Dealing with difficult or unsatisfied patients is my least favorite aspect of being a dermatologist. Frequently, you are unaware of the fact that a patient is dissatisfied because he or she simply leaves the practice. Sometimes you do know because the patient badmouths and berates you on the Internet. Occasionally, you find out about it because the patient returns to the practice demanding that he or she be “fixed”.

The first type of patient (the leaver) is gone but sometimes returns when unable to find care that meets his or her expectations. It is sometimes helpful to call this type of patient and find out what prompted his or her departure. These phone calls are brutal but insightful. Early in my career, I realized that some people either don’t think I am as funny as I think I am or do not understand my particularly succinct way of dealing with certain situations. The fact that not all patients share my insights was made crystal clear to me about 13 years ago. After a patient transferred care to another dermatologist, my office called to find out the reason and we were informed that he wanted a dermatologist who would help him rather than tell him to figure out his disease himself. My crime — I had written the name of the disease that he had (Grover’s disease) on a piece of paper and instructed the man, who by profession was a pilot, that if he wanted to read about his condition, there was a lot of information to help him understand the process. In an attempt to educate him I had succeeded in alienating him, but I learned that not everyone hears what I say the same way and I changed my approach in the future.

The second type of patient (the Internet commando) realizes that in the abyss of the Internet his or her voice can resonate forever and allow the patient to exact some form of retribution since physicians are bound by confidentiality from putting posting a patient’s name on the Internet. Physicians also tend to not have the time to put in the public relations work to correct the record. Unfortunately, happy patients usually do not spend the time in Healthgrades or Google or anywhere else to help provide a more balanced view. In fact, this phenomenon was recently cited in the New England Journal of Medicine, although the author arrived at a rather puerile conclusion to the effect that all will be well in the end1 (Read the article by Dr. Shaili Jain here: http://content.nejm.org/cgi/content/full/362/1/6 ). I suspect that many of the people that end up berating their physicians on the Web are either unrealistic or that they suffered a bad or sub-optimal outcome. Medicine in general and dermatology in particular are not exact sciences and the human body can heal in many different ways (witness the keloid). Patients who do not obtain results that they expect may end up discussing them online. One way to avoid this is to have candid discussions with patients and have them sign consent forms that spell out the potential outcomes. Cosmetic patients who are being treated with injectables or lasers may not have the financial or emotional resources to attain an optimal result and these patients are likely to become unhappy when they do not get the outcomes they desire. If you are not likely to make someone happy and you, or your staff, have the sense that they will be an adversary rather than a partner, your best method of dealing with this unsatisfied patient is to avoid treatment. Once the damage has been done, to your reputation and to the patient’s expectations, it cannot be undone, so tread lightly.

The third type of patient (the returner) is easier to assess. Either there is something wrong or there is not. Asymmetry happens, lumps occur — if you can fix the situation, you should do what you can to make it right. Ignoring it or minimizing it is not the right thing to do. It is not the way we would want to be treated and it is really bad for the practice on many levels. Inject what you need to in order to achieve a good outcome, laser the area that does not look like it should or spend the time to work out a treatment plan that mitigates the problem.

More complicated is the situation that arises when there is not something wrong but there is not the outcome that the patient expected. In my practice, this is a judgment call and when my nurses or I believe that the patient has an agenda that includes free treatments, we explain to the patient that the outcome he or she desires will require the material or treatment that could have been performed at the initial treatment and that the cost will be whatever the additional cost would have been. I think that this is fair for all parties. If there is a patient in whom the botulinum toxin needs a few more units for a great outcome, I am happy to provide it at no cost. If a patient wants a different area treated but doesn’t want to pay for it, I will not agree to do it free of charge. The same holds true for fillers. While this is not a perfect system and I am sure that some patients find it objectionable, I think that it is fair and that over time it is the best system for patients and the practice alike.

There are many types of unhappy patients and I am sure that the reasons extend beyond my ability to either categorize or understand. Handling a dissatisfied patient involves either trying to avoid making him or her unhappy in the first place or figuring out what the situation is really about. Mechanical fixes of things that you could have done better are the easiest to solve. More complicated are the psychological ones.

1. Jain, Shaili. Googling Ourselves -- What Physicians Can Learn from Online Rating Sites. N Engl J Med 2010 362: 6-7