Tips for improving the patient experience

Mara C. Weinstein Velez, MD: “My patients want to look natural, and there are ways to achieve this by using less product and by using it correctly.”

Whether you are a senior or a junior dermatologic surgeon, you face new challenges. A July 27 symposium touched a variety of topics, including improving the patient experience, dealing with pregnant patients, and using fillers and toxin.

“No matter what level of experience you have, you always come away from these types of talks learning something. I’ve been doing this for 25 years, and when I listen to these talks, I still gain pearls that change my practice,” said Elizabeth M. Billingsley, MD, director of “Finessing Surgical and Cosmetic Techniques” (S001).

Improving the surgical patient experience

Patient satisfaction is an area of emphasis for all health care providers, but many of the measures of satisfaction for an office visit do not reflect what surgeons believe constitutes a good outcome. Still, surgeons can take steps to make the experience better for the patient.

“On the provider side, specifically for surgery, many of us assume that patients will be satisfied if their cancer doesn’t recur, the scar is imperceptible, and if there are no post-operative complications,” said Thuzar M. Shin, MD, PhD, assistant professor of dermatology at the Hospital of the University of Pennsylvania.

“When you compare these metrics to the questions patients are being asked about their visits, they are totally different. They are asked about wait times and how friendly your provider was. These ratings and the accompanying patient comments give us great insight on what patients value,” she said.

Surgeons can take steps to improve the management of the operating room and manage patient anxiety, said Dr. Shin, who presented “Optimizing the Patient Experience — Communication, Anesthesia, and More; Details That Make a Difference.”

For example, when a patient is prepped and draped for reconstruction, they are in a vulnerable position. They may have their face covered with sterile towels. In that extreme situation, friendly communication helps.

“If you want to know if they are comfortable, you can ask them in two ways,” Dr. Shin said. “One way is, ‘Are you OK?’ Or, you can say, ‘Everything is going great. How can we make you more comfortable?’ Which one is more reassuring? We can make a conscious choice to choose words that don’t alarm the patient and provoke anxiety, and are reassuring and show you care.”

Administering anesthesia is also an opportunity to show you care about the patient. Tips to lessen discomfort have been published in medical literature.

“Some examples include injecting slowly using a small-gauge needle, warming up the anesthetic, buffering the solution, injecting perpendicular to the skin, and using distraction techniques,” Dr. Shin said.

After the surgery, make yourself available to the patient and educate them about the recovery. For example, you can warn a patient that their eye may swell, or prepare them for the number of stitches they will have, she said.

“I’ve started showing patients what their stitches look like in the mirror before they get bandaged because they will be the one taking off the bandage and dressing the incision,” Dr. Shin said. “Patients are almost always surprised at how many stitches are needed to close a wound. This gives the patient an opportunity to express their anxiety or worry, and it gives you a chance to reassure them before they leave.”

Caring for the pregnant patient

Almost 2 percent of pregnant patients require non-obstetric surgery. Many dermatologists and dermatologic surgeons have anxieties about the dangers of such surgery, but most treatments will not change if a patient is pregnant, said Keith Harrigill, MD, MBA, MPH/TM, who presented “Surgery in the Pregnant Patient.”

“Most care that a dermatologist would provide for a typical patient can be provided for a pregnant patient with little adjustment to standard techniques or indications. The optimal times to perform procedures are in the second trimester or in the postpartum period,” said Dr. Harrigill, a former perinatologist and now a Mohs surgeon at Southern Skies Dermatology and Surgery in Birmingham, Alabama.

Dr. Harrigill shared tips based on recommendations by the American College of Obstetricians and Gynecologists for pregnant patients who require non-obstetric surgery:

  • Biopsy anything that is clinically suspicious for malignancy at any gestational age. Avoid the risk of delayed diagnosis because of fear of the pregnancy.
  • Divide clinical situations into three groups: Urgent (for example, melanoma, aggressive non-melanoma skin cancer); non-urgent (nodular basal cell carcinoma); and elective (scar revision). Perform the indicated surgery for the urgent group ASAP, regardless of gestational age. Perform indicated surgery for non-urgent indications in the second trimester or postpartum period. Delay surgeries for elective indications until after the pregnancy.
  • For extensive cases at advanced gestational ages or when general anesthesia or fetal monitoring is required, collaborate with an Ob/Gyn and an anesthesiologist.

“Most biopsy techniques, local anesthetics, antibiotic selection, or postoperative medications we are likely to choose are safe in pregnancy,” Dr. Harrigill said. “A few medications such as sulfamethoxazole/trimethoprim or doxycycline can create problems for fetuses and should be avoided, but we have good alternatives that are safe. Minor modification to suturing techniques, such as subcuticular stitches with delayed removal, can benefit the pregnant patient.”

Update on fillers and toxins

Cosmetic surgery is increasing rapidly with the development of new techniques and products. Mara C. Weinstein Velez, MD, of Schweiger Dermatology Group in New York, presented “Fillers and Toxins — Updates and Practical Tips.”

“My patients want to look natural, and there are ways to achieve this by using less product and by using it correctly,” Dr. Weinstein said. “It is important to hand them a mirror during the initial consultation so you can address their concerns together.

“For volume loss, I like to start with one syringe and then reassess. You can always add more. I also see a huge advantage in combining treatments on the same day. It maximizes the end result and increases patient satisfaction. For new patients, I always find a way to follow up with them in two weeks.”

Three types of toxins are commonly used, but a new toxin, daxibotulinumtoxin A, could be a “game-changer,” she said. Daxibotulinumtoxin A is now in a phase 3 clinical trial that is looking at its longevity. Studies have shown that it lasts up to six months, compared with three to four months for toxins now in use.

Four new fillers were introduced earlier this year. They, too, offer greater longevity, lasting 12-18 months, compared with current fillers that last about six months, Dr. Weinstein said.

Dr. Weinstein also offered practical tips for procedures.

  • In the perioral area, she explained how to use toxins and fillers to help smooth out perioral rhytids and fill the lips with a more natural look.
  • She discussed prejuvenation and the advantages to starting treatment with neurotoxin at a low dose to soften and prevent, not “freeze.”
  • She explored alternative uses for botulinum toxins, including the Nefertiti Lift for neck and jawline rejuvenation.

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