Intro

Dr. Cameron Chesnut 0:00

Welcome to the Five Codes Podcast, where we discuss evidence-based methods to elevate yourself to the next level through optimizing the way you look, move, perform, feel, and connect.

The Friend Surgeon

Dr. Cameron Chesnut 0:12

Welcome to today's OR diary. Today is a story of the friend surgeon. This is a really interesting one to me because this was a colleague, actually of mine, another physician, who lives in a big city and works in a large hospital system and was coming to me for a revision of a procedure that was done by a friend and colleague of hers in her local

What Went Wrong

Dr. Cameron Chesnut 0:33

town. Her local plastic surgeon, Big City, left her face with asymmetric eyebrows, asymmetric upper lids, hollowed out upper eyelids, an osteoma, like a bony injury on her forehead that had grown into a lump that we had to remove with an osteotome today, like take off the lump of bone. And then maybe the most dreaded complication of all is that she had had asymmetric lower eyelids. One of them in particular was scarred and pulled down. We call that lower eyelid retraction. It required a really complex lower eyelid revision procedure with a graph from her hard palate. It's going to end up being absolutely incredible in the end, but it was just a very interesting scenario with a lot of dynamics in there that come from choosing somebody local, choosing somebody that was a friend, and choosing somebody that was a plastic surgeon, but not necessarily a super sub-specialist right in the spaces of the things that she was having done. And I think it brings up a lot of really interesting and common issues and questions, and I love cognitive biases or thought processes of how people make decisions. And I thought that this highlighted

Why Smart People Make Errors

Dr. Cameron Chesnut 1:38

a lot of them. So I think one of the real questions here is why do intelligent people make predictable thought errors? This person, this patient of mine in particular, was very educated. She knows a lot about the medical system. She knows about training. She knows about colleagues. She knows all of these things. But what happened? How did she end up in this situation?

The Psychology of Familiarity

Dr. Cameron Chesnut 1:59

And I think that part of this for her was a bit of the psychology of familiarity. And we're all guilty of this. We all use the financial planner that we know and like. I like this guy. He's her gal, he's nice. So that's the financial planner I'm using. You use the lawyer that your cousin Eddie uses because Eddie likes this person. You use the car mechanic, the contractor, or the surgeon that is familiar to you, the person that you know or that your friend recommended. Oh, I, you know, you should talk to this guy or this gal or whoever it is, right? So this is a common issue, this like familiarity. Um, but is that always the best way that we want to be choosing who we're working with with something that is so key? Friendship or familiarity lowers our estimation of risk, but ironically, the complexity of the situation in front of us does not change at all, regardless of the level of familiarity or friendliness

Loyalty vs Objectivity

Dr. Cameron Chesnut 2:51

there. For her, there was this other issue of loyalty versus objectivity with this person that she knew. And I would challenge everybody to think really deeply about this. Um, and it was, you know, she didn't go in and actually have a really in-depth conversation about this like she would with somebody that she didn't know. She just sort of trusted this person to, like, yeah, do what you need to do. Don't that she just sort of trusted he was going to do it. But that led to a lack of communication. It led to a lack of objective decision making together. It led to a lack of uh her surgeon getting a this is one of my main goals, is to like deeply understand, really seek to understand exactly what she was after. It wasn't just doing an eyelid surgery to do an eyelid surgery, which I hear and see all the time. It's the same cookie-cutter suggestion. It's like, well, what are you after? What did you look like before? None of those things happened. And it's so it created a situation where there was poor communication going into it. There was poor understanding. Uh, it was awkward to talk about these things afterwards. It was, there was lack of objectivity in decision making. Um, she found it difficult to communicate her dissatisfaction. He felt, uh, I'm sure, a similar amount of emotional friction with this person that he was, you know, in his mind doing a favor for. So there was some very interesting dynamics uh about the aftermath of this as well, um, that I would really want somebody to pay attention to because although I create a very tight relationship with my patients, and we often are in communication long after their procedure with very happy outcomes, uh, we want the initial objectivity to be very poignant. We want to know exactly what we're after. I want to deeply seek to understand, uh, but you know, it's we got to handle our business at first. We're doing this for a very specific reason, and we want there to be the ability to have open lines of communication about it, uh, which interestingly and maybe ironically from what you'd expect when working with a friend, we're actually more

The Cost of Convenience

Dr. Cameron Chesnut 4:44

complicated here. I believe another aspect that played into this was the cost of convenience. Um, this person was local to her. It was easy, did not involve travel, saved her time. A lot of friction seemed removed from those types of things, but it's human nature to overweight or place more emphasis on that immediate convenience and underestimate or underemphasize the long-term consequences of that. And in some situations, revision surgery is what results from that. And that is exactly what she experienced at that cost of her cost of convenience was needing a pretty complex revision

Why Specialization Matters

Dr. Cameron Chesnut 5:20

down the road. I think another interesting part for her is uh the lack of recognition that specialization exists for a reason. And this is not necessarily saying that one specialty is better than the other. It's just saying that repetition in one area changes people. Someone performing hundreds or thousands of surgeries in one particular area has the opportunity to recognize nuances and problems and thought processes in an area that somebody who doesn't do as much just doesn't have the opportunity to recognize and understand on as deep a level. Just straight up that idea that the repetition changes the way that somebody thinks and looks at something.

Comfort vs Competency

Dr. Cameron Chesnut 5:56

So I think the bigger lesson here for her and for us is just about life and how we make decisions and especially not substituting comfort for competency, which is very much kind of how she communicated to me what the situation was. And it's very interesting now in that our going through this and talking about using her photos or sharing her experience, she's really um uncomfortable doing that because she still at this point doesn't want to offend her friend, uh, even though it has led her to uh a pretty challenging position in which uh this friend didn't have the capability to manage, basically, uh, because of those repetitions and that expertise and this the depth in this space. Even really great surgeons, really, really great surgeons, which I'm sure a friend is an incredible surgeon overall, just hasn't had enough time in these very nuanced areas, enough repetitions to understand exactly what's going on and what she needs, and do these more types of complex revisions that she needs to finish off things that were maybe underdone, to correct some things that were done poorly or done asymmetrically, and then to fix some frank complications of uh the situation that she had. So I think there's a lot of really interesting things here.

Why My Patients Travel

Dr. Cameron Chesnut 7:12

Um, again, I, you know, with full disclosure, um 100% of my patients travel to me. So this is a very common uh position that my patients find themselves wrestling in. I am from New York or I am from Los Angeles uh or anywhere in between. I'm from, you know, England or Australia. There's really good surgeons in this area that I live to. Why am I going to travel, right? Why am I not going to go to the local person? Maybe you live in, you know, a small place and there's a really great local surgeon that all your friends love, um, or that does your Botox for you, or something like that. Well, this is a common wrestling scenario, and I always like to think of the cognitive processes that lead us where we need to go. Because I most often find um that when the comfort, the ease is chosen, and I do end up seeing somebody down the road to fix things that were um not done well, that they kind of knew in their gut that this wasn't the right thing to do, but it was the easy thing to do. It was the more convenient of the things to do.

The Seven Out of Ten Result

Dr. Cameron Chesnut 8:15

And sometimes, this is another full disclosure of the spectrum of things. Sometimes they're like the patient that I'm talking about today, where it was a really complex revision. They were in trouble. They needed help. And sometimes, on the other end of the spectrum, they went to their local surgeon and they just didn't get quite where they wanted to get. They got those like seven out of 10 results. And for some people, that's happy. And that's their friends that told them this so-and-so, local so-and-so is great. They had a seven out of 10 result. They didn't even know what an eight, nine, and ten out of ten looked like. And so they're just happy that something happened and they look different, and they just assume that that's better because they look different than they did before, right? Um, but anybody watching this probably is much more sophisticated to know the depth of where results can go as far as recreating, rejuvenating, and keeping things looking natural is not just about changing, actually, at all. Um, and so sometimes I find people who did the local option, the ease option, and they got that shoot result. It's not terrible. They don't look bad. They just there's a lot left on the table. And then it's honestly quite challenging to kind of like pick up where things left off and make things work from

Choosing the Harder Option

Dr. Cameron Chesnut 9:27

there. And so um, you know, this is where you you've gotta listen to what things are telling you, do what feels right. Um, and sometimes, it's like I tell my kids, you have to choose a slightly harder option because in the end, that's what's gonna be what's best for you.

Closing Thoughts

Dr. Cameron Chesnut 9:42

If you have any questions or topics you would like me to explore further, please leave them in the comments. I read them all and they often help shape the future conversations here. I also want to be clear that the views shared on this podcast are my own and are not associated with or representative of my clinical teaching affiliation with the University of Washington School of Medicine, nor should this be taken as individual medical advice. Thank you for spending your time with me. I appreciate you being here, and I will see you on the next episode.