Psychological assessment prior to cosmetic procedures

It is in the news again about the need to protect patients from unscrupulous practitioners who may prey on the vulnerable and perform unnecessary cosmetic procedures on patients who may have an underlying psychological or mental health problem.
The concept of this is welcomed by our specialty and has always been welcome, but it is the implementation that is more difficult.

There are questionnaires and screening questions that we can use which can go some way to identify underlying psychological issues that may need to be addressed prior to any physical treatment, but it is a challenge to find something that can reliably score and identify a patient who may need some other intervention prior to their procedure.

If it were easy to do, I am sure most plastic surgeons in the land would have no qualms in adopting a pre-operative screening tool.

However, one of the main reasons for the lack of this, is that there is no simple and reliable objective tool that we can use, and most of us rely on our clinical acumen supported by some broad screening questions or surveys.

Plastic surgery is one of those specialties that remains an art rather than a science and the treatment of a cosmetic patient cannot be done by algorithm or pathways.
We do not have clearly defined outcome measures such as reduction in blood pressure or complete removal of a cancer, so our outcomes are entirely subjective and our treatment plans are bespoke and often unique to the practitioner.
There are many ways you can address a breast asymmetry or the aging face and it is a combination of the plastic surgeon’s skills with the patient’s desire that helps us to come up with a plan.

Plastic surgery relies on us as practitioners, to talk to patients and get to know them, so that we can make an assessment and judgement and this goes beyond the physical attributes we see before us.
We are taught to pick up on signs and symptoms that might lead us to request further intervention before proceeding with our treatments.
Things like an unrealistic expectation or a discrepancy between the amount that a physical feature concerns a patient and the degree of abnormality associated with that feature.

These are things that it is hard to score and put a number to in an objective way.

It comes from years of experience and talking to patients and dealing with the outcome.

The media love to portray plastic surgeons as being uncaring and only interested in the surgery rather than the patient behind the surgery.
But in fact, we all want to get good outcomes for our patients and operating on patients with an underlying psychological or mental problem is not only bad for the patient but it is bad for the doctor too, because we do not want to have people who are unhappy with what we have done to them.

We want people who are delighted with their results and want to tell the world.

I have no doubt there are unscrupulous practitioners who do not spend enough time and consideration with their patients, but I do not think it is simple enough to just say that they should be offering a questionnaire prior to have a procedure.
The problem goes deeper and it goes back to training and qualifications, and the fact of the matter is, that there is an enormous variety of doctors who treat patients with cosmetic problems, ranging from fully training plastic surgeons who have gone through an accredited and rigorous set of training and exams in order to achieve a place on the specialist register of the GMC and be awarded a specialist fellowship in the Royal College of Surgeons, to doctors who have no surgical training whatsoever, right the way through to practitioners who may have no medical training whatsoever.

I think this is the underlying problem.

The lack of training and experience resulting in bad decisions and poor patient selection.

This is not good for the patient or the speciality.
Pre-operative psychological assessment is essential but it is not as simple as filling in a questionnaire.
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