Safer practice of dermatosurgery

KHS Rao

 Member, IADVL Dermatosurgery Task Force* and Senior Dermatologist and Chief of Polyclinic, Central Government Health Scheme, Bangalore, India

Correspondence Address:
KHS Rao
Senior Dermatologist and Chief of Polyclinic, Central Government Health Scheme, Bangalore
India

Introduction

The demand for dermatosurgery, especially cosmetic procedures, has increased because of various factors that include greater awareness about aesthetic procedures, the importance given by society to beauty, the availability of safe and simple procedures, increasing affluence of the population seeking surgery and affordability of the surgery. ^{[1],[2],[3],[4],[5],[6]} Simultaneously, patients′ expectations from such procedures have increased, often to unrealistic levels, mainly because of exaggerated and misleading advertisements and false claims appearing in the media. Frustration and litigation are likely to arise from mismatches between expectations and results. Patients desire to get procedures done by "safe" hands and dermatosurgeons desire to practice "safer" surgery. Such a balance is achievable provided certain key issues are kept in mind. The guidelines presented in this article seek to present a safe and realistic approach for the practice of dermatosurgery.

Selection of Patients

This should be done based on careful consideration of various criteria that include patients′ age, medical indications, contraindications, chances of complications, etc. It would be unethical to yield to unreasonable and unrealistic demands for cosmetic procedures. Patients with depression, dysmorphophobia and those obsessed with beauty must get a psychiatric consultation before being subjected to any cosmetic procedure.

Counseling

Adequate time must be given for information exchange between the patient and the doctor. Mutual trust is crucial-the doctor should always keep the best interest of the patient in mind and the patient should have faith in the doctor.

Informed Consent

Before subjecting a patient to any kind of procedure, the patient should be given adequate information that a "prudent patient" may expect or demand to know so that he/she can make decisions about treatment. This should include the type of condition that the patient has, need for treatment, consequences if any, of non treatment, modes of possible treatment, duration, number of sittings, approximate cost of treatment, expected results, need to follow instructions before and after the procedure and the possible side effects or complications. Important information should not be withheld, e.g., if a better / cheaper / more effective / safer procedure is available elsewhere.

Important points to remember are:

1. Consent should be taken prior to the procedure.
2. It should not be a routine affair like getting the patient′s signature on a dotted line by a staff member.
3. It should be preceded by adequate exchange of information.
4. Adequate opportunity should be given to the patient to ask questions and clarify any doubts.
5. Consent form should be signed by the patient or the parent/guardian in the case of minors.
6. In the case of teenagers (13-18 years), it is better to take the signatures of both the minor and the parent.
7. The patient should have the liberty to revoke his consent at any time.
8. Consent cannot be a blanket one to carry out any procedure that may be deemed fit by the dermatosurgeon.
9. Consent form cannot have clauses to the effect that seems to absolve the dermatosurgeon of all mishaps.

Preprocedure Work-Up and Care

This includes investigation to rule out certain diseases/conditions, treating/controlling them, preprocedure use of tretinoin in some procedures, allergy skin testing with lignocaine, test procedure in case of certain procedures, etc.

Surgery/Procedure Proper

1. The dermatosurgeon must desist from carrying out procedures in which he / she does not possess necessary expertise / skill / experience.
2. The dermatosurgeon should follow standard protocol / procedure.
3. The dermatosurgeon should not be negligent while carrying out the procedure.
4. Surgery must be carried out in a well-equipped centre.
5. The centre must have facility to handle all medical emergencies.
6. The IADVL-approved standards of care in dermatosurgery / cosmetic surgery are a useful guide for the practice of safer dermatosurgery.
7. Dermatosurgeons must realize that they have to bear the ultimate responsibility for the work done by their trained staff.

Postprocedure Care

There should not be any disinterest / negligence while providing postprocedure advice / care. Early recognition of a bad job / complication helps in its rectification / management. Unintentional errors can happen at any time. Its graceful acceptance and timely remedial measures are often appreciated by patients. Remember: A satisfied patient means a repeat patient.

Ethical Angle

The patient has the right to autonomy, information, privacy and confidentiality. The basic dictum "above all do no harm" must be followed. The risk-benefit ratio should be weighed before performing any procedure. Patients′ information must not be disclosed to third parties without specific permission from the patient. The privacy of the patient must be protected while treating the patient and while presenting / publishing medical data.

Legal Angle

The patient has the right to demand standard care. The dermatosurgeon is bound by duty to provide it, subject to the fact that no kind of guarantee can be given as to the final result. An aggrieved patient can approach the consumer forum with a complaint of medical negligence within a period of two years from the date of cause of action. The following points must however, be kept in mind:

1. Adherence to the various criteria and protocols, are considered adequate to prove in any forum that "Standard care" has been provided to the patient.
2. Prior, written, informed consent is a must.
3. Documentation should be accurate, chronological, complete and clear.
4. Pre- and post procedure photography is very helpful.
5. Records must be maintained for at least three years.

Conclusions

A cordial doctor-patient relationship, empathetic handling of patients, proper counseling, proficiency in skills, and adherence to established guidelines are the best insurance against litigation. However, in this present age of consumer activism, it is recommended to avail professional indemnity insurance to cover the risk of allegations of medical negligence and its consequences. ^{[1],[2],[3],[4],[5],[6]}

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