Factors Influencing Litigation Compensation in Plastic Surgery: A Retrospective Analysis in China

Abstract

Background:

Doctor–patient disputes have become a prominent problem in contemporary society. The analysis and discussion of the factors leading to litigation compensation are essential to prevent and resolve doctor–patient conflicts, reduce litigation events, and provide better service for patients.

Methods:

We reviewed the medical lawsuit cases of a plastic surgery hospital over the past 8 years. After excluding 11 withdrawal cases, we analyzed the types of surgery, surgical sites, and causes of litigation compensation in the remaining 36 cases. Subsequently, we proposed preventive measures to avert similar occurrences.

Results:

Thirty six medical malpractice lawsuits were filed, 23 of which involved cosmetic surgery. In 72.2% (26 of 36) of the cases, disputes were resolved through compensation, with the majority involving facial plastic surgery, including procedures on the skin, eyes, nose, forehead, ears, and jaw. The primary reasons for pursuing legal action included dissatisfaction with surgical outcomes, postoperative complications or disabilities, lack of informed consent, inadequate doctor–patient communication, and insufficient preoperative examination records. Additional factors included improper medical documentation, deviation from established medical protocols, noncompliance with surgical indications, and insufficient attention to patient needs. Furthermore, 1 lawsuit was filed due to an incident in which a patient’s family member fell on hospital stairs.

Conclusions:

Plastic surgery often leads to lawsuits because patients are not satisfied with the cosmetic results. In reconstructive surgery, the causes of litigation are mainly postoperative complications, mainly infections. Doctor–patient communication remains the most important issue, especially effective and active communication.

Takeaways

Question: What are the causes of doctor–patient disputes in plastic surgery, and how can they be avoided?

Findings: Patients undergoing plastic surgery often have disputes with doctors due to complications, unsatisfactory results, and lack of information. Doctors should understand the patients' expectations for the surgery, provide reasonable suggestions; maintain good communication with the patients, and follow standardized diagnosis and treatment procedures.

Meaning: In the diagnosis and treatment process of plastic surgery, it is particularly important to carefully listen to the patients' needs, conduct timely and effective doctor–patient communication, and provide reasonable suggestions.

INTRODUCTION

Patient complaints assist physicians in comprehending patient demands and safety-related information to a significant degree.^1,2 By analyzing data on negative patient experiences, healthcare providers can identify neglected parts of the daily treatment process, which encompasses both healthcare staff–related behaviors and safety issues associated with medical facilities.³ Plastic surgeons are more likely to encounter lawsuits or formal complaints than physicians in other specialties; this heightened medico-legal risk stems from various factors, including unrealistic patient expectations, insufficient preoperative evaluations, and operational errors committed by a minority of medical professionals.⁴ Consequently, analyzing lawsuit cases can facilitate an enhanced understanding of patients’ needs, promote the continuous improvement of physicians’ processes, and enable the timely implementation of necessary measures addressing safety issues related to healthcare facilities.

METHODS AND DATA

Related Data

This study retrospectively collected patient data on medical disputes and legal proceedings from the Plastic Surgery Hospital of the Chinese Academy of Medical Sciences and Peking Union Medical College from 2016 to 2024, irrespective of the hospital’s liability for compensation. The study excluded 11 cases of withdrawal during an 8-year period. Multiple complaints arising from a single patient and concerning the same event were documented as 1 case. The study received approval from the ethics committee, and the requirement for informed consent was waived.

Collection Methods

The hospital comprises 32 plastic restoration and aesthetic departments, each of which manages information regarding patient complaints originating from the doctor–patient relations department. This is the sole department within the hospital responsible for addressing complaints. Patients have the option to register complaints within the hospital via telephone or written correspondence. Occasionally, patients may submit their complaints directly to the higher regulatory body, namely, the state regulatory authority. The higher regulator body subsequently refers the complaint to the doctor–patient relations department, which then contacts the patient to address the complaint. Following the receipt of complaint information and its initial classification, the doctor–patient relations department contacts both the patient and the involved physician to gather detailed data, including the patient’s and physician’s basic information, the treatment performed, the reason for the complaint, the status of the complaint, and the final resolution or judgment. In this study, the researcher screened all complaints from the hospital based on “department name” and “final resolution” criteria for patients who underwent restorative and cosmetic surgery and experienced doctor–patient disputes, ultimately resolved through legal proceedings. Data recorded included the year of hospitalization, the patient’s sex and age, preoperative diagnosis, the procedure name, the reason for the lawsuit, the patient’s claim, and the outcome of the judgment. Complaints were categorized according to the standardized coding classification established by Reader et al,⁵ which encompasses 3 primary problem areas: clinical, managerial, and relationship complaints. This classification was further detailed into 26 subcategories, as illustrated in Supplemental Digital Content 1, with individual cases potentially encompassing multiple subcategories. (See table, Supplemental Digital Content 1, which displays the patient complaint classification, https://links.lww.com/PRSGO/E249.) The number of occurrences and their corresponding percentages of the total are provided in parentheses.

Statistical Analysis

Data were entered and processed using WPS Office 2019 (Beijing Kingsoft Office Software Co., Ltd.) and subsequently classified. Descriptive analyses were conducted on the sex and age distribution of patients, treatment items, surgical sites, reasons for complaints, and judgment outcomes.

RESULTS

Type of Surgery

From 2016 to 2023, a total of 47 documented medical dispute cases related to plastic surgery were recorded, with 11 cases excluded due to withdrawal during the initial phase. Of the remaining 36 litigation cases, 23 were associated with primary plastic surgery procedures, whereas 12 pertained to repair or reconstructive procedures, and 1 case was unrelated to plastic surgery (Fig. 1).

Fig. 1.

Type of surgery.

Site of Surgery

Generally, with the exception of 1 lawsuit unrelated to the surgical procedure, the cases can be broadly categorized into facial procedures and procedures on other body parts. As illustrated in Figure 2, facial plastic repair actions resulted in 31 legal cases stemming from medical disputes, encompassing issues related to facial skin, eyes, nose, forehead, ears, and the submandibular region. Conversely, 4 medical dispute cases in legal proceedings involved operations on other body areas, including the neck, chest, waist, abdomen, and urinary tract.

Fig. 2.

Site of surgery.

Cause of Action

In all 35 lawsuits related to diagnosis and treatment, the primary reason cited is dissatisfaction with the outcomes resulting from improper surgical procedures, which led to severe complications such as infections, scarring, disfigurement, functional impairment, or even death. Patients undergoing these procedures were sometimes not adequately informed by their healthcare providers. In a case unrelated to diagnosis and treatment, the patient’s family members filed a lawsuit seeking compensation after a fall on the hospital stairs.

Results of Judgment

The judgment is categorized into 2 categories: those in which the hospital provided compensation and those in which it did not. In 26 cases, compensation was agreed upon through mediation; through judicial appraisal, it was found that 10 cases did not require doctors to provide compensation (Fig. 3).

Fig. 3.

Judgment results.

DISCUSSION

Reasons and Measures for Claim

The management policies regarding medical and legal litigation differ across countries and regions. It is essential to understand that not all doctor–patient conflicts in China escalate into legal disputes. Medical malpractice is typically defined as the actions of medical institutions and their staff who violate medical and health management laws, administrative regulations, departmental procedures, diagnosis and treatment guidelines, and standardized practices during medical procedures, resulting in harm to patients. Such cases are generally referred to the relevant medical association for a technical assessment of malpractice. At this stage, both the doctor and the patient can choose to negotiate a settlement or pursue legal action through court proceedings, referred to as medical litigation. In a highly competitive social environment, personal image has become increasingly important in job hunting, social networking, and other spheres. Plastic surgery is seen by many as a means of enhancing social acceptance, and this expectation makes patient satisfaction with the surgical results extremely important. In China, many individuals feel ashamed to reveal that they have undergone plastic surgery. If the surgical outcome is unnatural or postoperative complications seriously affect the patient’s normal work and life, or if the final results fail to meet expectations, the patient may feel a decrease in confidence and social status. Feeling threatened, they often seek psychological and financial compensation through litigation.⁶

In general, litigation rates for plastic surgery are higher than those for reconstructive corrective surgery, a trend attributed to patient expectations. Reconstructive surgery primarily focuses on restoring appearance and function to address immediate patient needs, whereas plastic surgery aims at cosmetic enhancement. Patients often hold high expectations for postoperative aesthetics.⁷ Lawsuits related to facial plastic surgery frequently center around procedures involving the nose and eyes. In addition to increasing the likelihood of surgical complications, we believe that patient demand for aesthetic results significantly influences these cases. The eyes and nose occupy a central and prominent position on the face, exerting a more significant impact on aesthetics than other facial features; even minor deviations in surgical results can result in noticeable differences. In some instances, surgery in these areas risks adopting an overly aggressive approach solely to achieve an ideal appearance.^8,9 Additionally, many patients do not fully understand how their facial appearance will transform after surgery before undergoing the procedure. Historically, beauty standards have evolved across dynasties, influenced by globalization and Western aesthetic concepts in modern society. Patients frequently request European and American cosmetic procedures, such as European-style double eyelids, fuller lips, or tall and straight noses. However, such expectations may not be suitable for Chinese facial aesthetics. Therefore, blindly accommodating patients’ demands is likely to lead to increased dissatisfaction and potential lawsuits following surgery.

We believe that the key to the issues mentioned earlier lies in communication problems between doctors and patients, particularly regarding the formulation of preoperative surgical plans, informed consent, explanations of surgical details, estimated postoperative effects, and possible complications.¹⁰ This issue, in fact, involves many influencing factors. When we analyzed cases from the past 6 years, we found that most were concentrated between 2016 and 2019, with no relevant cases occurring thereafter. This period is particularly sensitive and critical. In China, plastic surgery–related content has only recently gained public attention through media promotion. Many people lack familiarity with relevant knowledge in the field, leading to significant information gaps between doctors and patients. The knowledge gap between medical professionals and patients is a common and important issue in medical practice. This gap primarily arises from the complexity and specialized nature of medical knowledge. Patients often lack the necessary medical background knowledge and familiarity with the materials, techniques, postoperative effects, and associated risks relevant to their chosen surgery. Additionally, many patients may struggle to fully understand physicians’ explanations during medical consultations due to factors such as nervousness, anxiety, or time constraints. Consequently, insufficient communication between doctors and patients is likely to occur. In particular, the field of plastic surgery involves expertise that is not encountered in daily life. When doctors offer professional advice, they may use industry jargon that patients often find difficult to understand, impacting their comprehension of surgery effects and compliance with treatment plans. Furthermore, complications are inevitable in both plastic and reconstructive surgeries. However, nonprofessionals frequently lack sufficient knowledge in this area. Additionally, methods of obtaining information in modern medicine have diversified, allowing patients to access medical information through the internet, social media, and other platforms. False advertising and the use of photograph-editing technology can lead patients to develop unrealistic expectations regarding postoperative results. However, doctors may not always have the capability to deliver the desired outcomes, leading patients to question their judgment and recommendations. Moreover, another crucial factor is frequently overlooked: financial incentives. The so-called economic reward refers to the ability of doctors to increase their personal surgery volume through various methods to generate more income. Some plastic surgeons may be tempted by the desire for increased income, leading them to overlook essential preoperative communication; simultaneously, to maintain their reputation, they may exaggerate their abilities and anticipated outcomes, agreeing to terms they cannot guarantee. This can result in surgical procedures with no therapeutic effect whatsoever. Regarding improvement measures in this area, we align with other researchers who state that plastic surgeons should prepare for the informed consent process.^4,11,12 Most physicians recognize the importance of the informed consent process. Therefore, effectively conducting the informed consent process is the key to resolving this issue.⁶ Informed consent should be viewed not only as a means to uphold patient autonomy but also as a mechanism for protecting doctors.¹³ Relevant research identifies 4 primary goals of doctor–patient communication: providing necessary information to patients, obtaining essential information from patients, fostering an atmosphere of trust, and establishing reasonable expectations.^14–16 Studies indicate that anger is the primary cause of medical malpractice claims.¹⁷ Therefore, surgeons’ behavior should be closely monitored during diagnosis and treatment. Doctors should conduct thorough patient assessments, provide detailed recommendations based on each patient’s aesthetic goals, and clearly and accurately express expected results when consulting cosmetic patients. Additionally, doctors should strictly control surgery indications, communicate in detail with patients before surgery, and clearly outline the specific location and number of surgical incisions tailored for each patient. This approach helps avoid misunderstandings about the surgical process and ensure timely communication both preoperatively and intraoperatively.^14–17 For cases with an uncertain surgical process, doctors should transparently communicate the potential uncertainties to patients. For procedures beyond their expertise, doctors should decisively decline patients’ requests and provide suitable alternatives. For patients with unrealistic expectations or psychological disorders related to excessive plastic surgery, doctors should reject requests while providing appropriate guidance. Furthermore, plastic surgeons must take steps to protect themselves legally. Although verbal consent may be convenient, opting for written informed consent offers greater professional protection by significantly reducing legal and financial liability. Therefore, a detailed preoperative informed consent document must be developed to outline all potential risks associated with the procedure, including severe cosmetic outcomes (eg, infection or extensive scarring), as well as more typical results.¹⁸

Documenting medical records and preoperative examinations is a standard procedure for every physician during daily patient consultations. Medical records alone cannot serve as grounds for a patient’s lawsuit. However, once a legal dispute arises between a doctor and a patient, medical records become the most direct, compelling, and comprehensive evidence for defending the doctor. Therefore, comprehensive and detailed medical records are vital in supporting physicians during legal proceedings. A complete medical record should include written informed consent, preoperative and postoperative images, and a detailed description of the surgical procedure.¹⁹ When managing a large number of inpatients, physicians may encounter issues such as unintentional errors caused by the rush to document medical records. Therefore, healthcare practitioners must exercise greater caution and precision in clinical practice to prevent detail-related errors. Negligence can lead to unnecessary complications. Off-label use of medications and failure to adhere to surgical guidelines are red flags, requiring physicians to have a thorough understanding of available medications and surgical options. If there are uncertainties or concerns, a thorough review and verification process should be conducted. Moreover, the scope and methods for applying new or imported technologies or drugs in China must be clarified.

In contrast to plastic surgery, litigation related to revision surgery primarily centers on the management of postoperative complications. Postoperative infection is a significant clinical concern that directly impacts the patient’s recovery quality and overall satisfaction. Despite the ongoing advancements in modern medical technology, postoperative infection remains one of the most common complications in plastic surgery, adversely affecting postoperative outcomes and the patient’s psychological state. Factors such as surgical technique, individual patient factors, and postoperative care are closely linked to the occurrence of infections. To reduce the incidence of postoperative infection, a series of effective preventive measures should be implemented, including preoperative assessment and patient preparation, strict aseptic technique, and comprehensive postoperative care and follow-up. Although antibiotics play a crucial role in preventing and treating postoperative infections, they should be used judiciously. Rational use of antibiotics can significantly reduce infection rates; however, misuse may lead to the development of drug-resistant strains. Consequently, doctors should carefully formulate an antibiotic usage plan based on the patient’s specific circumstances and aim to discontinue use within 24 hours after surgery. Additionally, the patient’s understanding and cooperation are essential for preventing postoperative infection. By offering health education to patients and enhancing their understanding of postoperative care and self-care, the risk of infection can be reduced, thereby improving the quality of postoperative recovery.

We found that, in addition to litigation concerning a doctor’s professional competence, there was also a case involving a claim filed by a patient’s family after a fall on hospital stairs. The comfort and completeness of the hospital environment significantly influence the overall patient experience. Safe and comfortable environments and facilities can enhance patient confidence and satisfaction. The standardized coding classification established by Reader et al⁵ categorizes this aspect as an institutional management issue. This underscores that, in addition to delivering safe, high-quality professional services to patients during diagnosis and treatment, healthcare providers must also upgrade hospital infrastructure to ensure the safety of patients and their families.

Comparison

Some studies suggest that healthcare quality can be categorized into 2 components: technical quality and functional quality. Functional quality pertains to patients’ perceptions of the services received and is defined by factors such as the professional attitude toward the patient and the quality of hospital facilities and equipment.^20,21 The overwhelming majority of patients perceive functional quality as reflective of how services are delivered.²² This illustrates that, regardless of the physician’s specialty, service quality plays a crucial role in the diagnostic and treatment processes. It has been traditionally believed that, among various medical specialties, plastic surgeons are more prone to doctor–patient disputes. Subsequently, a literature review was conducted to identify the similarities and differences in doctor–patient disputes among the fields of orthopedics, dermatology, and plastic surgery. Related research identifies orthopedics as one of the most frequently implicated subspecialties in medical malpractice claims.^23–26 Research indicates that intraoperative errors represent the most frequently cited category of negligence in total shoulder arthroplasty-related malpractice claims, with infection identified as the most commonly reported specific injury. A study found that male physicians were 3 times more likely than their female counterparts to fall into the high-claims category.²⁷ The study suggests that this disparity arises because female physicians tend to interact more effectively with patients. Understanding the reasons behind the disparities in claim rates among physicians can inform the development of strategies to reduce malpractice claim rates. A study on dermatologists indicated that they were more successful in establishing rapport with patients with more severe symptoms compared with those with less severe conditions, despite the latter having compromised quality of life.²⁸ Physicians and patients differed in their evaluations of physician content and process skills. Patients of the same physician exhibit a higher consensus regarding the content and process of care; those who believe that their physicians possess strong communication and processing skills report greater satisfaction with their visits. Enhancing physicians’ interpersonal skills can significantly boost patient satisfaction, potentially leading to improved compliance with treatment and, consequently, optimal health outcomes.²⁹ This part is also used in plastic surgery. Assessing and improving patient satisfaction is important, as it may lead to better compliance with treatment and, thus, optimal health outcomes.^30,31 Regardless of specialty, physicians should actively recommend trustworthy online resources during patient consultations and support the development of informative web pages through scientific societies to disseminate high-quality information.³²

Limitation

This study has several limitations that warrant acknowledgment. First, this study used data from a single-center database, which may constrain the comprehensiveness of the findings. The data exclusively encompass legal litigation cases from the Plastic Surgery Hospital of the Chinese Academy of Medical Sciences and Peking Union Medical College, thus excluding litigation cases from the plastic surgery departments of other medical centers. Our analysis was restricted to cases in which legal proceedings were initiated; cases involving complaints that did not escalate into legal actions were not analyzed, although this aspect holds considerable importance. Furthermore, there is a notable lack of data regarding physicians who have encountered legal disputes, which is an area of significant research value. One critical factor that should not be overlooked in litigation cases is the competence of the attorney. The Mayo Clinic, recognized as the leading hospital globally, boasts a 98% win rate in lawsuits filed by patients. The high win rate of attorneys deters many potential lawsuits from being pursued by patients. Unfortunately, we lack access to comprehensive and accurate data. Despite these limitations, this study contributes to understanding the causes of legal proceedings among Chinese plastic surgeons in the context of diagnosis and treatment and highlights the aspects that physicians should prioritize to mitigate the occurrence of such incidents. To fully understand the underlying factors and draw more accurate and beneficial conclusions, further multicenter studies with larger sample sizes and comprehensive evaluations are necessary.

CONCLUSIONS

In summary, our study indicates that plastic surgeons frequently face litigation due to patient dissatisfaction with cosmetic results, whereas in cases of revision surgery, litigation primarily arises from postoperative complications, particularly infections. Our findings suggest that doctor–patient communication continues to be a critical issue, particularly emphasizing the need for effective and positive interactions. During the consultation phase, physicians should thoroughly understand the patient’s surgical expectations, collaboratively develop a detailed surgical plan, discuss potential postoperative results and complications, and, if uncertain of a procedure’s success, confidently refrain from proceeding with the surgery.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.