It's Psychological: The Plastic Surgeon Relationship w/ Dr. Jonathan Sykes

Doreen Wu (00:01):
Welcome to Park Avenue Plastic Surgery Class, the podcast where we explore controversies and breaking issues in plastic surgery. I'm your cohost, Doreen Wu, a clinical assistant at Bass Plastic Surgery in New York City. I'm excited to be here with Dr. Lawrence Bass, Park Avenue plastic surgeon, educator and technology innovator. The title of today's episode is "It's Psychological: The Plastic Surgeon Relationship." Psychology is such a big part of plastic surgery. So much is about how we feel about how we look. How does this translate to the plastic surgeon?

Dr. Lawrence Bass (00:37):
There are a couple of things I typically think about Doreen. First is the patient's perception of the result doesn't necessarily match the plastic surgeon's less personal, more technical perception. So a typical example is looking at a postoperative result. And sometimes the surgeon's saying, okay, this went okay. Nothing good, nothing bad. And the patient is thrilled with the result. And other times the surgeon's saying this was difficult, but it just came out A+, patting themselves on the back and the patient is bitterly, bitterly disappointed. So it shows that there's this mismatch between whatever we might like to think of as reality and each individual, both the surgeon and the patient's perception. The other big thing to me is about the doctor patient relationship. In plastic surgery, the working relationship is particularly important because the goals and desires of each patient vary. In many other fields of medicine, the goal is obvious.

(01:57):
If you have a tumor, you want to get rid of the tumor. If you have appendicitis, you want to get rid of the appendix. If you have a broken bone, you want it to heal strong and pain-free. But in plastic surgery, that's not true. And that puts a big burden on the patient to express these concerns clearly and on the surgeon to make sure he or she understands them. So to discuss these issues in more depth, I've invited my dear friend and colleague, Dr. Jonathan Sykes, to come back on the podcast for another episode. He's spent a great deal of time thinking about and lecturing about these issues, and I'm looking forward to hearing his perspective. Dr. Sykes is a facial plastic surgeon in Beverly Hills who spent more than 30 years as the director of Facial Plastic Surgery at UC Davis. He's the past president of the American Academy of Facial Plastic and Reconstructive Surgery, has written hundreds of papers given over a thousand lectures and trained many, many residents and fellows. Dr. Sykes, thank you for joining us.

Dr. Jonathan Sykes (03:07):
Thank you, Dr. Bass.

Doreen Wu (03:09):
Thanks for joining us, Dr. Sykes. We're very excited to have you on again. So let's run down the issues that Dr. Bass raised at the beginning of the episode. What do you think is going on in patient's heads when they think about their appearance and how does that ultimately lead them to the plastic surgeon's office?

Dr. Jonathan Sykes (03:26):
So your question, what's going on in their head? I don't know the answer of it too. There's a different thing going on in everyone's head, and our job as the plastic surgeon is to get an idea of what's going on in their head and what their abilities are to tolerate what we think will make them look better. So the first thing is communication, as Dr. Bass said, is really, really key in this. And that communication starts with hearing who they are as people, not just what they want to do to their face or their body, but who they are as people. Because who they are will have a lot to do with their tolerance for the postoperative period, their outlook on what their result is, and everything relating to the surgery, whether or not they feel pain or more pain or it will impact everything. And there are people that are totally ideal.

(04:31):
The people with positive outlooks who are self-assured, who see the good most things, who are happy, happy individuals who are employed, employed people tend to do better than unemployed people with this. And none of this is a hundred percent. And then there's the exact opposite of that. People that are unhappy with their life, they're pessimists, they're not optimists. They see the bad in things. Things tend to hurt them more than they hurt other people. And what Dr. Bass said is, well, the outlook of a spine surgery, appendicitis, they want the same thing. Actually these same people, their outlook from appendix surgery, they get, some people do really well with that, and some people don't do well at all. I mean, we get this variance of people in all walks of life. It's worse in plastic surgery because we're doing something that doesn't have any functional potential positive outcome.

(05:40):
It's not functional that your neck skin is tighter and that looks better than that looks. That's not a functional thing. And the big question isn't, can Dr. Bass or I make someone's neck look better with this? Is if it's 85 or 90% better, are they likely to see that as a good result? And likely to see the positive parts of that or dwell on the negative, the 10% that didn't get accomplished. And all of us in plastic surgery deal with this every day. So when I lecture about this, I say it's important for the plastic surgeon to do one thing in both the pre and the postoperative period.

(06:28):
It's to listen. So when you listen in the preoperative period, we get an idea of who the patient is and what their tolerance is going to be to withstand what we're going to do to them. And if we listen in the postoperative period, we listen to what all of their issues are wrapped together. And we can't circumvent this listening in either place. So in the preoperative period, the plastic surgeon has to be a listener to what they want, but they have to be a little bit of a different kind of person. They've got to be an educational person and a little bit of a salesperson and a communicative person in the postoperative period. If somebody comes in with a problem, it's important to not educate. It's important to listen. So listening is important in both, but there's a different kind of listening before than there is after.

(07:26):
And I fought through this a lot because obviously as a guy that's done this for a lot of years, I've had a bunch of issues. And in all of us that want good for our patients have had issues. And the interesting thing about plastic surgeons is because we tend to be pleasers, we try to please our patients, it really affects us when we have somebody that we don't please that they're unhappy with. What we did, we're we're trying to put all of our education and all of our experience and all of it, all that into something that makes a good result for them. And that's why when we don't please, it's, I wouldn't say it's devastating to us, but it really hits us more so than just they're unhappy. It's like, I didn't please them. That's problematic. So what I tell people to do, what I tell plastic surgeons to do, young plastic surgeons, and I get calls about this all the time, Dr. Sykes. You know how to deal with this. I actually don't. I just listen. I actually don't know how to deal with this. I just listen more. And it's not in my nature.

(08:41):
If I go out with Dr. Bass and he says, I want the beer, I don't say, Larry, tell me more about why you want the beer. Tell me. I don't say that. I just get him the damn beer. But actually with our patients that say, I've got this pain behind my ear, and you can't, as a doctor, you can't feel the pain. You can't see the pain, you can't even touch the pain. But I'm numbing behind my ears that normal, our natural tendency is to be logical with them and to say, well, that's sort of normal. It's going to go away. That's not listening. My advice to you is listen. Say to them, it sounds like that really bugs you. Tell me more. I actually don't want to hear more. Jonathan Sykes doesn't want to hear more, but I say to them, tell me more. Tell me about it, it seems like that's impacting your life. Is it? And they tell me, and the more they talk like that, the more they feel like I'm listening and accepting who they are. And it lessens the negative claim in the room. So the big thing is to listen beforehand because that lets you potentially see the people that are going to be really difficult afterwards and then to listen afterwards. So listening is a big part of the plastic surgeon. And because a lot of plastic surgeons have big egos, it's tough for us to listen.

(10:16):
I took a course many years ago, not very far from where you live, Larry in New Haven about communicating. And I took it with three doctors. I took this course because my dean said to me, Sykes, you would've a communications course when everybody in the world thought I was a good communicator. And this is what they told me at the end of the course, at the end of the week, they said to the two other doctors who were pediatricians, you ought to get bigger in the room. What do you think? They told me, you ought to get smaller in the room. Everybody listens to what I say. They say the people that were in the room as the educators that we're teaching, they say, we actually like to listen to you. I realized that was really screwing me up with my patients afterwards. I don't need to tell them what the logic said, what was going to happen with their scars or their, I didn't need to be logical.

(11:09):
I needed to listen to them. And I wasn't as good at that. I was not as good at that. So it makes me have a different, I tell plastic surgeons, if a patient comes to you afterwards and they're upset, they're dissatisfied, and they just could maybe be angry. And it's like, why would you be angry at me? I tried my best with your face? And you're looking at them and they've got a good result. Why are you angry? I don't say that. I sit low in the room. I don't sit by the door. I don't put my hand on the doorknob and I don't get logical with them. I never use logic. Logic sucks with an unhappy patient. Don't use logic. Listen to them and they'll hear that you're listening to them and things will get softer in the ring. It may not solve it, but it'll make it better.

(12:02):
And then you say to them, would you mind if I told you what I think is going to happen? You ask them for permission because they're vulnerable at this point. Actually beforehand, they're vulnerable and you have all the knowledge afterwards, you're vulnerable and they have the knowledge. But afterwards, the surgeon is vulnerable. What I say to them, would you mind if I told you what I think's going to happen? And then maybe propose a potential solution down the road. Would that be okay? Would that be okay? That's the way I talk to them. So psychology is so important in this, and we get before surgery, a little glimpse of the person's life. It's very small unless we try and we, so I always start my consultations at the very beginning by tell me about yourself. Tell me what, and I listen to how they talk about themselves. And they often say, well, this bothers me. I said, no, don't tell me what bothers you. Tell me about who you are. Tell me about yourself. I just want to hear them talk. I try and get myself to not talk and try to listen to them. Listening is key.

Doreen Wu (13:21):
Dr. Sykes, what is your approach to the doctor patient relationship? You've already elaborated on how you emphasize listening as part of the communication style, and how does your approach differ for different patients or different goals?

Dr. Jonathan Sykes (13:35):
Well, I think that's a really important question. Patients are different, just like their faces are different, their minds are different. And they come with this bag of issues that you don't know about unless you ask them. But getting them to talk about what's going on in their life lets you know, have they had trauma? Has their wife or husband been verbally abusive to them? Did they have issues with, I get people that come into me that talk about their nose and they say things like, my dad started to criticize my nose when I was eight years old.

(14:21):
I mean, first of all, what father does that to their 8-year-old kid? But secondly, I don't know what got said in that room, but something about the interaction with the father made it so they were really vulnerable and really sensitive to that. And now you're going to operate on somebody that brings 30 years of baggage about how their nose looked. That's an important thing to me. And so you get all of that. You get every piece of baggage that a person has from their life, and it culminates on how their face or body looks, and then how they perceive how their face or body looks. And we've got to understand that. We may not fully understand it, but we have to accept it. We've got to accept it, and we've got to let that play into how we treat them. Because how we treat their psyche is as important as how we treat them physically, their appearance.

Dr. Lawrence Bass (15:20):
And that's really the classic quote from Tagliacozzi, that we're doing this more to buoy the spirit than to heal the flesh. I mean, that's at least as important, if not more important.

Dr. Jonathan Sykes (15:36):
And the damage to their spirit, we don't know about unless we get an idea of it or not damage, but the way their security, an ideal patient has a lot of inner security, but if they have no insecurity, they don't arrive on our step. They never come to us. So they have to have a little insecurity. But if they have a lot of insecurity, then they're very difficult to treat. These super insecure patients are very, and we don't know what they have. We don't know that until we talk to them. Until we listen to them.

Doreen Wu (16:14):
I'm wondering, Dr. Sykes, overall, do you feel the benefit of plastic surgery is mostly psychological or should it stay more focused on features and achieving beauty? Would you say, how subjective and psychological is our perception of beauty?

Dr. Jonathan Sykes (16:32):
I think it's probably 80 or 90% psychological. It isn't whether we have a wrinkle here. It's whether it bothers us and then how much it bothers us. So it's the bother part that gets us in the office and we'll accept if we treat it, if we get it somewhat better versus totally better. And the people that are highly insecure that have a really odd body image, body perception, face perception. Once you fix one thing, they have another thing. It's like a PEZ dispenser of problems. You're too young during to know what a PEZ dispenser is, but a PEZ dispenser is when you pull one, another one pops up. These people that have these bad body images, bad, I'll call it body images, but it's about their face too. The next one's right around the corner after you fix one. And if you don't fix it to their liking, then it's really bad for them.

(17:38):
The people that are really happy with what they do, they've got a definite thing that they don't like. They're healthy in their dislike of it. They're able to have the surgery move on with their life. But some people can't move on with their life because working on their face or their body is a lifelong thing for them. It's never acceptable to them. And those people are, they're difficult to ever treat. And we think of that as, we're body dysmorphic or not. I think it's a continuum of stuff because all of us have a little dysmorphia that get into a plastic surgeon's office. I mean, there's somebody like me. I don't own a comb. I didn't comb my hair this morning. It's almost six o'clock here. I never comb my hair. I don't own a comb. And it's not that I'm not clean, but I don't really look, if my hair's a little out of, some people can't leave their home without their makeup on perfectly. They can't do that, which is an odd concept to me, but I get it or I have to get it.

(18:46):
And we have to know about the person to be able to treat that person and say to them, I can't get this a hundred percent better. My patient that I just had the consult with talked to me about all these other noses that she liked that were really narrow and she had really thick skin. We did a FaceTime consult today, an hour before this. And I said, I can't get you that kind of nose. I can make your nose better. I can make it thinner, but I can't make it that thin. It's not possible. And I don't know if she heard that.

Dr. Lawrence Bass (19:23):
That's always a concern when sometimes you can tell that someone's not hearing something and when you're saying, I can't do something, or this is not something that I have expertise in, and they're saying, no, no, but I know you are going to take care of this for me, that's an alarm bell that there's not good reality testing. The person at the extreme of body dysmorphia clearly is not a good candidate to have plastic surgery because they're not going to end up happy. And I don't worry about how many cases I book in a year. I want happy patients. It's what you said before. I'm doing this to make people happy and if I can see it coming that they're not going to be, I don't want to get started. But so

(20:19):
Those patients clearly ought to head towards psychotherapy and maybe they can rework their perception of life. But for other patients, I used to joke, I can do more for someone's self-esteem with three hours of plastic surgery than three years of psychotherapy. And not to denigrate the psychotherapist. And I was joking, not totally serious, but there's an element of that. Some features are disruptive, discordant, it's as you said, real perception in the proper perspective of how much that's disrupting someone's life and how much it will be better if they fix it. If it's ruining your life that you have this tiny wrinkle, you probably don't have the right perspective, and if you fix it, your life is going to be better, but it's not going to be that much better. So it's matching up all of those things when you talk to people and the need to listen is key to that because it's the only way you can have a prayer of perceiving what's going on.

Dr. Jonathan Sykes (21:39):
So true. Yeah, really true. Well put.

Doreen Wu (21:42):
Lastly, as we wrap up this discussion, Dr. Sykes, what takeaways would you leave our listeners with?

Dr. Jonathan Sykes (21:49):
Well, the plastic surgeons and the surgeon has to really analyze the person's psychological strength as to why they want surgery and whether or not they can with go through it, whether or not they can psychologically go through the surgery and the postoperative period and so forth. And then of course, their ability to deal with the result and what for them might be a less than perfect result. And then we have to have a different code on when we deal with them afterwards, when we've already gotten to the cocoon with them because we've done a surgery on them and they are who they are, and maybe we understood it beforehand and maybe they evaded our radar and now they're unhappy with the results. How we deal with them when that happens. And that's its own set of stuff. Both of them involve careful listening and the doctor talking less and listening to what they hear, a real listen to what they hear to decide who's a good candidate and who's not a good candidate at all. I can't operate on them. And then afterwards to make them feel accepted and understood for what they don't like. And then the ability to propose a solution to this so that it's a complex thing, but it's clear that what people expect from the surgery has a lot to do with their satisfaction of the surgery. I don't think as doctors, we alter people's expectations that much. We try to, but I think their expectations are what they are, our ability to communicate with them. And we always say afterwards, patient had unrealistic expectations. That's a common thing. If a patient just says, well, they had unrealistic, well, their expectations are the same before as they were after, we just didn't take the time to figure out what they were. And so they really haven't changed that much. And if they were unrealistic beforehand, we probably shouldn't have operated on them. But our own ego and economics get in the way of doctor's good judgment. We may make good judgment in the operating room, but we don't. Let's make good judgment in the psyche. And so our ego gets in the way. We think we can solve everything with our knife, and then economics get in the way because we want to do the case because it pays us.

(24:33):
It's pretty simple. I'm a simpleton.

Dr. Lawrence Bass (24:36):
But that's really interesting because I think it's really key. One thing that you just said, because I take a very consumerist approach with my patients. I like to be very realist and be very forthright about what I expect I can do and can't do. But you said that patient's expectations don't really change that much. The doctor doesn't really succeed at changing them that much. And that makes a lot of sense to me because I'll tell patients, we're going to do this lift, but we never get a hundred percent of the skin out. We're always going to keep a little bit of skin here and here, and you can look younger, but you can never be 20 again. And the patients uniformly say to me, oh, Dr. Bass, I don't need to be 20 again. I don't need it perfect. And then I say, what that means is that feature that you don't like, that you're going to pay all this money and go through this procedure to address is going to be better, but it's not going to be all better. You're still going to see it. It's still going to be there. It's not going to be zero. And I feel like, okay, I'm trying to be very fair and set a realistic level of expectation, but the fact that I may not be, I know I'm not getting into their head completely. I can't just pour it in there, but the fact that they may not move more than an inch or maybe at all in their expectations is something I think is a key thing for doctors to understand in deciding if a patient realistically is going to be happy when they're done.

Dr. Jonathan Sykes (26:38):
They have to understand the margin of error that we have in what we do. But some of them can do that really well, and some of them can't do that at all. And our job is figuring out who those people are, who's going to be okay with what we do. I mean, we're trying to do everything for everyone. That's what we try and do. That's what, we're pleasers. We try and when I have a psychologically good patient and I do a good job on them, there's nothing that makes me happier in the world. But when I have a patient that I've done a really good surgery on and they're unhappy and I can't feel or touch what they're unhappy about, that's one of the most stressful things in the world for me. And I've just tried to figure out in my career how to deal with that, how to best deal with it.

Doreen Wu (27:28):
Finally, Dr. Bass, would you like to add any takeaways for our listeners today?

Dr. Lawrence Bass (27:32):
So Dr. Sykes talked a lot about how the doctor needs to think about what patients are thinking about. Let me flip it a little bit the other way and talk about from the patient's point of view, what they should expect in the relationship and how the relationship ideally should go. So perception of psychological needs and psychological support before, during, and after a treatment or a surgery are just as important in the doctor patient relationship as the technical aspects of the medical care. And we have this incredible luxury of time and a much more personal encounter in aesthetic plastic surgery than almost any other part of medicine has. That's becoming more and more of an assembly line. So that's a tremendous luxury. That's very important for what we're trying to do. Not only that, but the relationship is different than a classic surgical practice nowadays because there are a lot of recurrent treatments. Dr. Sykes talked about injectables and other things, and these things are recurrent. So we now have a relationship with people rather than just a short term encounter of selecting a surgery, helping the patient through recovery for two or three or four visits.

(29:14):
The patient ideally wants to use the surgeon for their technical expertise and their judgment, especially in that initial encounter. And picking someone based on reputation, the results that they can show, not micromanaging the technical details of care. You need the surgeon for that expertise. But at the same time, you want a surgeon who's responsive and who's listening, as Dr. Sykes said. So Jon, I'd like to thank you for joining us again on the podcast. This was a really stimulating discussion, and I think it points up a lot of the challenge both to plastic surgeons and to plastic surgery patients to try to get a positive experience to try to do the right thing. And it's a seldom discussed, but obviously critical aspect of what we do.

Dr. Jonathan Sykes (30:22):
Just to add one more thing, there's one thing that you said really quickly, just a personal anecdote, and you talked about the recurrent relationship and how we have a stronger bond and how we've got to take care of the patient. So a bunch of years ago, 30 years ago, a little more actually, I had back surgery and I went back to my neurosurgeon six days afterwards and he said, how are you doing? I said, I'm doing pretty well. He said, everything looks good. And I said, so when do you want to see me again? He said, I don't want to see you. I don't need to see you.

(30:57):
If you have a problem, you'll just call me, pass me in the hallway or whatever. And if I did that with my facelift patients or my nose job patients, 99% of them would be very annoyed with me. Not a little annoyed, but very annoyed. Their expectation is that I talk them through this process of doing it. It's as important as the surgery itself. It's as important. So we develop a relationship, as you mentioned, Larry, that goes beyond just the knife patient. We're not just taking out a tumor. We're not just fixing a herniated disc, whatever. And for surgeons, we have to recognize this and patients know that, and they all want a different aspect of this, but I just wanted to share that anecdote at the end.

Doreen Wu (31:42):
That was wonderful. Thank you, Dr. Sykes. I'll echo Dr. Bass and say thank you for coming on our podcast and sharing your thoughtful insights with all of our listeners.

Dr. Jonathan Sykes (31:50):
Thank you. It's been my pleasure.

Doreen Wu (31:52):
Thank you for listening to the Park Avenue Plastic Surgery Class podcast. Follow us on Apple Podcasts, write a review and share the show with your friends. Be sure to join us next time to avoid missing all the great content that's coming your way. If you want to contact us with comments or questions, we'd love to hear from you. Send us an email at podcast@drbass.net or DM us on Instagram @drbassnyc.