Retrospective analysis of aesthetic medical malpractice in mediation proceeding: A single-court experience

Recently, the number of aesthetic procedures has exponentially increased worldwide. Over 1.56 million surgical and 5.5 million nonsurgical aesthetic procedures were performed in the United States in 2021.1 However, the occurrence of mishaps involved in aesthetic procedures has become prevalent and troubling, comparable by some to chronic inflammatory skin diseases.2 Nearly every practitioner of aesthetic procedures has encountered malpractice-related legal issues to some extent, which are expensive, time-consuming, and harmful to physicians' reputations. Mediation (alternative dispute resolution) prevents lawsuits, thereby saving time, labor, and money, and minimalizing damage to patient-provider relationships. However, medico-legal assessments of malpractice cases relating to aesthetic procedures are limited.3, 4 Therefore, we seek to analyze aesthetic disputes and factors associated with successful mediation. We reviewed court records of 51 aesthetic medical malpractice cases (with identifiable personal medical information removed) from a single court, the summary division of Taiwan Taipei District Court, between February 2019 and November 2022. The cases were categorized into successful mediation (n = 6), failed mediation (n = 40), and withdrawal (n = 5; Table 1). Court dossiers, including scenes of medical malpractice, medical expense, parties' attendance at mediation, frequency of mediation, claim amount, solatium, degree of aesthetic impairment, and key elements of medical malpractice, were evaluated. The aesthetic procedures included surgeries, thread lifting, injection treatments (botulinum toxin or fillers), laser treatments, and other energy-based devices. The differences of characteristics between successful and failed mediation were compared after excluding withdrawn cases. Fisher's corrections and one-way ANOVA were used to analyze category variables. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. The means between two continuous variables were compared with Mann–Whitney U tests. Two-tailed p-values < 0.05 were considered significant. Statistical analysis was performed with PASW statistics (version 18; SPSS). In Table 1, the ratio of physician's attendance at mediation was significantly higher in successful mediation (n = 3, 50%) than in failed mediation (n = 1, 2.5%; OR: 39; 95% CI: 3.046–499.323; p = 0.005); furthermore, in such cases, the mean claim amount of successful mediation (17 669 ± 15 590 USD) was significantly lower than failed mediation (134 112 ± 193 964 USD; p = 0.031). There were no significant differences resulting from the patient's attendance at mediation, frequency of mediation, medical expenses of aesthetic practice, degree of impairment, and aesthetic procedures between successful and failed mediation. Overall, successful mediation resulted in a 70% reduction in claim amounts. All the physicians achieving successful mediation violated neither reasonable professional clinical discretion nor medical routines and guidelines. Most aesthetic procedures in mediation cases involved surgeries, yet this type of case only attained a 11.8% success rate in mediation; a small minority of cases resulted in disability or death but all subsequent mediation attempts failed (Figure 1A,B). The disputed issues of surgical procedures included asymmetric appearance or dissatisfaction with the results of cosmetic procedures (n = 16, 47.1%), nerve injury (n = 8, 23.5%), and violation of the doctrine of informed consent (n = 6, 17.6%); blindness (n = 4, 33.3%), skin necrosis (n = 4, 33.3%), and burn (n = 4, 33.3%) ranked top three in non-surgical procedures (Figure 1C–E). To conclude, we summarize the five key elements which facilitate successful mediation for aesthetic medical malpractice (Figure S1): (1) comprehensive communication before procedures, including managing expectations for treatment outcomes and disclosing a risk, (2) doctrine of informed consent, (3) avoiding violation of reasonable professional clinical discretion or medical routines and guidelines, (4) physician's attendance during mediation, and (5) reasonable claim amounts by patients. First of all, dissatisfaction with the results of cosmetic procedures and violation of the doctrine of informed consent was the root cause of many medico-legal disputes, highlighting the necessity of comprehensive communication before procedures.5 Unrealistic expectations for treatment outcomes and patient hesitation prior to treatments are deemed contraindications to cosmetic procedures. The patients need adequate time to make a decision after a preoperative interview instead of receiving cosmetic procedures directly during their first visit, and seeking a second opinion from another practitioner is also encouraged. Second, informed consent rarely works as planned, and thus, the informed consent process should be improved by involving patients in decisions, documenting the process in detail using an electronic medical record, and providing procedure-specific consent forms and patient education materials.6 Third, incidents due to medical uncertainty alone do not prevent successful mediation if physicians have complied with medical routines and guidelines. Fourth, physicians often rely on lawyers/counsels to handle their malpractice cases without attending mediation in person due to the time-consuming process; however, the physician's attendance, conveying empathy and sincerity to the patient, can facilitate successful mediation. Finally, preposterous, unreasonable claim are a clear indication of the patients' unwillingness to negotiate. Although this preliminary study is limited by the unavailability of patients' medical information due to privacy issues, and there are no similar studies in other countries to compare with, through our research, we conducted a preliminary assessment of aesthetic medical disputes and critical factors to successful mediation. In conclusion, we would like to flag two key factors in successful mediation in the field of aesthetic medicine: adequately communicating expected treatment outcomes with the patient prior to aesthetic procedures and the physician's in-person attendance at mediation. Study concept and design: Yi-Teng Hung and Yau-Li Huang. Acquisition, analysis, or interpretation of data: Yi-Teng Hung, Jinn-Min Lin, Yen-Wen Chen, and Yau-Li Huang. Drafting of the manuscript: Yi-Teng Hung and Yau-Li Huang. Critical revision of the manuscript for important intellectual content: Yi-Teng Hung, Jinn-Min Lin, Yen-Wen Chen, and Yau-Li Huang. Study supervision: Yau-Li Huang. All the authors approved the final version. None. No funding was received for this article. None declared. This study was approved by the Chang Gung Medical Foundation Institutional Review Board (IRB No. 202300215B1). None. Figure S1. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.