to perform the procedure.

Dr. Waldman: We are clear to avoid any promises about outcomes unless we have considerable experience with the technology or procedure. We never use industry generated pictures and never make promises based on any experience other than our own.

Jeanine Downie, MD: We need people to understand that laser, fillers and toxins will make them look and feel better. If they have expectations that they are going to look like they are 20 again then you will immediately fail them.

Educating the patient honestly about what their outcomes will be and what they will look like is one of best things that I can do for me and my practice.

When you have satisfied happy patients, they will refer other patients who will then be satisfied happy patients. Your reputation grows and it is wonderful. A disgruntled patient who has not been educated properly can be your worst nightmare.

ARE YOU SEEING ANY TRENDS IN EXPECTATIONS BEYOND RESULTS? HOW DO YOU HANDLE THESE?

Dr. Pearlman: We are in the era of communication and immediate gratification. This has affected every business. Patients are no longer satisfied by waiting for a post-op visit to discuss concerns. We get texts, emails and selfies with areas of concern that more often than not will either go away or not be addressed for months. A lot of this is left up to the support staff, not to give specific answers but to help manage inquires and triage those that may be a real issue.

Dr. Bucay: I give patients my contact information so they can reach me quickly after hours. As a rule, patients are very respectful of my time. Ever since I included a phrase to my consent forms that there is no guarantee regarding results, requests for free goods and services has decreased to almost zero. It all goes back to setting expectations. Ground rules have to be set as well.

Dr. Niamtu: I already give all patients my cell and email. We also do some value added things with patients that are paying a lot of money. I always try to produce an environment that puts forth high expectations that cosmetic consumers have come to expect. Once in a while, a patient wants something for nothing and unless it is a pro bono situation, we just say no.

Dr. Carniol: Expectations beyond the results at times can be associated with enthusiasm for a technology, procedure or product by broadcast or social media. We take time to show patients before and after photos as well as answer all questions to deal with possible inappropriate expectations.

Dr. Buford: I am seeing more and more clients trying to negotiate bundled services and a continued commoditization of the aesthetic marketplace. I do try to keep my price point competitive and so there are times when I will bundle. But I will also not give away my services for free. As far as access goes, I make myself available in a reasonable manner but I also set boundaries…When you set the tone for this with your patients from the get-go, I find that a majority of them are completely appreciative of your time and respect these boundaries.

Dr. Downie: A few patients will feel that if they purchase one or two syringes of filler, that I should pay for the rest of them. I try to manage this expectation by explaining to them that we lose a teaspoon of volume from our face every year from the time that we are 30. It is not until we get into our 40s that we start to notice significant volume changes. I explain to them that especially if they smoke or tan that they should decide how much money they want to spend on filler, and then we can go from there with managing what they would like to do with what they wish to purchase.

WHAT ABOUT YOUR EXPECTATIONS FOR YOUR OWN PROFESSIONAL EXPERIENCE OR PRACTICE? HAVE THEY CHANGED?

Dr. Pearlman: I don't think that we have changed much over the past few years, other than needing to answer many more questions both before and after procedures. As for staff, nothing beats quality, educated supportive staff.

Dr. Carniol: We manage our expectations by reserving our decisions about efficacy and outcomes until we have the opportunity to use the technology, product or procedure.

My staff and I have worked together for years; we share high standards and expectations.

Dr. Bucay: I have very high expectations, and they are getting higher all the time. I demand excellence of myself and of those who work with me, but I also invest heavily in staff education and training. Excellence does not materialize from thin air.

Dr. Buford: I expect that the level of customer service provided by me to my clients is matched by the customer service provided by my reps to the same. Without it, there is no consistency.

Dr. Waldman: The lines of distinction regarding who should be doing what have become very obscured and the public is confused. We try to act as an ethical information source for those who come to us for an initial consultation and we avoid any aggressive sales tactics. We do not offer commissions to our staff for “upselling” procedures. I know that this is becoming more common, but I am very uncomfortable with this and feel as if those who do have an obligation to advise their patients that they need to be aware that so and so on your staff is a commissioned sales agent.

Dr. Downie: I have actually increased my expectations expect my staff to strive for excellence—even when people are being unreasonable, even if people are not being professional. I expect them to rise above and give excellence at all times. This can be annoying for my staff to achieve. And it can be stressful for me to achieve. But we continue trying because it is something makes us better.