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A nose for trouble

01 May 2007

Ms C, a 30-year-old hotel receptionist, went privately to see Mr T, a plastic surgeon to discuss surgery to change the appearance of her nose. She had been unhappy with its appearance for a number of years, and finally decided to have a rhinoplasty. Mr T explained the risks and benefits of the operation as well as the limitations of surgery.

Two weeks later, Ms C was admitted to hospital for surgery and gave written consent for rhinoplasty. At the time of the operation, Mr T noted deviation of the nasal septum. Mr T decided that as the main consideration was the external appearance of the nose, and that no consent had been taken for septal surgery, he should not interfere with the septum. The procedure and recovery was uneventful and Ms C was discharged home later the same day.

Ms C was seen ten days later in Mr T’s outpatient clinic for removal of the external nasal dressing. Although Ms C was pleased with the external appearance of her nose, she was concerned that she could see the septal deviation in her left nostril when she looked in the mirror.

Mr T maintained that it “looked OK” and after a somewhat heated discussion, offered to correct the problem “if it’s that important to you”.

Mr T’s behaviour in this consultation was corroborated by his nurse, and he later admitted that he had been “having a bad day”. Mrs E did not return to see Mr T, but had the problem with her septum corrected by an ENT surgeon.

Two and a half years after the operation, Ms C began legal proceedings for negligence against Mr T, alleging that he had failed to correct the septal deformity as part of the nasal surgery. Mr T denied liability. 

Expert opinion

Plastic surgery and ENT expert opinion was not critical of the surgical technique or the satisfactory cosmetic outcome that had been achieved.

The revision operation required was a minor one and no irreversible harm had been done. However, Mr T should have assessed the septum and nasal airway preoperatively as part of his planning of Ms C’s rhinoplasty operation.

Expert opinion was critical of Mr T’s confrontational and dismissive attitude to the patient when she came back for her postoperative follow-up appointment. This claim may have been avoided if Mr T had spent some time explaining to Ms C why he had not corrected the septum. He could have offered to arrange for Ms C to see a colleague for an independent second opinion.

Notwithstanding these concerns, MPS defended the claim, as there was no evidence of any negligence. A short time after this the claim was discontinued.

Learning points

  • Although we cannot know for sure, there is a strong likelihood that Mr T’s attitude was a significant factor in Ms C’s decision to take legal action. There is a growing body of evidence to suggest that patients are more likely to sue doctors with poor interpersonal skills, and that this is unrelated to their clinical competence.
  • Communications with some patients can be extremely challenging, but it is a mark of professionalism to refrain from reacting with anger. The UK’s General Medical Council, for example, states that: “To fulfil your role in the doctor–patient partnership you must (a) be polite, considerate and honest; (b) treat patients with dignity… extra care should be taken with challenging patients.”
  • When something goes wrong, be open, apologise, investigate, learn and provide support. Apologising to a patient is not an admission of liability and lowers the chances of them taking matters further. Being defensive encourages patients to believe that you have something to hide.

Further information

  • Entman SS, Glass CA et al, The Relationship between Malpractice Claims History and Subsequent Obstetric Care, JAMA 272 (20):1588-91 (1994).
  • General Medical Council, Good Medical Practice (2006).
  • The British Association of Plastic, Reconstructive and Aesthetic Surgeons has some useful patient information leaflets available on its website:www.bapras.org.uk