The doctor-patient relationship is the foundation of aesthetic surgery, built on trust, collaboration, and shared goals. But what happens when that trust erodes, communication breaks down, or patient demands become unrealistic? While you have a professional and ethical duty to provide care, in a field like aesthetic surgery where patient expectations are often both high and subjective, there are times when continuing the relationship is not just difficult—it’s impossible. Knowing when and how to step away can be just as critical as knowing when to operate.
Recent literature in Plastic and Reconstructive Surgery examines how aesthetic surgeons can ethically navigate these complex relationships, particularly when dealing with patients who have psychiatric comorbidities. With this advice in mind, we’ll share some strategies to prevent patient abandonment when you’ve decided to end a doctor-patient relationship that’s less than ideal.
When the Surgeon-Patient Dynamic Turns Toxic
Aesthetic surgery attracts highly motivated patients, but that motivation isn’t always healthy. Some patients fixate on perfection, resist medical advice, or repeatedly seek procedures that will never satisfy them. Others struggle with psychiatric conditions like body dysmorphic disorder (BDD) or borderline personality disorder (BPD), making it difficult to maintain a productive doctor-patient relationship.
In 1978, J.E. Groves described the “hateful patient”—individuals who evoke frustration, anxiety, or resentment in their physicians. While surgeons are trained to manage challenging personalities, there are cases where the relationship becomes untenable. Keep an eye out for these red flags that may indicate it may be time to cut ties:
- Futile Expectations – If a patient insists on procedures that won’t deliver the results they imagine—or worse, may cause harm—continuing treatment is unethical. The American Society of Plastic Surgeons (ASPS) Code of Ethics is clear: performing a surgery that doesn’t truly benefit the patient is a breach of professional integrity.
- Chronic Noncompliance – Patients who skip post-op appointments, ignore care instructions, or even sabotage their own results can put both their health and your reputation at risk. If they won’t follow your guidance, how can you guarantee a good outcome?
- Erosion of Trust – Once a patient doubts your expertise or questions your every move, the relationship becomes a liability. This can lead to legal issues, negative online reviews, or even malpractice claims. If trust is gone, it’s nearly impossible to rebuild.
When to Stay, When to Go
Not every difficult patient relationship should end. The key is knowing when to work through challenges—and when to make an exit. Here’s how to handle different scenarios:
The Demanding but Treatable Patient
If a patient is pushy, entitled, or overly anxious but still medically treatable, the best strategy is clear communication and firm boundaries. Reinforce realistic expectations and, if necessary, require psychological clearance before moving forward. The goal isn’t to dismiss concerns—it’s to ensure they align with reality.
The Patient Who Shouldn’t Have More Surgery
Some patients may not need additional procedures, but they still need guidance. In cases of self-sabotaging behavior, psychiatric struggles, or dissatisfaction that won’t be solved with more surgery, consider continuing non-surgical care while declining further procedures. This keeps the door open without enabling harmful cycles.
The Patient You Must Let Go
When every effort to manage the relationship fails, ethical termination is the next step. But dropping a patient requires careful handling to avoid accusations of abandonment. A proper termination includes a written notice explaining the reason, a reasonable transition period (typically 30 days), referrals to other providers when appropriate, and continued emergency coverage if complications arise. Document everything. Keep records factual—avoid emotionally charged terms like “difficult” or “noncompliant,” as negative language can bias future providers.
When Termination is the Best Treatment
In rare but serious cases, continuing to operate on a patient may actually do more harm than good. For instance, some patients with BPD or self-harming tendencies use surgery as a form of emotional regulation, damaging their own results and demanding endless revisions. In these situations, the most ethical action isn’t to operate—it’s to stop. This concept, known as therapeutic discharge, means that ending the relationship is actually a necessary step for the patient’s well-being. Referring them to psychiatric care rather than another surgeon can prevent a cycle of harm.
Protect Yourself
Patient abandonment claims can be a real threat if termination isn’t handled correctly. To protect yourself, here are some basics:
- Put everything in writing, clearly stating the reason for termination.
- Provide at least 30 days for the patient to find a new provider.
- Offer emergency care for complications during the transition.
- Never terminate based on a mental health diagnosis alone—document behavior, not labels.
A final but critical step: Keep your notes objective. Studies show that biased language in medical records can lead to substandard care from future providers. Stick to the facts and let the documentation speak for itself.
Finding a Balance
Aesthetic surgery is as much about psychology as it is about physical transformation. While you’ll encounter plenty of high-maintenance patients, most can be managed with firm boundaries and honest conversations. But when trust is broken, expectations are impossible, or continued care becomes more harmful than helpful, walking away isn’t just an option—it’s an obligation.
By balancing empathy with professional integrity, you ensure that every patient you treat gets the best possible care—even if that means knowing when to say no.
SOURCES: Plastic and Reconstructive Surgery
