The Red Flags We Watch For in a Cosmetic Surgery Consultation

Announcer (00:02):
You're listening to Alabama the Beautiful.

Kirstin (00:05):
I'm Kirstin Jarvis and I'm here with Alabama Cosmetic Surgeons, Dr. James Koehler and Dr. Vincent Gartner. Hey, Dr. Koehler and Dr. Gardner.

Dr. Koehler (00:13):
Hey, how are you?

Dr. Gardner (00:14):
Hey, KirstIn.

Kirstin (00:15):
Y'all know what we're talking about today?

Dr. Koehler (00:16):
No, please tell me.

Kirstin (00:20):
We talk about a lot of different procedures on this podcast, but today we're going to back it up a little bit actually back it way back to the consultation because picking the wrong surgeon is a problem that no revision surgery wants to fix. Dr. Koehler and Dr. Gardner, let's get into it.

Dr. Koehler (00:40):
All right.

Kirstin (00:41):
When a patient walks in for a consultation, what do you look for in them and what should they be looking for in you?

Dr. Koehler (00:49):
Well, I mean, there's actually a lot of things that I'm looking at and actually I'm not going to share some of them on here because I don't want to give that. There's some red flags that I definitely look for that are things that concern me. I'm always looking for those types of things. So just to give an example, for instance, let's say a patient comes in for a facelift and in the conversation we find out, oh, her husband just died four weeks ago. Not to say that she isn't a candidate for a facelift and all that kind of stuff, but in the midst of a recent death of a loved one and stuff like that, she may be making an emotional decision to get this surgery done. So anyhow, there can be red flags. That would be an example of maybe a red flag. But the main things that I'm looking for in the patient is like, what's their motivation?

(01:42):
Is it something that they want to do or is it something their spouse wants them to do? That's an important thing. If it's for themselves, well, that's great. But there's another red flag when they're really not doing it for themselves or doing it for someone else. So I'm looking for that type of information. I'm looking for what their expectations are and are those expectations realistic? So sometimes people will bring in photos and then sometimes I'm looking at the photo and I'm like, "Yeah, no way that's going to happen ever." And other times it's like, "Yeah, no, that's really ... I think that person looks like you. They've got similar skin quality, whatever the case is. " I'm like, "Yeah, I think that's achievable." So what their motivations are, what their expectations are and just their general knowledge, like have they looked into this significantly or is this just a whim, spur of the moment thing?

(02:32):
So those are just a few of the things that I look for. I don't know. What about you, Dr. Gardner?

Dr. Gardner (02:36):
I agree. I think having somebody who has been researching it for a while who really does know what they want. They've been on the before and afters, they've kind of researched you and they've done their homework. So they're educated. I do agree that if you have a significant other boyfriend spouse and they're the only ones doing the talking, that to me is a big red flag. I agree with you. The patient needs to be the driver in this. They need to be the one that wants to do this. And obviously having spousal input or significant other input is really important, but they don't need to be the ones driving the boat. So I agree wholeheartedly with that. We do see a lot of people with significant life changes and I think that you're right, sometimes those can be overwhelming the stress of everything that's going on in their life.

(03:29):
And so sometimes I think they need to ... It's fine to have the consult but then maybe not jump too quickly and sleep on it so to speak before they make some decisions. But having a good informed patient, there's nothing better because they know the expectations and I think that's the key is setting expectations. And I always get really nervous when I have somebody that has crazy expectations and if we're not seeing eye to eye, then we either have to recalibrate till we do see eye to eye or maybe they need to find somebody who does see eye to eye with them.

Kirstin (04:06):
Yeah. Is there a such thing as a bad consultation even if the surgeon is super qualified?

Dr. Koehler (04:13):
Yeah. I mean, there could be a lot of reasons for bad consultations. Patients that's not properly informed coming in with, again, unrealistic expectations or thinking a procedure can do one thing and it can't. There can be bad consultations from the patient's experience with the doctor that they just don't, whatever, they don't connect in a way, they don't feel good. And I remember a surgeon telling me one time, he says, "Listen, just don't ever operate on someone you just don't like. " And I thought, I'm like, "What?" And he's like, "Some people just rub you a wrong way or whatever." And he's like, "It's just been a great rule for me. It's like if for some reason I just don't get good vibes and I don't know that I click with that patient," he says, "I'd prefer to not operate on them than if they do have a complication or a problem and now I've already had a hard time communicating with this person even before something negative happens, then if you are in that situation, it makes it really hard." And so I would say the same for a patient.

(05:15):
If they get a negative vibe about their doctor that something just doesn't feel right, well then go with your gut because I mean, it is a big decision. So as doctors, we have sometimes like we get a gut feeling like, maybe this patient isn't ideally suited, whether it's timing or what there could be a number of reasons. And when we're in our consultation, we're not trying to probe into the deepest parts of your life, but we are trying to make sure that you're doing it for appropriate reasons, that you have good expectations, all of those things. So when those things aren't lining up, it concerns a doctor. And like I said, the patient should feel the same way.

Kirstin (05:56):
Dr. Gardner, what should a patient look for when they're vetting a surgeon?

Dr. Gardner (06:01):
Like Dr. Koehler said, first off, you have to make sure that you're compatible and that you're a good fit just from a likeability or agreeability standpoint. And from there, I think you need to learn about them as far as their experience, what they like to do. And what I mean by that is are there certain procedures that they kind of enjoy more than others? For instance, I enjoy massive weight loss. I like to do everything, but I really enjoy the massive weight loss. But I think that to me is key looking at their before and after photos and again, just making sure that it's somebody that you're comfortable with that has the experience to get what you're interested in done. And I think reading reviews can really help. I mean, it kind of does kind of paint a picture of what you can expect post-op.

(06:52):
Remember, anybody can operate and obviously some people are better than others, but being there for the patient for postoperative care and any issues that can arise is something that I think you really want. And we've all heard it like, "Hey, I had this done and I never saw the doctor again. I saw some support staff who took some stitches out and said I was doing great. And for whatever reason, I just can't get the doctor back in the room with me. " So I think that's a big problem. And I think that's where we tend to give our patients the face time that they need post-op and not even that anything could be wrong, but just that they need that reassurance that, "Hey, this is going to get better. That swelling is going to go down and we're going to be here for you through the whole process."

Kirstin (07:42):
Dr. Koehler, let's talk about what hospital privileges are and why it should matter to somebody who's getting an elective procedure.

Dr. Koehler (07:51):
To get hospital privileges, a committee reviews your application, their reviews what your credentials are and it's reviewing what you're planning on doing in the hospital and they make sure that, yeah, this person has got adequate training experience, et cetera, to do these procedures and perform these procedures. And so when they're granted these privileges to do these procedures that they can do them quote in the hospital. And it's just one more thing that kind of reinforces like, "Okay, well, my doctor's credentials are good and they're competent to do that. " Sometimes surgeons can, if they perform certain procedures poorly, they may still have hospital privileges, but they may have privileges removed for a certain procedure or a certain whatever. Anyhow, so again, it's a confirmation, but some doctors don't operate out of the hospital. They don't want to take call at the hospital and so they may not have hospital privileges because they don't want to operate in a hospital and don't want to have to take call.

(08:53):
So not having them is not necessarily a red flag, although I would say for most people, if you have an issue or problem, I want my doctor to be able to take me to the hospital and take care of me if there's an issue. Now, granted, most of the stuff we do is outpatient and doesn't require that, but in the event you want to have that backup.

Kirstin (09:13):
How about office-based surgery accreditation? What does it mean to be accredited and is it a red flag if your surgeon is doing surgery in the office and they're not accredited?

Dr. Koehler (09:25):
Well, it will be now. The reason I say that is up until this year, you did not have to have an accredited facility in the state of Alabama to operate, which that was the rules. We've always been accredited. We've been accredited through AAAHC and I've always operated in an office facility or hospital. And if I operate in the office setting, it's an accredited facility, AAAHC or some type of accreditation. And our facility is, and we have been ever since I've been here, but the state of Alabama just this year is passing rules that require surgeons now if they do office-based surgery that their facilities should be accredited and they've got, I think in the next whatever, it's a year or two to get, because it takes time to get that whole process done. So the point is going forward, that shouldn't really be a concern in the state of Alabama because if you're getting surgery in an office-based facility, it should be accredited.

(10:27):
But yeah, it's a good thing to ask. I think it's important. It sets a standard for safety and for just peer review and a lot of other stuff. So there's lots of important things that go along with accreditation, but to me it just sets the bar up here to make sure that you're in a safe environment for your procedure.

Kirstin (10:49):
Dr. Gardner, if a surgeon quotes you a price before they actually examine you, is that an issue?

Dr. Gardner (10:56):
I think it can be. I think that pricing comes up and it's a conversation that's had, but it's based on many things. It's based on the duration of the procedure, the actual type of the procedure. Some procedures are more difficult than others. It's based on anesthesia fees. It's based on facility fees and you say, "Okay, well, what are the facility fees?" Well, it takes a lot to run a surgery facility. And so we pay nurses, we pay very qualified people, assistants, anesthesia staff to run an OR, not to mention all of the machines and the equipment that it takes to do the procedure. So it can be a big deal. But again, if somebody's just getting a random price, you don't know exactly what you're getting. Are you really, like Dr. Kohler said, are you getting an accredited office-based surgery facility or are you getting a really small office with a skeleton crew?

(11:58):
You typically are going to pay for what you get. I mean, that's kind of true throughout all aspects of life. And I think quality, you do pay for quality and it's just like going to a nice restaurant. You're going to pay more and you're going to get a lot better cut of meat and you're going to get a lot better meal. And so I think you pay for what you get. But I do think if you're getting a lot of pricing and you've never even talked to the surgeon or at least you're not expecting to have a conversation, not that it's bad, I mean, because there are plenty of places that are going to say, "Okay, this is kind of our range and then you're going to come in and we're going to see what you need done because think about it this way. A lot of people bring a lot to the table, meaning everybody brings something different.

(12:41):
Somebody comes in and say they're five, 10 and they weigh 230 pounds versus somebody who their best friend who comes in and they are 5'4", 135 pounds, completely different as far as body type. And so when we go to quote those people, the quotes are not going to be the same because one of those cases is going to take a lot longer than the other one and there's going to be more involved. So you have to take that into consideration. And I hear people say," Well, my best friend had it and they had this and this. "Well, okay, maybe they had just a little bit of liposuction or no liposuction with their tummy tuck. Well, we might do lipo 360 all the way around. That takes a lot of time. And there are times where we spend more of the case doing liposuction than we do actually doing the tuck. So not all apples are the same and you have to kind of see what you're getting.

Kirstin (13:39):
Dr. Koehler, should patients be concerned if there are not many before and after pictures for a specific procedure on a doctor's website?

Dr. Koehler (13:48):
Can be, but not necessarily. So it depends what it is. So one of the things that is always a struggle is like, for instance, for facial procedures, particularly things like facelifts, there's a lot of people out there that are like, "Oh, I'm fine if you can use my pictures in consultation, but I don't want it on the internet. I don't want it on your social media. I don't want it on your website." So if you feel like there should be a larger volume of pictures, it depends on the procedure That can be one reason. And a lot of times there's pictures that we have in the office that are not going to be available online just because again, they haven't given us permission to use it online. Sometimes it can be because a procedure maybe is not as frequently done and so there can be fewer before and after pictures just because of the magnitude of it.

(14:37):
Some operations you do every week and some operations you do maybe once every three months or once every five months because they're just not very common. I'll give you an example like otoplasty, ear surgery, which is something I actually love doing that operation. It's great, but it's not an operation we do every week and it's an operation that I do a few times a year and I do it on five year olds and I do it on 50 year olds. I mean, it's a big wide age range, but the reality of it is my experience is probably ... If you were to call any doctor's office and say, "Well, how many otoplasties do you do a year?" I mean, most people are not doing that. That's not a weekly operation. That's once every few months. So you're going to have fewer before and after photos and that sort of thing. Versus for instance, for us like tummy tucks, like we do that every week. So there's lots of tummy tuck pictures.

Kirstin (15:30):
All right. What if I walk into the consultation, my doctor and I chat for a while. He tells me about the procedure and then he gets up to leave, but I've got questions and now he's sitting back down to answer my questions and he is annoyed that I'm asking. Red flag?

Dr. Koehler (15:49):
Well, you are rather annoying. Listen, I think obviously sure it could be a red flag. It could just be caught somebody in a moment where they're having a busy day and they thought you were done and you weren't. And so if that's the case, then that's a ... But it sounds like this person then sits back down. So maybe they thought, "Oh, well we were done," but you're not. So as long as you get the opportunity to ask your questions and you feel like they're being heard, because it's one thing to ask the questions, it's another thing to make sure that your doctor's actually listening to what you're asking and providing you with the information you need to make a decision. But yeah, I mean, that could be a red flag. If they were in too big a hurry to listen to what you had to ask and not interested in what you had to say, then maybe might be one to move on.

Kirstin (16:47):
All right. What if I am price shopping and I call around and I find a doctor that is $10,000 cheaper for my intended procedure than everybody else around us. Is that a red flag?

Dr. Koehler (17:02):
Huge.

Dr. Gardner (17:04):
Yeah. I mean, again, go back to the facility, how are they charging so little for that procedure? Are they doing it in a small little room with a skeleton crew and what are you going to get post-op? Are you going to get anybody if you have a problem or when you call up and say, "Oh, well so- and-so, he's not here, he's out of town and we don't know how to get him and you just need to go to the ER." I just think I agree to me, that's a red flag.

Dr. Koehler (17:33):
Yeah. I mean, there's one thing if let's say an office does a promotional event where they are offering a discount of a certain amount, maybe it's a certain time of year or maybe for whatever reason somebody runs a special, that's one thing, but it's not going to be that huge of a difference. It's not going to be like what you're talking about. And to Dr. Gardner's point, I mean, when you see that huge of a discrepancy between what everybody ... There can be discrepancies. There's some people who are very well known for a certain procedure and they cost a lot more if you want them to do your surgery and that's just the way it is, but there's a lot of procedures that are still going to be kind of clumped together and when there's a huge outlier and somebody's so much cheaper, you got to ask yourself like, "What corners are they cutting?

(18:21):
What am I not getting? What am I missing here? Why is it so cheap?" I'd have a lot of questions. And you made the comment right at the very beginning, I mean, people can't have complications with surgery, but obviously from a doctor's perspective, we're trying to make sure that people aren't smoking and doing all these things that affect our outcomes because we want to have great outcomes. We want our patients to be happy. But if you end up with a bad complication because of a doctor that had poor judgment because they were just trying to make a buck on a procedure, they cut all kinds of corners and you end up with this problem, it sometimes is not something that's an easy, "Hey, fix that. " It may not be fixable. So yeah, I'd be concerned.

Kirstin (19:04):
Let's talk about what questions patients should be asking their surgeons. Is there something that you've noticed that patients usually don't ask but maybe they should?

Dr. Koehler (19:14):
Yeah. My biggest on is they should ask about revision surgery. Nobody wants to ask it. Nobody talks about it. We have a revision policy the patients sign and we give it to them and all that stuff, but I swear nobody reads it or talks about it. We talk about it, but nobody wants to really address it. But the bottom line is whatever procedure you pick, there is a revision rate, a number. I don't know what it will be exactly for your surgeon and I bet your surgeon doesn't know exactly their revision rate, but they got a ballpark idea if it's under 10%, over 10%, whatever the case, all procedures carry a certain revision rate. And sometimes it's a minor thing and it's no big deal. Sometimes it can be managed under local anesthesia, sometimes it needs to be under general anesthesia. But regardless, you should at least understand what your surgeon's policy is for revision work.

(20:13):
So if it's just a minor thing, it can be done under local, what kind of charges should I expect? What does the surgeon charge for that? If I have to go to sleep for it, all these kinds of things. So having a discussion about how revisions are handled and what we do in those cases and what you could expect to pay, because just as an example, I mean if you went in for heart bypass surgery and you end up in afterwards you're in the recovery room or the ICU or whatever and you have a bleed and you have to go back to surgery, there's cost involved and somebody's paying that insurance company, there's cost involved. So when you go back for revisions, touch ups, whatever, there are costs. We obviously in our practice, our philosophy, we want to obviously do the best work that we can and we try to minimize the amount of revisions, but when they do happen, we try to make it as painless as possible. But again, it's not cost-free. There's still cost involved.

Kirstin (21:20):
Well, along those lines, is it offensive if a patient comes in and asks about complication rates? Is that something that they should be asking their surgeon?

Dr. Gardner (21:30):
Yeah, absolutely. I mean, ask all the questions that you feel that you need to ask. And if you feel uncomfortable asking about that, then you maybe need to find somebody new because that shouldn't be an offensive question. In fact, it should be a nice discussion with regards to what your expectations are. And like Dr. Kohler said, unfortunately, my analogy is if you walk across a busy street, eventually somebody gets into an accident, somebody gets hit. That risk is one out of whatever, 10, 20, 30,000, but sometimes that's going to happen. And that's the way I see complications is that it can happen and eventually sometimes if you do enough surgery, something will happen. And so you just have to be prepared to take care of it. And so I agree with Dr. K on that.

Kirstin (22:23):
What should patients ask about who's in the room during surgery? For example, anesthesia staff, scrub techs, nurses, should people be asking questions about them or their credentials or qualifications or anything?

Dr. Koehler (22:38):
I mean, I don't know. If you've got an accredited facility, that to me is kind of the more important thing because that actually means that you've got all the pieces in place that a facility would require to, whether that be how instruments are sterilized. Should you get into the specifics of how you sterilize your instruments? I mean, how far you go with the questions, I don't think it's unreasonable to ask those things. I just don't know if a facility is accredited and whatnot, do you need to ask, okay, and I can't tell you until the day of surgery who specifically is doing their anesthesia, because we have a group of people that do them, but yeah, who's doing your anesthesia? Who's in the room? What's their role? I mean, that's all good questions. It's all good things to ask.

Kirstin (23:21):
If you could give patients one piece of advice before they booked a consultation, what would it be?

Dr. Koehler (23:27):
The piece of advice before scheduling your consultation is spend some time doing your research so that when you do schedule that consultation, that you've got appropriate questions and that you're not just trying to figure out what's best for you. You probably already have a good idea like, "Oh, based off of what I'm wanting, I probably will need a lift or I probably will need a tummy tuck or whatever, but it'll help direct your questions. So spend some time doing a little research on your own before you just head in the door and schedule your consult.

Dr. Gardner (24:00):
Well, I mean, I think that's huge in the sense that it really does. There are plenty of people that come in, they're just looking. They have no intention of really pulling the trigger and they'll go to multiple consults and it's just something to do and yeah, maybe I'll have surgery at some point, but they're really not very serious and they're just kind of kicking the tires. And those are not people that we want to see because time is valuable. And if I've got somebody kicking the tires and they really have no intention and I've spent 30 minutes with them in a consult and it's just they've wasted their time, they wasted our time. It's just not fruitful whether or not you charge for a consult because you unfortunately will eliminate a lot of people that have really or really don't have any intention of doing anything that's coming in for a looky loo.

Kirstin (24:52):
Okay. Do you have a burning question for Dr. Koehler or Dr. Gardner or me? You can leave us a voicemail on our podcast website at alabamathebeautifulpodcast.com. We'd love to hear from you. Thanks, Dr. Koehler and Dr. Gardner.

Dr. Koehler (25:06):
Thanks.

Dr. Gardner (25:06):
Thanks, Kirstin.

Kirstin (25:07):
Go back to making Alabama beautiful.

Announcer (25:11):
Got a question? Leave us a voicemail at alabamathebeautifulpodcast.com. To learn more about Eastern Shore Cosmetic Surgery, go to easternshorecosmeticsurgery.com. The commentary in this podcast represents opinion and does not present medical advice, but general information that does not necessarily relate to the specific conditions of any individual patient. If you enjoyed this episode, please share it and subscribe to Alabama the Beautiful on YouTube, Apple Podcast, Spotify, or wherever you like to listen to podcasts. Follow us on Instagram @EasternshoreCosmeticSurgery. Alabama The Beautiful is a production of The Axis T-H-E-A-X-I-S.io.