On 1 June 2016 the GMC published ‘Guidance for all Doctors Who Offer Cosmetic Interventions’ which set out the standards expected from doctors who provide cosmetic interventions.
One of the key messages in the guidance is that a doctor must consider their patients’ psychological needs and whether referral to another experienced professional colleague, such as a psychologist, is appropriate. Specifically, the guidance advises doctors that:
‘When you discuss interventions and options with a patient, you must consider their vulnerabilities and psychological needs. You must satisfy yourself that the patient’s request for the cosmetic intervention is voluntary.’
Is it fair to ask surgeons to do this? Does it fall within their professional expertise to determine where to draw a line between say an insecure patient looking for results that would increase confidence and on the other hand, a patient who may also be suffering from a psychiatric disorder, such as depression?
The Royal College of Surgeons has also issued guidelines in April 2016 echoing the GMC guidance. It requires that if a doctor is concerned about a patient’s psychological profile, he should avoid or defer the operation pending a psychological assessment and refer that patient to a mental health expert. They should do this when they consider that the psychological state of the patient may affect the patient’s satisfaction with the outcome of surgery. The guidelines offer three examples of when referral should be considered:
- When surgeons consider that the expectations of the outcome of surgery are unrealistic, and this discrepancy is not resolved as part of the consultation.
- When the patient has a history of repeated cosmetic procedures, particularly where those are in one anatomical area and there is evidence of dissatisfaction.
- When the patient’s mental health history reveals co-existing psychological disturbances.
Considering these in more detail:
Managing expectations and a history of repeated cosmetic procedures
It is crucial that doctors, as part of the consenting procedure, work hard to manage their patient’s expectations. They should make efforts to understand why the patient wants that surgery and what outcome they are hoping for. If the intervention in question is unlikely to deliver that result it must not be provided.
In the matter of Karen Turner -v- Mr Nigel Carver , the claimant had undergone several breast augmentation surgeries in the past and wanted to increase her breast size further. Post-operatively she brought a complaint that, amongst other things, the implants used were too large and produced an unnatural result.
The court considered whether the defendant should have refused to insert the large implants requested. It was held that negligence would occur only if the outcome went ‘outside the very wide range of natural human variation’: if it fell within that broad definition and if the doctor had managed the patient’s expectation, it would not. The defendant won and it was held that if the claimant was now unhappy with her outcome, it was not due to any negligence on the part of her surgeon but rather, it was simply ‘a case of buyer’s remorse’.
Patient’s history reveals co-existing psychological disturbances
If a patient has not consented to the sharing of their GP records or does not volunteer information relating to their psychological history during consultation, the treating doctor will not know. It will then fall to the doctor to assess whether a patient who is perhaps low in mood/confidence and is affected by the way they look, may also be suffering from e.g. a psychiatric disorder. Is it within a cosmetic surgeon’s competence to make this assessment?
The following tips are offered to doctors or to legal advisors when considering whether a referral should have occurred:
- If concerned about their patient’s psychological profile raise this with the patient as early as possible.
- The treating doctor should speak to the patient’s GP, with consent, to get a clearer picture of the medical history.
- Document their concerns and the patient’s response carefully in the records.
- If the patient is not satisfied with this, they should advise that they cannot proceed until they are satisfied that the patient’s mental health is not affecting his/her decision.