Bigger but not better

At a private clinic I saw a 30 year old woman who wanted a breast augmentation. After the procedure, the patient said she was happy with the results. Later on I read a newspaper article about cosmetic surgery that had gone wrong and was shocked to see my patient featured prominently, complaining she had failed to achieve the size of breasts she wanted and was getting depressed. To my surprise, a year later she came back asking for another augmentation, saying she was initially happy with the outcome of the first operation but now wanted to be 'bigger'. Am I obliged to carry on treating her?

You should consider whether the patient is suitable for a breast augmentation procedure now. It is important to follow the GMC's "Guidance for doctors who offer cosmetic interventions" (2016). If you believe that the operation is unlikely to deliver the desired outcome, you must explain this to the patient. Give her adequate time for reflection and keep a careful record of your conversations. In addition, you must consider her psychological needs and consider whether it is necessary to consult her GP to inform your discussion about risks and benefits. If the patient is determined not to involve her GP, you must record this in her notes and consider how it affects the balance of risk and benefit and whether you should go ahead with the operation. If, after discussion you believe that the operation will not be of benefit to the patient, you must not provide it.  

If asked, you should forward the patient's medical records to any surgeon the patient subsequently goes to see. 

Given the patient's behaviour, you may feel that there has been a breakdown in the patient-doctor relationship, in which case you should explain this to the patient, ideally in writing. 

'...you should end a professional relationship with a patient only when the breakdown of trust between you and the patient means you cannot provide good clinical care to the patient.'

Remember paragraph 62 of Good Medical Practice (2013), which states that you should end a professional relationship with a patient only when the breakdown of trust between you and the patient means you cannot provide good clinical care to the patient.

The GMC has provided explanatory guidance on ending your professional relationship with a patient, which explains that 'You should not end a professional relationship with a patient solely because of a complaint the patient has made about you or your team.' The guidance goes on to say that you must be satisfied that your reason for wanting to end the relationship is fair and does not discriminate against the patient.