Body dysmorphic syndrome
Legally Speaking
Clifford Warren Lober, MD, JD, presents legal dilemmas in dermatology every other month. He is a dermatologist in practice in Florida and a partner in the law firm Lober, Brown, and Lober.
By Clifford Warren Lober, MD, JD, December 3, 2018
Lori: Bryan, I recently excised a biopsy-proven malignancy from the right cheek of a patient. When he returned to my office today he was absolutely livid and complained that the “radical” surgery I had done was unnecessary and left him “butchered” and “scarred for life.” He also told me he went to the local hospital emergency room last weekend because the surgical site was “red and tender.” He was not treated with antibiotics. He stormed out of my office this morning and said he would never return.
Bryan: Wow! I’m sure that ruined your day. How large was the incision? How well was it actually healing?
Lori: The incision was approximately an inch long and was placed in a relaxed skin tension line so that it would be as inconspicuous as possible. It was really healing well and I anticipate that he will have a good result when it is fully healed.
Bryan: Did you get informed consent before you performed the excision?
Lori: Absolutely. He signed the consent form and I placed it in his chart.
Bryan: As you know, informed consent is not simply a signed sheet of paper. A signed paper simply memorializes that you discussed the necessity, risks, benefits, and treatment alternatives with him and gave him a chance to ask questions. Did you have that discussion with him and, if so, was anyone else present?
Lori: Yes, and my surgical assistant was present when the discussion took place.
Bryan: Excellent! When you initially took his history, did he focus on the cosmetic outcome of the procedure or complain about other surgical procedures that he may have had in the past?
Lori: He mentioned that he had previously had an appendectomy but did not complain about the scar it left. Bryan, I am concerned that this patient may have body dysmorphic syndrome. Patients with this psychiatric condition display an intense, obsessive, unreasonable, or disproportionate preoccupation with imagined or real defects in their appearance. They may spend hours focusing on what would normally be perceived as minor or trivial. They often have a history of multiple surgical procedures, many of which were done to correct perceived imperfections due to prior interventions. Patients with body dysmorphic syndrome also frequently have psychiatric comorbidities, such as depression, anxiety, social withdrawal, delusional fixation, obsessive compulsive disorder, self mutilation, and even suicidal ideation. Evaluation by a psychiatrist is appropriate.
Bryan: Was this patient on any psychiatric medications?
Lori: No, he was not. Although dermatologists do not usually take a psychiatric history before performing surgery, there were no indications in his medical history or clinical affect that he might have psychiatric issues.
Bryan: Good. Having correctly obtained informed consent for a medically necessary procedure, we are off to a good start. Another legal concern is failure to diagnose body dysmorphic syndrome, a true psychiatric illness. However, in the present situation given (1) an absence of behavioral indications of an unreasonable concern of the cosmetic outcome, (2) the further absence of any prior psychiatric illness in his medical history (taken within the standard of care of a board-certified dermatologist), and (3) the absence of psychiatric medications, it is unlikely that failure to diagnose body dysmorphic syndrome could be successfully alleged.
Lori: What should I do now?
Bryan: Although the patient said he would not return to your office, I would send him a letter by certified mail (or any other carrier which can provide proof of receipt) advising him that he needs to be seen in your office to receive appropriate follow-up care, such as removal of his sutures. This will avoid the possibility of the patient alleging that you abandoned him. Should he return to your office, do not see him without another person such as your nurse present in the examination room so that he cannot falsely state what occurred. Referral to a mental health professional should be considered and documented. This will avoid the possible future allegation that this should have been done.
Furthermore, although other attorneys may differ in their advice, you could properly terminate your relationship with this patient. If you chose to go that route, I would state in that certified letter that whether or not he decides to allow you to provide appropriate follow-up care, you will be available to see him for the next 30 days and that thereafter he should see another board-certified dermatologist or comparatively trained physician. Patients like this will probably never be happy with your efforts and cause you 99% of your aggravation.
Lori: Thank you, Bryan!
