DEALING WITH A PATIENT'S FEAR OF SCARS WITH A PATIENT'S FEAR OF SCARS BY CHERYL TOTH, MBA ... NC, the clinical team is trained to set patient expectations early in the consultation

DEALING WITH A PATIENT'S FEAR OF SCARSBY CHERYL TOTH, MBAKARENZUPKO & ASSOCIATES, INC.

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In 15 years of asking more than 2,000 patient care coordinators about the non-financial reasons patients don’t schedule surgery, fear of scarring is consistently ranked as reason number four.1 In fact, it just may be a clandestine objection that’s keeping your patient acceptance rate (PAR) from being as good as it could be. As we conduct mystery calls, pose as patients to evaluate the patient experience in aesthetic offices in competitive markets, and observe the consultation process of client practices across the country, we find that many practices do not handle this patient concern effectively. Most surgeons do not prospectively show photos that illustrate the healing process. Incision care is typically explained only verbally, often with incomplete or vague post-op instructions that aren’t completely understood by patients. And it’s the rare practice that has developed educational materials which explain the physician’s complete incision care plan, including the basics about what causes a scar, as well as how the patient’s genetic heritage and environment, and compliance with product usage and other instructions, impact the end result.It takes a village, as it’s been said, to do incision care and treatment well. Surgeon and staff must have a unified approach to allaying patient fears - one that follows the surgeon’s treatment plan and is consistently delivered by everyone in the practice. Success requires staff training, comprehensive educational materials, and a bit of patient nudging. But the effort is worth the benefits: happier patients and a healthier bottom line that results from removing this silent “objection” from the patient’s decision to have surgery.

Empathy is Essential“When surgeons and staff blow off or get irritated with a patient’s scar questions, it’s usually without understanding the core reason the patient is asking them,” says Darshan Shah, MD, an aesthetic surgeon practicing in Bakersfield and Malibu, CA. “We’re quick to react defensively when patients ask, and that’s not productive. If your typical response is, ‘Of course you are going to have a scar,’ the patient may feel like you don’t care about them.”Addressing a patient’s fear of scars is critically important, Shah says, because it’s a real fear that keeps patients from scheduling. “Patients are lay people. They don’t see scars every day. Whether they saw a bad scar on Internet and it stuck in their head, or they have seen a bad scar on a friend, their fear affects their decision to have surgery.”When patients don’t have their fears assuaged, their trust in you as their surgeon can erode, leading to them choose another surgeon. Or, they may opt for a non-invasive option instead of having surgery at all. And because few patients express the fear of scars as the reason they don’t schedule, practices often don’t realize that the patient’s fear of scars is impacting their PAR and reducing the number of surgeries on the books.

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1 This exercise has been given to participants at workshops led by Karen Zupko, in her firm’s regional workshops for patient care coordinators, as well as at the American Society of Aesthetic Plastic Surgeons (ASPS), over multiple years.

“If the surgeon thinks it’s a non-issue but the patient thinks it’s a huge problem, the surgeon won’t be successful at making the patient feel comfortable,” Shah proposes.

That’s why aesthetic practices need a plan to address this under-recognized patient concern head on.

Establish Expectations Early“Surgeons know that everyone who has an incision will heal with a scar,” says Edward Dickerson, MD, a facial plastic surgeon Fayetteville, NC. “We know this is how skin handles trauma. But we need to explain this to patients.”Dickerson does this using layperson’s terms. “When a patient asks me, ‘hey, will I have a scar?’ I take a pencil out of my pocket, draw a line on a piece of paper and say, ‘I can’t get to where you want me to fix things without making an incision or a small pin hole. And this is how thin we expect it to be. Because I will hide it in a natural crease, you are probably never going to notice it, because plastic surgeons are great at camouflaging the incision.’”Dickerson feels that plain language and analogies help set patient expectations by using words that they can relate to. “I tell facelift patients, you’ll be able to wear your hair up and no one will see it. And for hair transplant patients I say something like, your hairdresser may have a tough time finding the incision once it heals.” “Everything has to be positive with the patient,” Dickerson says, “with us as the cheerleader.”Gwen Maxwell, MD, an aesthetic surgeon in Tucson, AZ tells patients, “It’s my job to put the incision in a place that has the best healing, and where no one can see it.” To establish realistic expectations about the way the incision heals, Maxwell asks questions to get a sense of the patient’s lifestyle and past healing. For instance, she says, “we know that tan skin doesn’t heal very well. If I learn that the patient takes several beach vacations each year, I’ll tell the patient 2

Word Choice MattersA kitchen accident or a bad fall leaves a scar, but “an aesthetic artist makes an incision,” says Dickerson. “In my practice, we refrain from using the word ‘scar.’ We’re consistent about calling it an incision.” Which words do you and staff use with patients? Moving from the use of scar and scar management to incision/incision line and incision care or incision treatment is a small change that can yield big results. A patient can be motivated to participate in an incision care plan when they understand that following or not following the plan will impact their healing.

Take Action:1. Query staff about the words

they are using with patients.

Choose your lexicon: incision, incision line, incision care, or incision treatment.

Consistently use the new lexicon with patients. Discontinue using scar; incision is more positive and appropriate.

Review patient handouts and Web site content and edit the copy to use incision instead of scar - except when describing the end result, which is, in fact, a scar.

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she must take that into consideration. Or, I ask if they’ve had a biopsy or a C-section or a scope and look at another scar on their body, telling them that this is what they can probably expect with an aesthetic surgery scar, but that as a plastic surgeon I use techniques that can result in it healing even better.”Carol Oliva, Maxwell’s surgical first assist, uses plain language to reinforce what Maxwell shares in the consultation, and convey the techniques used to minimize scarring potential. “Since I’m in the O.R. with her, I can give patients accurate details,” Oliva says. “For example, with abdominoplasty patients, I point to the spot on the hip that creases when the leg is lifted, and explain that this is where Dr. Maxwell will hide the incision so it is barely visible. I explain that the scalpel blade Dr. Maxwell uses makes a very fine incision and I describe how her suturing techniques close the incision in a way that reduces the chance of creating skin bags and flaps.”At Hunstad Kortesis Plastic Surgery + MedSpa, a two-surgeon practice with two offices located in Charlotte and Huntersville, NC, the clinical team is trained to set patient expectations early in the consultation process too. “We perform the highest volume of full body lifts in our area,” says Rachel Hill, Practice Manager of Hunstad Kortesis, “Concern about scarring is a huge issue for these patients, so there is a lot of hand holding with our patients.”A registered nurse (RN) or medical assistant (MA) educates patients before the physicians enter the exam room, explaining where incision lines will be, and that the surgeons make every effort to do the incisions where they can’t be seen, like below the bikini line for tummy tucks. This team approach for Hunstad Kortesis has two advantages beyond just making the patient feel cared for and supported. First, Hill says, when the doctor enters the exam room, many of the concerns around scarring have already been addressed by the staff. Second, “the doctor can just focus on being the ‘wow factor,’ describing how he plans to achieve the results the patient wants.”And what’s the best way to discuss less-than-optimal incision healing?Stephen Weber, MD, FACS, a facial plastic surgeon in Denver, CO sets that expectation like this: “I tell patients that most of the time incisions heal beautifully, to the point that the incision is almost non-existent. But that as we monitor you through follow up visits, if the healing is not what we expect, don’t worry. We know how to take care of it, using lasers or a scar revision procedure.” Dickerson’s approach is the same. “I let them know I have a CO2 laser and that scar revision surgery is an option. I tell them what’s possible if they end up with a less than expected result, or are unhappy with the width or aesthetic appearance.” Maxwell and her team provide assurances too. “We provide information about all the things we can do if they end up with a scar that they don’t like,” Maxwell says.

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Show, Don’t Just Tell“The first week after surgery is an emotional time, and if patients haven’t been shown what their incisions will look like, they can become fearful, angry, or depressed,” Weber says. “Showing visual evidence of what the incisions will look during the healing process goes a long way.” Weber proactively promotes photos that illustrate healing using digital photo shows that run on monitors in the consult room and reception area. They show close up photos of patients before, immediately after, three months, and one year after surgery for procedures such as facelift surgery, to illustrate how the incision heals. So before Weber enters the exam room, the stage is set through these visuals. Seeing the difference between a fresh post-op incision and the same incision only a few weeks later helps patients cope in that first emotional week after surgery. “If a patient knows what the incision is supposed to look like in the first few weeks after surgery, they are a lot less likely to think that their incision is bad or that they have a problem,” says Maxwell. Providing images is more effective than just saying, ‘right after surgery your incision will be red and swollen but after a few weeks, it will look much better.’ Maxwell and her team have meticulously documented a series of five photos for all breast and facial procedures, full body lifts, nasal surgery, and more - for nearly every skin type. Each series includes photos at one, two, and six weeks, then two and four months. The photos provide a visual for Maxwell to educate patients about what to expect, based on their skin type and the procedure they are considering.“It’s especially helpful for the breast patients who are really afraid of scars,” she says. “I stress that ‘yes, you are going to have a scar.’ But using the photos I show them how using certain sewing techniques and incision line placement for the patients shown in the photos, I do everything I can to minimize it,” Maxwell explains.Drs. Joseph Hunstad and Bill Kortesis review photos with patients too, using the imaging software, TouchMD, to show a timeline of the incision line healing process. “Before and after photos of patients with similar skin types are reviewed as part of the consultation process,” says Hill.

The Patient’s RoleShah has a simple framework for helping patients understand their genetics and their role in the healing process: “I explain there are three things that will impact how the incision line will look: The surgeon’s skill - how the doctor you choose creates and closes the incision during surgery - the patient’s will - how well you take care of the incision after surgery - and God and grace (your genetics). Your genetics have a big impact on how you heal, but you have very little control over that.” For the patients that say they don’t care about the scar, Shah suggests that it’s important

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Don’t Leave Staff Training to “Osmosis”Nothing is more unnerving than when the patient care coordinator’s or nurse’s explanations are different than the doctor’s. It makes the patient wonder. And that is never good.“Physicians often think that staff will pick up what they should say about incisions and scarring by osmosis, in the office,” says Shah. “But that doesn’t really happen. “Remember that most employees are lay people. You have to explain exactly what you want them to say.” Add incision care philosophy to the new employee orientation checklist, and don’t limit it to clinical staff and the patient care coordinator. Everyone on the team must be able to offer comparable explanations of your incision care plan and product recommendations.

Take Action:1. Sit down with the team and review all

educational materials. “Take all their questions seriously,” urges Shah. “This is their chance to learn, so don’t poo-poo them.” Review photographs and explain what “good” and “bad” healing looks like.Direct staff to use incision instead of scar. Create a cheat sheet or script for staff to use, with answers to common questions, as directed by the surgeon. Ask five friends to call the practice as a “patient,” and ask questions that indicate a fear of scarring. Have them document staff responses and word choices. Include incision care training in new employee orientation, for every employee.

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to care. “Because once one problem is resolved with the initial recovery from surgery, your eyes will focus on a different problem. Plus, I tell them that we take a lot of pride in our work as surgeons and we want them to take care of that incision line for the best result, as they will be showing friends and family who DO care about the scar.”“A lot of patients don’t want to be proactive or invest the money or the time required,” Oliva laments. “It’s our job to explain why it’s so important for them to be involved.” So during the pre-op, Oliva sets expectations around the timeline for healing and the patient’s role. “I tell them this is a one year long process that depends on them. Whether the incision turns out to look good or bad depends on how they care for it, so they need to take it easy after surgery, massage the incision line in the way we show them how to, and stay out of the sun.”Shah uses the initial consultation to set the stage for the patient’s role in compliance and follow up, as well as to let patients know that there are things that can be done if the incision does not heal as expected. His basic script: “During the first full year after surgery, we are going to teach you how to take care of the incision line. We’ll give you things that I believe work best for an optimal result. These things may change based on how you are healing. We’ll take a look at how you are healing when you come in for your post op appointments. We’ll know if we need to change something based on how the incision looks. So don’t skip these visits!

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Develop an Education ArsenalDon’t just rely on the informed consent conversation, or overload the patient with instructions during the pre-op. Educate patients at all touch points, providing content on the practice Web site, handouts at the consultation, and videos online.

Take Action:1.

After a year has gone by, both of us will take a look at the incision, and if both of us are unhappy with it, we can talk about revising the scar using a laser or surgery. But we will wait a full year before we have that discussion.”Setting up the one year healing timeline and focusing patients on the importance of follow up visits gives Shah’s staff a launching pad for the next educational conversation.

Patient Care Coordinators Play a Critical Role Because of their initial and ongoing contact with the patient, patient care coordinators (PCCs) often have the best opportunity to create the practice’s closest “gal pal” relationship with the patient. In most practices, the PCC is a non-clinical layperson, and patients feel more comfortable asking them questions. (Patients don’t like to look “dumb” in front of their surgeon.) It’s in the PCC’s office, behind a closed door, where all of the patient’s fears and concerns surface as fees and scheduling are discussed.Some surgeons tell the PCC not to talk about anything clinical with the patient, insisting that the nurse is the only one who can do the education. This is a mistake. If your philosophy is that the PCC’s role is only to “sign them up for surgery,” you are short changing the surgery schedule as well as the patient. Train the PCC thoroughly to address the patient’s questions about healing, scarring, and what can be done if the result is less than optimal. Here’s why: First, the patient you saw this afternoon might well have had a consultation with a competitor this morning. You told the patient about tape and incision massage, and your competitor focused on the use of gel therapy and forgot to emphasize massage. The point is that the patient has heard multiple plans and treatments and you can’t be sure what has lodged in his or her brain. The PCC can reinforce

Develop a fact sheet about what causes scars, and the impact of genetic history, environment, and patient healthy and behaviors (such as smoking or a diagnosis of diabetes). Post online, provide in consultation packets, and give it to the patient at pre-op.Post photos and your commentary about them on the Web site. Address the fear of scars and what you, the surgeon, do to minimize them. At the pre-op, review and provide an Incision Care Plan, which includes instructions for using the products and treatments you recommend.Record a 2-minute video of the surgeon or nurse demonstrating incision massage, and post it on YouTube. Make a link from the Web site.Create a 3-minute video of the surgeon or nurse explaining what things impact a scar, and the patient’s role in the healing process.At early follow up visits, ask the patient to ‘teach-back’ components of your incision care treatments. Ask questions about product usage.

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your recommendations and incision care plan.Second, while you were eloquently explaining the details of your after care approach during the consultation, the patient was thinking about who would take care of the kids, whether she could take the time off work, and how to explain this whole thing to her spouse. So, all those important things you thought the patient heard didn’t register. As she speaks with the patient about fees, the PCC is in a great position to answer the same questions you already have - but this time, at a moment when the patient is ready to hear them. Add education about incision line care to your new employee orientation and ongoing staff education. Provide written protocols on aftercare techniques by procedure. If you do abdominoplasties, breast reductions, or Mommy Makeovers, write these protocols first, due to them requiring the biggest incisions. And if one PCC covers two doctors, make sure she is provided detailed treatment recommendations for both.

Tell Them. Show Them. Involve Them. Repeat. A classic communication strategy is to tell people something seven times, seven different ways so they get it. From your Web site content to the first phone call to the consultation and beyond, such a “7x7” approach starts before the patient ever comes in to the office. For maximum impact, this communication should be a mix of verbal discussion from multiple people at multiple points in the process, paper handouts, online content, and images. Weber has developed handouts and instruction sheets, specific to incision care. They stress the importance of post op sun care by using a high quality sunscreen, as well as information about how to use incision care products. “Giving people paper is really helpful,” he says. “People don’t remember everything you tell them in the consultation, and sometimes I don’t have time to review all the details. Patients can review the handout after they go home.”Shah devotes page of his web site to a detailed article he wrote about what causes a scar and what patients can do - along with what they should not do - in order to improve healing.2 “It’s a comprehensive paper that supports everything we tell patients in the office,” he says.According to Hill, “Education is an important element in our practice. Whether it’s educating the patient about managing medications, taking care of drainage tubes, or caring for the incision, each person on the team plays a part in the education process for the patient.” When patients come in the day after surgery, the following week, and for other follow up visits, the Hunstad Kortesis team asks questions to ensure they are following self care and post-op instructions properly. For instance, Hill explains, “We ask questions about how and how often they are using the bioCorneum® gel, and provide 2 Avoiding Scars, Darshan Shah, MD, http://www.beautologie.com/patient-resources/beautologie-tips/scars/. Last accessed October 15, 2015.

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more if they need it. Our all-inclusive surgery fee includes garments, products, and all the gel they need to heal to the point they are happy with the result.” This philosophy is part of the surgeons’ “whole person healing” approach to care.Drs. Hunstad and Kortesis have integrated this philosophy and the details about incision care into a multi-page booklet that includes what to expect before and after surgery, consent forms, and other information. It explains, for example, the importance of keeping tape on the incision for three weeks, applying bioCorneum® gel, and staying out of the sun for one full year.What are the ideal topics to cover in your patient educational material? Best case, they outline the impact that skin type, environment, and health conditions have on healing, the basics about the healing process, and the surgeon’s recommended incision care plan. They also include the value and benefits of the products you recommend, at what point in the healing process to use them, and why the patient’s participation is vital to a good outcome. Your material has the biggest impact if it’s written by the practice and includes the surgeon’s specific treatment recommendations and plan.All of these educational elements are intended to supplement verbal education and photo review, pre-op instructions, and content or videos on the practice Web site. It’s a tell them, show them, involve them approach that promotes patient involvement and reinforces learning using different modalities - whether those be listening, reading, doing, or teach-back of techniques you’ve shown them. Remember the “7x7” communication strategy: tell people something seven times, seven different ways so they get it.Maxwell and her team demonstrate the proper technique for massaging their incision during the pre-op visit, and provide re-training during follow-ups. Weber and his staff monitor patient usage of bioCorneum® gel and ask specific questions about usage during follow up visits.Shah advocates for a mix of treatments throughout the healing process. “We evaluate the patient’s incision self care when they come for follow ups,” Shah says. “In addition to monitoring the incision’s response to tape and massage, at six months, we provide a healing stick that I developed. It includes Vitamin E, silicone, and other good stuff to help the scar along. We tell patients to use it as much as they want until the incision line is to their liking.” “It’s important to keep patients involved in their therapy,” Shah adds. “When they are an active partner in the healing process, they develop a more vested interest in their outcome.”.

ConclusionIt takes a village, as it’s been said, to do incision care and treatment well. Recognize the role surgeons play in whether a patient’s fears are allayed, and how this impacts the surgery schedule. Train staff about what to say and how to say it. Educate patients

All-in-One Pricing “Removes Excuses” & Promotes “Whole Person Healing”Hunstad Kortesis provides patients an all-inclusive fee that includes surgeon fee, garments, binder, skin care products, and “as much bioCorneum® gel as the patient needs,” which, according to Hill, encourages patients to use it without worrying that they won’t have enough. “The inclusive fee is part of our surgeons’ “whole patient philosophy,’” she adds. “Our physicians want patients to know that we are investing in them, because they are investing in us. They are part of our family now and we will do everything possible to make them happy until they are fully recovered.”

Weber’s practice has seen success with an inclusive fee too. “It’s human nature to cut corners,” he says. “Patients try to nickel-and-dime and cut corners to save 10 or 20 dollars on a major surgery. They don’t understand the benefits of all the products we recommend. Or, they tell us they are too busy to pick them up before surgery.”

So Weber’s team simplified this by wrapping all costs into the procedure fee, and putting everything into people’s hands at their pre-op. The results have been very positive. “We removed the excuses of ‘I forgot’ and ‘I can’t afford it,’” he says. The patient is given all the tools they need to take optimal care of the incision - and a lot of reinforcement through phone calls and follow up visits. “We are seeing more and more patients invested in their recovery, and using the products properly.”

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Cheryl Toth, MBA is a consultant and trainer with KarenZupko & Associates, Inc. She brings more than 20 years of consulting, as well as product and executive management experience, to her projects. At KZA, Cheryl works with aesthetic and other surgical specialists on management, marketing, and financial issues. She writes regularly for Aesthetic Society News and other practice management journals and publications that include Physicians Practice, American Journal of Orthopedics, and Journal of Medical Practice Management. Reach her at: [email protected].

About KarenZupko & Associates, Inc. (KZA) KZA is a Chicago-based practice management and marketing firm that has consulted with, trained, recruited for, and provided interim management support to thousands of aesthetic practices across the country and internationally. For 30 years, Karen Zupko has advised and educated aesthetic surgeons on management and marketing issues, including personnel, billing, technology, coding, and practice expansion. Ms. Zupko and her team are featured regularly at workshops and events held by the American Academy of Facial and Reconstructive Plastic Surgeons, American Society of Aesthetic Plastic Surgeons, IMCAS Paris, the Vegas Multi-Specialty Meeting, Association of Dermatology Administrators and Managers, American Society of Plastic Surgery Assistants, and the Plastic Surgery Administrators Association.

verbally and in writing, and deliver the information online, on paper, and in the office. Use images to illustrate the healing process. Provide ongoing monitoring and reinforcement about the patient’s role during follow up visits. The practice that consistently delivers the combination of these tactics will eliminate the fear of scarring as a surgery scheduling showstopper.