Cosmetic surgery is often an art form, occasionally a necessity, and sometimes even a private obsession. As a result, it’s tricky to sort out what to do when you’re dissatisfied with your results, and where the blame lies.

Consider this: As exaggerated looks fall out of fashion, plastic surgery reversals are on the rise. People that went under the knife to achieve their perfect “Instagram Face” now want a more natural appearance. Others seek to reverse once-trendy cosmetic enhancements like fox eye thread lifts, ski slope noses, and even Brazilian butt lifts. Sadly, most invasive cosmetic procedures can’t easily be reversed.

What about surgeries that leave patients unhappy from the get-go? Here the issues are murkier.

I’m going to guide you through the tricky challenge working with your surgeon when you’re not thrilled with your cosmetic results. But first, here are steps you should take if you are dissatisfied in any way.

• Take well lighted photographs of your results on a regular basis as you’re healing.
• Make an appointment to see your surgeon.
• Document your communication with your surgeon’s office via contemporaneous, written notes. Consider recording your phone calls and post-op visits, too (you’ll need permission in certain states that require two-party consent).
• Seek a second opinion from a surgeon that specializes in the type of surgery you had.

In my experience, patient dissatisfaction usually results from one of the following problems:

1. The surgeon doesn’t carefully manage patient expectations or explain risks or fails to screen out patients that are unfit for cosmetic surgery.
2. The patient blames the surgeon for irregularities that sometimes occur during the healing process or loses patience with a lengthy healing time.
3. The surgeon botches the surgery by being overly aggressive or otherwise inept at producing the patient’s desired aesthetic result.
4. The patient experiences serious complications requiring surgical repair.

Now let’s explore each of these problems in reverse order.

Serious Complications

Bad plastic surgery fascinates us. There are entire websites devoted to exposing before-and-after calamities, and some celebrities have even found the courage to “out” themselves after poor results. But there’s a big difference between unsatisfactory aesthetic outcomes and medical complications requiring immediate attention.

Medical Complications

Medical complications are no joke, and can leave patients with permanent pain, paralysis, and disfigurement. I’ve seen patients lose nipples and the tips of their noses, suffer drooping eyelids, and even become blinded by simple filler procedures.

Though generally safe, complications can occur even in the best of hands. Hematoma and bruises, seroma formation, nerve damage causing sensory or motor loss, infection, scarring, blood loss and complications of anesthesia can occur in any surgery. More serious complications such as deep vein thrombosis and pulmonary embolism can cause death.

Khunger N. Complications in Cosmetic Surgery: A Time to Reflect and Review and not Sweep Them Under the Carpet. J Cutan Aesthet Surg. 2015;8(4):189-90. doi:10.4103/0974-2077.172188 (link)

Medical complications usually show up shortly after surgery, and your surgeon is obligated to do everything they can to help you free of charge. But you have to make a quick decision whether to allow your original surgeon to take corrective action, or seek a different surgeon that will charge you for their work.

Many people quickly dismiss their original surgeon out of frustration, but the fact is that your original surgeon, by knowing how you heal, and how your surgery turned out, may be in the best place to make sure corrective surgery is effective. 

Kita, Natalie (1 June 2022). What to Do If Bad Plastic Surgery Happens to You. Retrieved from verywellhealth.com (link)

Aesthetic Complications

Unsatisfactory aesthetic results don’t cause physical harm but are often emotionally traumatizing. These typically result from surgeons being overly aggressive. With liposuction this can lead to skin dimpling, and with facelifts, an overly tight look. I’m even aware of cosmetic surgeons that decided to up-size breast implants while their patients were asleep in the table.

Unlike with a medical complication, if you’re desperately unhappy with your aesthetic result and believe your surgeon botched your surgery, you’re likely to face a challenge convincing them to address your aesthetic concerns free of charge. Upstanding practitioners will try working with you one way or another. But the devious ones will attempt to run out the clock on the one-year statute of limitations for filing a lawsuit against them by treating you with fillers and light energy devices, then throw up their hands and tell you they can’t help you any longer.

If you experience a serious issue — whether medical complication or botched aesthetic result — you should consider seeking help from a mental health professional, as disfiguring injuries can be psychologically devastating. If you believe your problem resulted from a surgical error, pull together your documentation and file a complaint with your state medical board (click here to access state-by-state contact information). If you wish to file a lawsuit seeking financial damages from your surgeon, be aware that this will be a frustrating and time-consuming process, so make sure you’re up to it, as cases like these can be surprisingly difficult to prove.

Minor Irregularities

This grey zone is a much tricker one to navigate, in part because the healing process can sometimes stretch out 6 to 12 months (and up to 24 months for some nasal procedures). If your surgeon asks you to wait and see, a little voice in your head might be telling you that your healing process is not normal, and something is wrong. What to do?

“After a nose job, your nose isn’t REALLY healed until two years after the fact. You might love it initially, but it will change during that time, and there’s a high chance you won’t like it after it’s healed. My nose job was great until it actually healed. Now it’s crooked and obviously collapsing on one side from the surgeon removing too much.”

Herenda, Devin (26 Aug 2022). People Who Have Had Plastic Surgery Are Sharing Their Stories, And the Comments Will Totally Change Your Perspective on the Subject. Retrieved from BuzzFeed.com (link)

In my decades of experience, despite what your surgeon might say, irregularities that appear early in the healing phase sometimes don’t resolve satisfactorily. For instance, if a patient has poor skin tone, their facelift might begin sagging again only months after surgery, or dents or ripples might appear. Breast implants may encapsulate at any point, requiring a revision procedure. For rhinoplasty patients, over time their noses can become crooked months or years later as the cartilage slowly heals. And some patients experience excessive scarring for no reason at all.

In cases like these where the surgeon likely didn’t do anything wrong, it’s their call about whether and how to address your concerns. Some surgeons will agree to perform a free revision and only charge you for their “hard costs” (anesthesia and operating room time). Others will avoid you, hoping you’ll go away. Still others will tell you that they don’t feel confident addressing your concerns and refer you to a different doctor.

If your surgeon is dragging their feet, your best recourse is to seek a second opinion to help you determine if your concerns result from surgical error, are simply part of a normal healing process, or just bad luck.

Mismatches Between Patient Expectations and Surgical Results

In cosmetic surgery, unrealistic patient expectations are never a good thing. These can result from communication errors on the surgeon’s part, or from patients that aren’t psychologically fit and might suffer from obsessive compulsive disorder or body dysmorphic disorder.

Communication errors. To reduce the chance of a mismatch between your expectations and your surgical result, sit with your surgeon and review before-and-after pictures from other patients until you find the precise “look” that you’re after. Communication errors also occur during the surgical consent process, when surgeons are supposed to explain the risks and potential complications of your procedure in language a layperson can understand. For instance, I recently consulted for a patient that suffered a catastrophic complication called empty nose syndrome after her nasal turbinates were removed by a cosmetic surgeon during a rhinoplasty. She claimed her surgeon never informed her of the risk of this syndrome or properly consented her for this irreversible procedure, and they are now in litigation.

Patient psychology and lifestyle. Even when surgeons are crystal clear about the risks and limitations, some patients are simply unrealistic about what cosmetic surgery can achieve, or have psychological or lifestyle risks that make them unfit for such procedures. For instance, after a liposuction procedure, it’s common for overweight people to complain that the surgeon didn’t remove enough fat, even after being told that taking any more would have been unsafe. Naturally, patients that smoke or abuse drugs or alcohol might be poor candidates for certain types of procedures. Before you undergo cosmetic surgery, be honest with yourself about whether you’re a good candidate and are resilient enough to handle imperfect results. After your surgery, if you’re fixated on imperfections, try insisting that your surgeon do something to help you, and consider working with a friend or maybe even a therapist to explore your concerns.

People with body dysmorphic disorder may still have true bad surgical outcomes just as anyone else, and it can be helpful to have a therapist help make the distinction.

Kita, Natalie (1 June 2022). What to Do If Bad Plastic Surgery Happens to You. Retrieved from verywellhealth.com (link)

Takeaways

If nothing else, I hope this article helped you appreciate how important it is to do your homework before undergoing any elective surgical procedure. Take your time evaluating prospective surgeons, read and understand everything in your surgical consent form, and take responsibility for your decisions and healing process. For tips on all these subjects, click over to my companion articles:

Trying to evaluate surgeons for your elective procedure? Good luck! (link)

So, you’re having elective cosmetic surgery? Keep an eye on your surgical consent form. (link)

You need to care about your aftercare (link)

Nothing in this article should be relied on for medical or legal advice.

Copyright © 2025 by Monica Berlin

When a surgeon is sued by a dissatisfied patient for battery or harm, this litigation often revolves around the informed consent process. To wit:

• “My surgeon never told me that my filler injection could cause blindness…if he had, I never would have consented.”
• “My surgeon told me he might have to remove my nasal turbinates to restore my breathing, but never mentioned there was a small chance this could backfire and result in even worse breathing problems.”
• “I only authorized liposuction on my love handles, but during surgery, my doctor also performed lipo on my inner thighs.”

How is it possible for a patient and their surgeon to have such different understandings? Let’s look at it from both sides.

From the surgeon’s perspective. During pre-operative consultations, patients can be indecisive about the options offered by their surgeons, sometimes even vacillating or putting off final decisions until the day of surgery. If a patient insists at the last minute that a procedure be done or not done, sometimes consent forms aren’t updated. Other times, the patient has already been given a sedative and might not remember the conversation. Also, during surgery, a surgeon may find an urgent reason to perform an unconsented procedure — a situation that is permissible under law.

From the patient’s perspective. Surgeons often rush through the informed consent discussion as if giving a 30-second speech. In my experience, surgeons rarely cover all the potential complications that are listed in the fine print on their consent forms. Instead, they might boast that their complication rates are vanishingly small, then hand you a consent form with a long list of very serious potential risks related to your procedure(s). If any of this happens to you, ask your surgeon to slow down so that everything is explained to you clearly and slowly in terms you can understand.

During pre-operative consultations, some surgeons pressure patients to perform additional elective procedures without properly disclosing risks. In cosmetic surgery, some practitioners might be so enamored by their own aesthetic sensibilities that they decide to take a different approach while you’re asleep on the table, believing you’ll be pleased once you wake up. The most deplorable surgeons might even forge your consent during surgery or after the fact.

The purpose of obtaining informed consent is for the patient to make an informed decision, to prevent surprise to the patient and, at the same time, to protect the physician from a potential lawsuit for damages if a risk or complication manifests itself as a result of the procedure.

Carolyn Oill, Esq.

I’m going to describe how informed consent should work in a patient-centered care context, give you examples of how misunderstandings can arise (especially in elective same day surgery), then explain how patients can ensure they are in lockstep with their surgeons.

The Informed Consent Process

Surgical consent is not an event or a signature on a form, but a process of shared decision making between patient and surgeon in which the parties build trust and exchange views. During this process, the surgeon must provide sufficient information for the patient to make an informed decision about what is to be done to their bodies.

This means the surgeon has to explain diagnoses, treatment alternatives, expected outcomes, and potential risks and complications — as well as the risks and benefits of doing nothing. To help the patient decide on whether to proceed, the surgeon must also describe the short- and long-term recovery process. Discussions like these help the patient develop realistic expectations. Throughout, the surgeon needs to encourage questions, avoid clinical terminology as much as possible, and carefully explain clinical words and concepts.

Sometimes, the surgeon won’t be able to provide a definitive treatment plan beforehand, as a diagnosis cannot be made until surgery is underway. (For example, if a patient presents with breathing problems, a plastic surgeon might first have to open the nose to pinpoint the cause of the blockage, whereas an ENT surgeon might use imaging to diagnose the cause beforehand.) In such cases the surgeon needs to explain how, during your operation, s/he will make the decision about how to proceed. Most obviously, it’s crucial that the patient understand the range of possible surgical approaches.

“Consent is an opportunity to guide the patient to the right decision for them, and also dispel any unrealistic expectations concerning the procedure. Ultimately it is an opportunity to create a relationship of openness and trust between doctor and patient, which may help if operative complications are encountered.”

Anderson OA, Wearne IM. Informed consent for elective surgery–what is best practice? J R Soc Med. 2007;100(2):97-100. (link)

The Informed Consent Form

The informed consent process culminates the patient’s signature in a form that memorializes their mutual understanding with the surgeon. Valid consent requires the patient be competent to make such a decision, understand their treatment options and the risks and benefits of each, and not be acting under duress.^1,2

The specific wording on consent forms varies from state to state and may also depend on the agency that accredits the surgical facility in which the procedure will be undertaken.

“Unfortunately, the emphasis on obtaining a patient’s signature as documentation of informed consent results in varying effectiveness of the communication between a clinician and a patient.”

The Joint Commission (April 2022). Informed consent: More than getting a signature. (link)

Patients should take the time to read the entire consent form in an unhurried fashion and be encouraged to ask any final questions that may arise. Ideally, the surgeon will be present during the signing so the patient feels welcome to explore any remaining uncertainties they may have.

When Informed Consent Goes Off the Rails

According to The Joint Commission, a standards-setting and accreditation body, problems that contribute to misunderstandings during the consent process include³:

• Failure of providers to assess the health literacy of the patient and adjust their consent process to account for this.
• Poor provider-patient communication and lack of shared decision making during the process.
• Missing information on consent forms. (In one study, only one-quarter of consent forms included all the relevant elements of informed consent – nature of the procedure, risks, benefits and alternatives.⁴)

In my over 25 years assisting in surgery and supporting patients before and after, I’ve seen errors in each of these areas. For instance, when the consent form is completed on the day or surgery the risk of a misunderstanding increases, as some patients may develop doubts as they read through their form but feel pressure to sign it anyway. This is especially true if the surgical team is waiting for the patient to be wheeled into the operating room. Sadly, I have seen many consent forms signed after a sedative or sleep-inducing medication was administered.

Especially with cosmetic procedures, I’ve also seen patients make changes or additions to their surgical plans on the morning of surgery, during their final consultation with the surgeon. This obviously doesn’t give the patient much time to reflect on their decision. Moreover, rushed additions or corrections to the consent form might not be properly dated, time stamped, and signed by both parties.

Then there’s the question of how much information to share with patients during the process, especially concerning potential surgical complications. Too little information fails to inform, while too much information may cause undue worry. Should the consent form list every possible complication, even minor ones with extremely low probabilities that the surgeon did not even bring up during pre-op discussions? In my experience most consent forms include long lists of complications that are never discussed with patients beforehand, or are couched in language that’s too technical or lacks specificity. These are bad practices. Also, if a surgeon asks you to sign additional forms describing risks and complications, please take a pause, as this is not standard practice. Your official consent form should describe all consequential risks, making supplemental forms unnecessary.

Let’s go back to the example patient presenting with breathing problems. Assuming the surgeon might have to reduce or even remove nasal tissues that warm and moisten air flow (called turbinates), should the patient be warned that this might result in permanent disability from a rare and life-changing complication colloquially called Empty Nose Syndrome? This is a tough call. If the surgeon describes this risk as potentially resulting in a “permanently impaired nasal airway,” this description might meet the letter of the law, but it doesn’t convey the nature of this rare complication in terms a lay person can understand. It’s more helpful to explain how a major complication might affect the patient in the future (e.g., permanent feeling of nasal blockage and excessive nasal mucus, permanently worse vision or even blind eye, etc.).

It’s always a good idea for the surgeon to assess the patient’s level of understanding before the consent form is signed. The best way to do this is for the surgeon ask the patient to repeat back his or her understanding of the information the surgeon has communicated. This will increase the likelihood that the surgeon has effectively managed the patient’s expectations.

“Informed consent for elective surgery is often obtained by junior medical staff…(who might not) have not received specialist training in advising patients about the procedure.”

Journal of the Royal Society of Medicine (2007 Feb). Informed consent for elective surgery — what is best practice? (link)

Of course, at any point in the process, if the surgeon or a staff member doing patient intake feels the patient’s questions reflect a lack of understanding about the procedure, then the process must slow down so that the two parties can first get on the same page.

How Surgeons and Patients Can Avoid Misunderstandings

Here are some simple steps surgeons and patients can take to solidify the consent process. In the hectic run-up to surgery, I’ve seen both patients and even experienced surgeons neglect crucial aspects of this process. In most cases, everything goes smoothly, and these oversights don’t have negative consequences. But not always.

Surgeons can mitigate their potential risks by:

• Making sure they describe major risk factors in in layman’s terms (both verbally and in writing on the form), preferably by describing how various complications might affect the patient in the future.
• Asking their patients to repeat back their understandings of what is to be done in surgery, and potential adverse outcomes.
• Being available for last minute questions when patient read and sign their consent forms.
• Ensuring that any same-day changes are carefully explained, documented, and signed by the patient before they are prepped for surgery.
• Videotaping their consent discussions with patients.

As for patients, you need to:

• Ask questions at every step of the process, especially about risks and complications.
• If your form includes a long list of risks that haven’t been previously discussed, ask your surgeon to explain each one before signing.
• Make sure that any additions or corrections to your consent form are dated, timed, and signed by both parties.
• Avoid signing your consent form the day of your procedure.
• For your protection, snap a photo of the fully executed consent form just before your surgery, or request a photocopy. (Otherwise, since most forms are paper-based, if something goes badly wrong, a dishonest surgeon might forge and back-date your consent form to cover up a poor surgical decision or technique.)
• Insist on having an interpreter when necessary for your informed consent discussion.

Of course, the vast majority of surgeries are properly consented. Still, as I often counsel readers at the end of my posts, “trust but verify,” and “you can never be too careful.”

Nothing in this article should be relied on for medical or legal advice.

FYI, I wrote a shorter, companion post about surgical consent that you can find here.

Footnotes

¹ Anderson OA, Wearne IM. Informed consent for elective surgery–what is best practice? J R Soc Med. 2007;100(2):97-100. doi:10.1177/014107680710000226 (link)

² Bernat JL, Peterson LM. Patient-Centered Informed Consent in Surgical Practice. Arch Surg. 2006;141(1):86–92. doi:10.1001/archsurg.141.1.86 (link)

³ The Joint Commission (April 2022). Informed consent: More than getting a signature. (link)

⁴ Bottrell MM, et al. Hospital informed consent for procedure forms: Facilitating quality patient-physician interaction. Archives of Surgery. January 2000;Vol. 135. (link)

Copyright © 2025 by Monica Berlin

I recently came across a fascinating piece of journalism looking at how the U.S. airline industry made revolutionary improvements in airplane safety, virtually eliminating plane crashes after suffering a record death toll in 1996. Of course better technology helped. But a big part of the story was how the industry made many small improvements in risk management — especially in the way it empowered employees to report issues, from airplane mechanics to flight attendants. Regulators created an aviation safety reporting system that incentivized people to share their concerns in a confidential, non-punitive manner, meaning that employees were held harmless for innocent mistakes. This led to a flurry of changes, from better in-flight pilot teamwork to improved taxiway signage.

The healthcare industry followed suit, sort of. Many of us are familiar with the “time out” that now takes place in hospital operating rooms, where staff introduce themselves by name, confirm the nature of the procedure, and learn a bit about the patient lying on the table. Simple safety checklists were introduced, and they dramatically reduced surgical infection rates.¹ Hospitals also embraced confidential patient safety reporting systems (but, unlike the airline industry, they are still struggling to demonstrate a clear link to improved patient safety.²)

Still, it wasn’t until 2006 that Marty Makary M.D., M.P.H. — a surgeon and bestselling author — introduced the idea of a surgical safety checklist. The following year, Dr. Atul Gawande wrote a fabulous book called The Checklist Manifesto promoting the importance of using checklists in complex environments like hospitals.

The ambulatory surgery sector lags further behind the progress made by hospitals. This is especially true of the two-thirds of ambulatory surgery centers (ASCs) that are physician-owned and not associated with a hospital system.³ Of course, many procedures that take place in ASCs are short and simple, like lasik surgery and colonoscopies. But even these procedures carry risks. Moreover, I’ve assisted in plenty of long, complex surgeries in ASCs lasting eight hours or more. And ASCs are now gearing up to do technically challenging orthopedic surgeries like hip and knee replacements, which have historically been the exclusive domain of hospital operating rooms.⁴

ASCs have a long way to go in embracing a culture of patient safety, as they have not implemented the best practices above. Having worked in physician-owned ASCs for over years, I only participated in two pre-surgical “time outs” during my entire career. Nor do ASCs do before-and-after “counts,” to make sure that surgical sponges and instruments aren’t accidentally left inside body cavities (a safety innovation hospitals reluctantly implemented once insurers refused to reimburse them for correcting mistakes like these). In over twenty years working in same-day surgery centers, I only participated in a count like this maybe half a dozen times. In fact, when nurses rotated into my ASCs from hospital settings, then tried to enforce safety protocols like these, they were scoffed at and never invited back.

“If you mock a nurse once, or yell at them for bringing something up, they will never feel as comfortable voicing a concern to you again, and your patients will suffer.”

Marty Makary, M.D., M.P.H. and author of New York Times bestsellers Unaccountable and The Price We Pay

Moreover, I never encountered a confidential patient safety reporting system similar to the ones that hospitals have embraced. Especially in physician-owned ASCs, when something is amiss, operating room staff are reluctant to speak up, fearing retribution. This isn’t surprising. ASCs are much more intimate spaces than, say, aircraft assembly lines, and personal relationships matter a lot. Also, operating room staff are usually contractors that don’t enjoy employment protections of any kind.

Let me paint a clear picture of how this can jeopardize patient safety. Over the years, I assisted in many liposuction procedures where surgeons extracted much more than the amount fat that California regulations say can be safely removed in an outpatient setting. In every case, I warned these surgeons just before they hit their limit, and got nowhere. As these “cowboy surgeons” kept going, our nurses and anesthesia providers usually whispered together worriedly. But only an anesthesia provider has the power to force a surgeon to stop. And none did. The takeaway is that, if a surgeon takes risks, the patient asleep on the table might not have an empowered patient safety advocate in the room with them.

It’s imperative that all staff members in ASCs — nurses, surgical technologists, and anesthesia providers — receive regular training about their duties and obligations as patient safety advocates. Again, in all my years working in such centers, this never happened.

Just as importantly, agencies that accredit ASCs must be compelled by law to provide an easy way for operating room staff to confidentially register complaints about events that jeopardize patient safety. In the food service industry, county health departments require “see something, say something” placards with hotline phone numbers to be placed in every kitchen. Why not something similar in ASC operating rooms? Also, accreditation agencies must be obligated by law to make surprise spot checks of ASCs, just like in food service, especially after a confidential complaint is received. Unfortunately, these agencies only make site visits once every three years, and these are scheduled well in advance. Is it possible that the kitchen in your local Taco Bell is better surveilled than an operating room in an ASC?

Of course, the vast majority of ASCs are safe and well managed. Still, as I often counsel readers at the end of my posts, “trust but verify.”

Patients scheduled for surgery in ASCs are wise to take matters into their own hands. For advice on how to accomplish this, click over to my blog post about how to evaluate the ASC your surgeon wishes to use. In the meantime, in addition to your legislators, please contact the organizations below, asking them all to do a better job getting ASCs to adopt the commonsense patient safety practices described in this blog post.

U.S. Department of Health and Human Services, Office of Inspector General (link)

American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) (link)

Accreditation Association for Ambulatory Health Care (AAAHC) (link)

Accreditation Commission for Health Care (ACHC) (link)

The Joint Commission (link)

Footnotes

¹ No Author (Fall 2008). A simple checklist that saves lives. Harvard School of Public Health. (link)

² Pronovost PJ, Morlock LL, Sexton JB, et al. Improving the Value of Patient Safety Reporting Systems. In: Henriksen K, Battles JB, Keyes MA, et al., editors. Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 1: Assessment). Rockville (MD): Agency for Healthcare Research and Quality; 2008 Aug. Available from: https://www.ncbi.nlm.nih.gov/books/NBK43621/ (link)

³ No Author. Ambulatory Surgery Centers: A Positive Trend in Health Care. Ambulatory Surgery Center Association. (link)

⁴ Sah, Alexander MD (host). (2022, 29 April). How the ASC Industry’s Growth is Improving the Surgical Process (episode 52) [Audio podcast episode]. In PSQH The Podcast. (link)

Copyright © 2025 by Monica Berlin

It’s a jungle out there. Bad surgeons are almost impossible to spot. But if you believe the 80/20 rule, you need to at least try to figure out if your prospective surgeon is among the small minority which are simply lousy at their jobs, or creeps, or both. Don’t trust your state medical board sanction poor performers — they rarely sanction doctors, and in some states, they almost never do.¹ (See my blog post about how state-run medical boards often fall down on the job.) What this means is that, even in hospitals, 13.5% of patients experience adverse events, about half of which are preventable.² Are adverse events more common in ambulatory surgery centers (ASCs)? Interestingly, 17 states don’t even require ASCs to report such events.³

Seeking recommendations from people you trust is often the best route to finding a good physician, as publicly available quality rating schemes are iffy at best. After this? Of course, a Google search may turn up some helpful nuggets. Even if we don’t want to admit it, many of us next turn to Yelp, a review site that embraces trust and safety. But are Yelp reviews really representative of a doctor’s skills? Yelp admits that can remove reviews that violate its content guidelines. Practitioners with lots of poor Yelp reviews can hire clever lawyers to petition Yelp to remove many of them, arguing they violated such guidelines.

In the cosmetic surgery world, getting trustworthy data is even more challenging. Unlike Yelp, sites such as RealSelf earn their revenue through surgeon advertisements, do not report how frequently patient posts are taken down, and ask reviewers to “avoid personal attacks.”

If you’re having elective surgery, another way to gain insights into your prospective surgeon’s character is to scrutinize their website and social media posts (many surgeons that perform elective surgery maintain their own sites). Are their pages and feeds professional, respectful and informative…or full of boastful media profiles (which are easy to obtain from any number of trade magazines)? If this person has a large number of social media followers, pull up some of their profiles to assess if they are real people, or if this practitioner might be paying for fake followers.

Once you’ve whittled down your list of prospective surgeons, it’s time to do some additional research and schedule in-person consultations with them.

First, call into the offices of your short-listed surgeons and find out if they:

• Have malpractice insurance for the procedures they perform? If not, are they self-insured?
• Are board-certified? Lack of certification may mean that a doctor did not complete the training requirements of the board overseeing their field of practice, or failed their final examination.
• And if your procedure is taking place in a same-day (ambulatory) surgery center, determine if the surgeons on your shortlist have admitting privileges at a nearby hospital. Having privileges to admit patients and perform surgery at a reputable hospital means your surgeon has satisfied the hospital’s credentialing committee and board of trustees that they are well qualified. Also find out how far away this hospital is from the facility proposed for your surgery.

During your in-person visits, your paramount objective is to ascertain how experienced the physician in question is with the kind of surgery you are planning to undergo.

Here are some other things to pay attention to during your consultation:

• Skills and experience. Willingness to share how many of this kind of surgery the doctor has done in the past year and over the course of their careers — and how this volume compares to the threshold that’s associated with good outcomes in the field. Ability to compare their surgical success and complication rates with averages in the field. If your doctor is unable or unwilling to answer these questions, consider looking elsewhere.
• Training. Comfort with answering questions about their post-doc education, mentors, fellowships, research interests.
• Listening skills. Eye contact, patience, note-taking, acknowledging your concerns.
• Verbal communication abilities. Ability to explain treatment options and the pros and cons of each. Precise answers stated in layperson’s terms, free flowing give-and-take.
• Character. Seeming authentic and caring, acting relaxed and affable, willingness to discuss risks and recovery challenges without hedging or whitewashing them.
• Personal chemistry. Sensing that this physician sees, respects, and hears you, and that the two of you are able to partner together to achieve the best possible outcome.

After you exit the consult room…don’t leave the building just yet! Now it’s time to sniff out how this doctor treats their staff. If their behavior is respectful, upright and honorable, this will give you confidence about their character and trustworthiness. In this step, your challenge is to get chatty with the medical and administrative personnel. You will learn a lot by interacting with staff and asking plenty of questions about the inner workings of the practice. For instance, ask staff members what it’s like when the doctor is having a bad day, if they enjoy working for this person, what this doctor’s pet peeves are, and whether there are other practitioners you might also consider.

After assessing your prospective surgeon’s character, below are a few ways you can try to determine which side of the 80/20 rule this practitioner falls (also check out my blog post about doctors that still use paper-based records…a possible red flag to consider). If you’re willing to dive into the resources below, just be aware that, if you discover any formal complaints or allegations that were not officially adjudicated, you ought not assume the worst — that is, unless you spot a pattern of alleged bad behavior, which you can then judge for yourself.

State medical boards. Every state has a different way to request disciplinary history for licensed physicians. ProPublica published a handy compendium of each states’ request procedures here. The Patient Safety Action Network offers an in-depth review of information resources here. You can also try to look up doctors on the Federation of State Medical Boards website, but not all states report, and the data does not go very far back in time. You can also try searching your state’s Department of Consumer Affairs website for disciplinary actions (in California, you can find such a site here).

Grassroots patient safety organizations. Often cobbled together by individuals with little funding, these organizations can be difficult to track down. Here in California, the Patient Safety League runs a searchable database that collects disciplinary information on California doctors that goes back many years.

Court case records. According to one law firm, an average of 20,000 medical malpractice lawsuits are filed each year in the U.S.⁴ Among elective surgical specialties, plastic surgery has by far the highest paid claim rate, coming in almost four times higher than the average for all surgeons.⁵ Many patient lawsuits go nowhere, and defendants are presumed innocent unless proven guilty in a court of law. Still, it’s a good idea to look up your prospective surgeon in an online court records database such as UniCourt, or in a government-run online court records portal in your state. Unless a lawsuit was sealed by a judge after an out-of-court settlement, these databases will give you a picture of how frequently your prospective surgeon has been sued by patients, and what the verdicts were.

Drug Enforcement Agency (DEA). The DEA maintains a public list of actions taken against prescribers and pharmacies, but this list is not user friendly or easily searchable. Although this is a lengthy process, you can also submit a Freedom of Information Act request for DEA sanctioning actions taken against any doctor using this website.

It goes without saying that physicians don’t enjoy being reviewed by their patients. As a result, patients confront enormous roadblocks in obtaining reliable data about a physician’s skills, experience, and track records. I hope this blog post helps you to make the right choice.

Nothing in this article should be relied on for medical or legal advice.

Footnotes

¹ No author (2021, 31 March). New Public Citizen Analysis Finds Major Differences Among States in Rates of Serious Physician Disciplinary Actions. (link)

² Wolfe, Sidney M.D. and Oshel, Robert E. Ph.D (2021, 31 March). Ranking of the rate of state medical boards’ serious disciplinary actions, 2017-2019. Public Citizen’s Health Research Group. (link)

³ No author (2019). Q&A with Bill Prentice, CEO Ambulatory Surgery Center Association. (link)

⁴ Whitt, Jeff (2022, 31 January). Shocking Medical Malpractice Statistics for 2021. Raynes & Lawn. (link)

⁵ Schaffer AC, Jena AB, Seabury SA, Singh H, Chalasani V, Kachalia A. Rates and Characteristics of Paid Malpractice Claims Among US Physicians by Specialty, 1992-2014. JAMA Intern Med. 2017;177(5):710–718. doi:10.1001/jamainternmed.2017.0311 (link)

Copyright © 2025 by Monica Berlin

When patients sue plastic surgeons for battery, their cases frequently revolve around whether or not they had properly consented to the procedure(s) beforehand. To wit:

• “I only consented to reducing the size of the tip of my nose, but my surgeon also removed my nasal turbinates, and now I have discomfort when I breathe.”
• “My surgeon never told me that my filler injection could cause blindness…if he had, I never would have consented.”
• “I only authorized liposuction on my love handles, but during surgery, my doctor also performed lipo on my inner thighs.”

How is it possible for a patient and their surgeon to have such different understandings? Let’s look at it from both sides.

From the surgeon’s perspective. During pre-operative consultations, patients can be indecisive about the options offered by their surgeons, sometimes even vacillating or putting off final decisions until the day of surgery. If a patient insists at the last minute that a procedure be done or not done, sometimes consent forms aren’t updated. Other times, the patient has already been given a sedative and might not remember the conversation. Also, during surgery, a surgeon may find an emergency reason to perform an unconsented procedure — a situation that is permissible under law.

From the patient’s perspective. During pre-operative consultations, some cosmetic surgeons pressure patients to perform additional procedures without properly disclosing risks and possible outcomes. Also, some surgeons are so enamored by their own aesthetic sensibilities that they may decide to take a different approach while you are asleep on the table, believing that you will be pleased once you wake up. The most deplorable surgeons might even forge your consent during surgery or after the fact. And surgeons rarely cover all the potential complications that are listed in the fine print on their consent forms. Instead, they might boast that their complication rates are vanishingly small, then hand you a consent form with a long list of very serious potential risks related to your procedure(s).

The purpose of obtaining informed consent is for the patient to make an informed decision, to prevent surprise to the patient and, at the same time, to protect the physician from a potential lawsuit for damages if a risk or complication manifests itself as a result of the procedure.

Carolyn Oill, Esq.

Given all these potential conflicts, surgeons can mitigate risks by videotaping their consent discussions, and/or ensuring that any same-day changes are carefully explained, documented, and signed by the patient before they are prepped for surgery. Patients can mitigate risks by carefully reading their consent forms, paying close attention to the potential complications and discussing them with their surgeons. Patients should also request a copy of the consent they signed during their pre-op visit and snap a photo of this same form on the day of surgery.

For a more detailed discussion of informed consent, see my companion post here.

Nothing in this article should be relied on for medical or legal advice.

Copyright © 2025 by Monica Berlin

In this post, I’m going to describe the risks you face if you visit a doctor that still writes notes by hand and keeps paper records or uses an electronic health record (EHR) system that isn’t certified (and might even have been developed in-house). Holdouts that have resisted making the transition to gold standard certified EHR systems are typically doctors in small, independent practices that don’t accept Medicare.¹

Of course, doctors hate using EHRs, as they decrease face-to-face time with patients. But this train left the station long, long ago. Today, four out of every five office-based physicians have adopted certified EHRs which provide the highest degree of security and integrity.²

Paper records (and most non-certified EHRs) pose a number of concerns for patients. Most obviously, paper charts can get lost or stolen, and doctors rarely keep backups. And if you’re interested in learning more about how easy it is for cybercriminals to hack non-certified EHRs, here’s a TV news interview I recently did on this subject.

But there are plenty of other ways that paper records and non-certified EHRs can cause problems. For instance:

• It’s easier to make errors or illegible notations in paper records, which are not often caught or corrected.
• Paper records (and non-certified EHRs) are not as secure as certified EHRs, as they can be viewed, copied or stolen by anyone with access. (In a certified EHR system, unauthorized access would be flagged as a data breach and forensic investigations could unmask the perpetrator.)
• Paper records (and non-certified EHRs) can be tampered with after the fact to cover up medical errors. In a certified EHR, it’s harder for a miscreant doctor to cover his tracks.

The final bullet above is worth pondering. While falsifying a medical record is a crime, it is not illegal for medical professionals to make honest updates to records as long as these notes are labeled as such.³ As a result, proving that a record has been tampered with is a difficult challenge.

“Falsification and tampering come in many forms – removing a diagnostic report, inserting information without standard documentation, rewriting or destroying the record, omitting significant facts, or even creating records for nonexistent patients or staff.”

— MedLaw Advisory Partners (link)

Record falsification does happen in healthcare. Shady doctors might be tempted to tamper with a patient chart to cover up an error or whitewash an adverse medical outcome, especially if they’ve been sued by a patient claiming injury. As a patient, if your doctor is still using paper records (or a home-grown EHR that isn’t certified for Medicare use) ask for copies of your notes immediately after your visit and pay special attention to any suspicious addendums or markings.

It goes without saying that the vast majority of physicians that still use paper records are honest, caring professionals. Nevertheless, as I usually say at the end of my posts, trust but verify.

Nothing in this article should be relied on for medical or legal advice.

Footnotes

¹ Centers for Medicare & Medicaid Services, “Certified EHR Technology.” (link)

² The Office of the National Coordinator for Health Information Technology, “Office-based Physician Electronic Health Record Adoption. (link)

³ “Alteration of Medical Records,” Miller & Zois. (link)

Copyright © 2025 by Monica Berlin

Prescription drug monitoring programs (PDMPs) operated by states collect data on every controlled substance that has been prescribed to you, including the date, dose, quantity, refills, dispensing pharmacy, and prescriber name.¹ With simple password access, these sensitive databases can be viewed by law enforcement, regulatory compliance boards, pharmacists, and prescribers. Many states require doctors to query the database when they first prescribe a controlled substance to a patient.

The earliest PDMPs were launched as law enforcement tools and also to identify drug abusers needing prevention and treatment. These days, PDMP databases are deeply integrated into health information exchanges, electronic health records, and pharmacy dispensing systems.²

Interestingly, researchers have found “limited evidence” that PDMP use has reduced opioid-related consequences.³ And some have suggested that PDMPs might lead physicians to refuse to prescribe pain meds to chronic pain sufferers in need, in order to avoid scrutiny.⁴

“PDMPs are predominantly law enforcement investigative tools dressed up in public-health-promoting rhetoric…that surreptitiously collect a stunning amount of sensitive health information.”

— Duke Law Journal

Another big concern is the fact that these sensitive databases can be misused by bad actors. A Duke Law Journal article concluded that “PDMPs are…investigative tools dressed up in public-health-promoting rhetoric [that] surreptitiously collect a stunning amount of sensitive health information.”⁵

The DEA often conducts warrantless searches of patient prescription histories, and many states are litigating to stop this practice on constitutional grounds.

This isn’t the only privacy concern. While they’re not supposed to do this, for the most part, everybody with PDMP account credentials can look up anyone‘s personal prescription history, even if this person is not a current patient or customer. This “scout’s honor” database access means that prescribers can all too easily invade the privacy of individuals that are not patients. Their staff members can even sign in to PDMPs using their employer’s credentials, to look up friends, family members, and even public figures. And password sharing for PDMP access is another serious privacy concern. All of this is scary and ridiculous.

In 30 states, patients have the right to view their own PDMP record.⁶ Sadly, this right is not explained to patients when a controlled substance prescription is written or dispensed.

Almost nobody knows this, but PDMPs log every individual record search — which means they can generate audit reports identifying who had accessed your personal prescription history and when.

This means that patients should be able to request their own audit reports to see who might have “looked them up.”

But after doing research, I wasn’t able to determine which states allow individuals to request their own audit reports.

Even if you’re in a state that allows you to request your own report, it’s difficult to figure out which government agency to request it from. For example, in California you have email the Department of Justice and obtain a request form that isn’t available on the DOJ’s website^.7 Ironically, depending on the state, these request forms may require a notary public certification that you are really you.

Prescription drug monitoring programs must be reformed to improve patient privacy and the accuracy of the databases. First, just like one can obtain one’s credit report today, all states must allow patients to view their own records to check for accuracy.

Along with this, states must make it easy for individuals to request their own audit reports showing who has viewed their private prescription records. Also, when patients receive a controlled substance prescription, they must be given instructions about how they can get these records. Finally, patients must be informed every time a prescriber reviews their private prescription records.

Finally, states must enable two-factor authentication and other means to stamp out illicit password sharing and ensure that only authorized personnel are able to access PDMPs.

If you agree, please contact your state’s attorney general, and re-post this piece on your social media accounts.

Nothing in this article should be relied on for medical or legal advice.

Footnotes

¹ Prescription Drug Monitoring Program, Training and Technical Assistance Center (link)

² ibid (link)

³ ibid (link)

⁴ Sullum, Jacob. State Regulators Punish Doctor for Cutting a Pain Patient’s Opioid Dose and Dropping Him After He Became Suicidal. Reason, July 10, 2019 (link)

⁵ Oliva, Jennifer D. Prescription-drug policing: The right to health-information privacy pre- and post-Carpenter. Duke Law Journal, January 2020 (link)

⁶ American College of Emergency Physicians – PDMP Legislation (link)

⁷ California Office of the Attorney General, CURES FAQs (link)

Copyright © 2025 by Monica Berlin

State medical boards are agencies that license medical doctors, investigate complaints, discipline physicians who violate the medical practice act, and refer physicians for rehabilitation when appropriate. If you’ve been injured by a licensed medical doctor, perhaps you’ve considered filing a medical board complaint to seek disciplinary action. The right to practice medicine is a privilege granted by states, and medical boards regulate this practice.

However, you should know that medical boards are funded by fees paid by physicians themselves, and their governance and procedures are heavily influenced by powerful physician lobbyists. Patient advocacy groups have long criticized state-level medical boards for being lax in disciplining doctors, complaining of regulatory capture — the process by which regulatory agencies can become guided by the interests they regulate instead of serving the public interest.

Something fishy is clearly going on with state-level medical boards, as demonstrated by a Public Citizen analysis of state-by-state disciplinary actions taken per 1,000 licensed physicians summarized in the chart below.¹ How is it that the rate of serious disciplinary actions can vary so widely, from a high of almost 1.8% in Michigan, to 0.2% in Georgia?

This nine-fold difference between Michigan and Georgia cannot be explained away by anything other than regulatory capture. Do you really believe that Michigan’s doctors are nine times more error prone than Georgia’s, or that patients injured in Georgia are nine times less motivated to file medical board complaints?

Some states are trying to address the regulatory capture problem. For example, in 2023, after a flurry of Los Angeles Times investigations into doctors that were allowed to continue practicing despite indisputable negligence, the California legislature enacted a series of reforms to address lax Medical Board enforcement. Their reforms included lowering the standard of proof required to initiate a disciplinary action, changing the composition of the governing board, and requiring the board to interview every complainant. ²,³

In their report, Public Citizen concluded that “many if not most state medical boards are doing a dangerously lax job in enforcing their states’ medical practice acts.”

“Many if not most state medical boards are doing a dangerously lax job in enforcing their states’ medical practice acts.”

Public Citizen (link)

What does all of this mean for you? If you’ve been harmed by negligent care and you have a clear-cut case with substantial evidence, of course you should consider filing a complaint with your state medical board. Any doctor who causes harm or injury, delays treatment, or otherwise provides substandard care is subject to a formal complaint. But if you’re in a state where your medical board is tilted in favor of the powerful physicians’ lobby, you will have to be a bulldog in working with your assigned medical board investigator to make forward progress. Educate yourself about your state board’s procedures, and if you feel as though your investigator is not doing their job, reach out to your local state senator or representative for additional muscle.

If you’re as disappointed as I am about all of this, please contact your state senators and representatives, and re-post this piece to your social media feeds.

Nothing in this post should be relied on for legal or medical advice.

Footnotes

¹ No author (2021, 31 March). New Public Citizen Analysis Finds Major Differences Among States in Rates of Serious Physician Disciplinary Actions. (link)

2 Dolan, Jack and Christensen, Kim (2021, 14 July). Botched surgeries and death: How the California Medical Board keeps negligent doctors in business. Los Angeles Times. (link)

4 Villanueva, Gabriela (2023, 12 July). Proposed Changes Coming to the Medical Board of California. (link)

Copyright © 2025 by Monica Berlin

After selecting your surgeon, the next most important step for patients scheduled to have same-day surgery in an ambulatory facility is to evaluate this facility. Patients almost always neglect this step in the hectic run-up to their procedures because they don’t know what questions to ask and why it’s important to do so.

Ambulatory surgery centers (ASCs) range from sophisticated outfits that look and feel like hospital operating rooms where procedures such as joint replacements and even some heart procedures are performed, to those that are purpose-built for less complex procedures like cataract surgeries and endoscopies. These days, Medicare is allowing more complex procedures to be performed in ASCs, of which almost two-thirds are owned by physicians themselves without any hospital oversight.¹

ASCs differ from hospital operating rooms in a couple of important ways. Most obviously, if you experience a serious medical emergency, you will have to be transported to a hospital. Less obvious differences have to do with the fact that such facilities may lack checks and balances which are present in hospital settings. For example, in hospitals, surgical instruments and devices undergo many levels of cleaning, maintenance and inspection. In outpatient facilities, this responsibility often falls to a single employee or contractor. And, compared to hospital settings, ASC staff members are generally not empowered or encouraged to speak up if they see something amiss. (The lack of a strong patient safety culture in many ASCs concerns me so much that I devoted a blog post to it.)

ASCs also have looser reporting requirements than hospitals. In fact, 17 states don’t even require ASCs to report adverse events to the authorities.⁴ Here in California, ASCs are supposed to report incidents, but, according to the California Health Care Foundation, because of a legal decision that removed some reporting requirements, “little is known about the volume of procedures, type of procedures, and financial operation of the vast majority of these facilities.”² In my over 20 years supporting surgeries performed in ASCs, I can tell you that many ASCs I worked in failed to report incidents such as post-surgical infections, unplanned hospital transfers, and narcotic thefts to the proper authorities. I attribute this to the weak patient safety cultures and protocols that exist in poorly-run ASCs — problems that start at the top, with owners that are so greedy or lazy or negligent that they simply don’t care.

Not all surgery centers in the U.S. are required to report to state or federal organizations. In New Jersey, for example, ASCs with only one operating room are not licensed by the state Department of Health, and therefore are not obligated to submit information on patient mortality or other events. These surgery centers are instead overseen by the licensing board for doctors.

Definitive Healthcare [October 2019]. Why Some Patients Face Higher Risks at Ambulatory Surgery Centers. (link)

It’s important to say that the vast majority of ASCs are safe and properly managed. But not all. Accreditation agencies are charged with ensuring the safety of ASCs, but there are issues here that you need to be aware of. First, accreditation agencies almost never perform surprise inspections, opting instead to schedule their site visits well in advance. And here in California, in 2011 the state allowed for-profit accreditation agencies to oversee ASCs. Since these private accreditation agencies are paid by the surgery center owners themselves, this raises a a conflict of interest concern. After California privatized surgery center accreditation, watchdogs and investigative reporters have repeatedly alerted the public of terrible mishaps that have even led to patient deaths. Kaiser Health News describes this situation as “a troubling legacy of laxity.”³

If your surgeon wants to use an ASC for your procedure, here are the steps I advise you to take:

• Determine who owns the surgery center: a hospital system, your surgeon, or a different physician or physician group?
• Ask if the facility is in good standing with the agency that accredits it, and whether this agency is Medicare-approved (such agencies have the most stringent standards). Here in California, the Medical Board operates a searchable database for this purpose, but some states don’t make this information easy to find.
• Visit the facility and meet with the Director of Nursing (DON). Ask the DON if they’re a part-time contractor or full-time employee of the surgery center, and request a tour of the operating room. Does it look clean and organized to you?
• Ask the DON when the last accreditation inspection took place and whether any corrective actions were required afterwards. Inquire about safety protocols, emergency procedures, and the patient recovery process: Will both the surgeon and anesthesia provider remain at the facility until you’re fully awake? (If your anesthesia provider is a nurse anesthetist and not a medical doctor, then make sure your surgeon will stay put until you’re awake and ready for discharge.)

After doing your due diligence, if something doesn’t feel right, you can request that your procedure take place in an operating room at the hospital where your surgeon has privileges. Be aware that your surgeon or their staff might try persuading that the ASC your surgeon owns or uses most often is your best option. Don’t feel pressured or guilty if you feel otherwise. It’s your body, and this decision is yours and yours alone.

Remember that most private surgery centers are well managed and perfectly safe. Still, it’s best to trust but verify. Good luck!

Nothing in this article should be relied on for medical or legal advice.

Footnotes

¹ Badlani N. Ambulatory surgery center ownership models. J Spine Surg. 2019 Sep;5(Suppl 2):S195-S203. doi: 10.21037/jss.2019.04.20. PMID: 31656875; PMCID: PMC6790806.(link)

² [No author]. (February 2018). California’s Ambulatory Surgery Centers: A Black Box of Care. Retrieved from http://www.chch.org (link)

³ Jewett, Christina. (20 September 2018). Despite Red Flags at Surgery Centers, Overseers Award Gold Seals. Retrieved from http://www.khn.org (link)

⁴ [No author]. (2019) Q&A with Bill Prentice, CEO Ambulatory Surgery Center Association. Retrieved from http://www.ascassociation.org (link)

Copyright © 2025 by Monica Berlin