SAN FRANCISCO Dermatologists who perform cosmetic surgery take a variety of approaches to obtain a patient's informed consent, with differing views on the best method to do so.
Some try to list every possible complication of a procedure on informed consent forms. Others see that as a trap if they omit the one problem that the patient develops, and prefer more generic references to potential complications.
Four experts in private cosmetic surgery practices shared best practices in obtaining informed consent on a panel at the annual meeting of the Pacific Dermatologic Association. All agreed that there should be two copies of consent formsone for the patient's chart, and the other to go home with the patient.
Dr. Roberta D. Sengelmann uses a fairly generic consent form in her current practice in Santa Barbara, Calif., and St. Louis, Mo., and after a thorough discussion with the patient, documents specific pertinent risks in their medical record.
In her experience as an expert witness for dermatologic procedures, she has found that the danger of itemizing every possible risk is that should something occur that was not listed, problems will arise.
Dr. Sengelmann said that important phrases to include in consent forms are that "No guarantee can be made" for specific results, and "Sometimes additional procedures are needed to obtain the desired result."
Dr. Ronald L. Moy of Los Angeles takes a different approach, influenced by his 8 years of service on the Medical Board of California. Many of the cases handled by the board involved patients who said they were not aware that they were at risk for a particular complication.
"It's true that you're not going to include everything, but you can include 99.9%" of potential complications on the form, he said, adding that an extensive list is best.
Dr. David R. Harris, who is from Campbell, Calif., agreed, and added that the form also should point out the cost of additional procedures; otherwise, patients might assume that the work is free.
His office developed an easy-to-understand format that uses bullets and short explanations on the consent form instead of "legal mumbo jumbo." He asks patients to sign a clause saying they will go to arbitration rather than file a lawsuit if they end up in a conflict over the results, even knowing that an arbitration clause is not binding.
Dr. Moy takes a different tack, asking patients to sign a statement saying that if they were to take legal action, they would use an expert witness from one of the four medical specialty societies in which Dr. Moy is a member. This would exclude expert witnesses from specialties that have had turf wars with dermatologic surgeons.
Dr. Greg S. Morganroth of Mountain View, Calif., asks patients to sign an arbitration agreement and tells them it is not binding. He uses the discussion primarily to develop a mindset that he and the patient are collaborators working together.
Malpractice carriers tend to frown on arbitration agreements, he noted, because physicians are more likely to win a case in a court of law than with an arbitration panel. The nonbinding nature of these agreements cut both ways, however, so that he could opt out of the agreement if it ever came to that.
His informed consent form includes a checklist of items that patients must initial. Patients must acknowledge, for example, that they are aware of how long healing may take, that Dr. Morganroth is not a plastic surgeon, and that some physicians would be critical of a dermatologic surgeon doing cosmetic surgery.
For larger facial surgeries, he numbers them, telling a patient that she is the third case he will have done for a particular procedure, or number 364. "I go a little bit overboard," but it avoids a patient getting angry later if he learns of this fact, he said.
The danger of itemizing every risk is that should something occur that was not listed, problems will arise. DR. SENGELMANN