Principles to Practice
Principles to Practice
For the inaugural commentary launching our new INDIE offering—the INDIE Standard—I thought it fitting to include a sort of glossary of many guiding “principles” by which I practice and operate. Some may sound familiar, as I have harnessed them to make a point during many of my talks and writings. I hope that even one will prompt you to pause, reflect, and ultimately deploy in your own practice.
Best,
Lorne K. Rosenfield
7/12/2025
The Metamorphosis that is Recovery: When a patient is concerned about what they see during the metamorphosis, that is the recovery period, I am wont to say: “Just know that everything you like will stay and everything you don’t like will go.”
Listening to the Patient: When swimming in a pool of clinical data, I will often invoke the wise words of our grandfather of modern medicine, Sir William Osler: “When all else fails, listen to the patient.” For often, the answer is sitting right in front of you!
A Loaf of Bread: When a patient is anxious to do something, anything to help the otherwise mostly natural process of postoperative healing, I reassure with: “Don’t worry. You could do nothing more than sit under a tree with a bottle of wine and a loaf of bread and heal just fine.”
Safety, Safety, Safety: When the patient hears my spiel about my philosophy about risk and safety, and then asks: “Doesn’t every plastic surgeon think about safety?” I like to respond with: “Kindly, some more than others.”
Too Good to be True: When the patient asks about a particular wonder treatment, laser, or unguent, I will usually advise thusly: “If it sounds too good to be true…”
A Surgical Solution: When alternative, enticingly “non-surgical” options are raised, I will often advise: “Sometimes surgery is actually the more conservative, more safe choice”
A Surgeon’s Boiling Point: When delivering the risks and benefits of a particular surgery, I will often explain: “I’m not saving your life or limb - This is elective, unnecessary surgery - so the surgeon’s boiling point should be low…very low.”
The “Uninformed” Consent: There are many roads to Rome, but some are more bumpy than others. All these “bumps” - length of surgery, most frequent complications, revision rates - must be disclosed if proper consent is to be given. Otherwise, it’s an “uninformed” consent.
Goldilocks and the 3 Bears: When I’m describing my philosophy of surgical moderation, I will invoke the well-worn Goldilocks allusion, what I call the “three bears of aesthetic surgery”: not too much surgery, not too little surgery - just the right amount of surgery.
Knowing Your Lines: When a patient describes their impending doomlike fear about surgery, I will bring perspective with this clarification: “The difference between an actor harbouring excited nervousness and one who suffers paralyzing fear: the former knows their lines and the latter doesn’t - so too with a patient and their impending - elective - surgery. You, too, know your “lines” now, and for the rest, we have drugs!
The Serenity Prayer: When patients are pressing to have me perform a surgery that I know in my heart will not end well, I will invoke and paraphrase the Serenity Prayer:
“Let’s embrace what can be fixed and accept what can’t”.Reputation, Reputation, Reputation: When I hear that a “competing” surgeon is boasting that their surgery is far more exhaustive and lengthy, I will often remind the patient (and hopefully, ultimately the other surgeon): “Reputation should be based upon the number of contributions you’ve selflessly contributed to the profession, the number of complications you mindfully avoided, the number of operative hours you have technically saved - not upon the number of hours of surgery clocked, the number of Instagram followers garnered or the number of selvies posted”
Putting the skin back: When patients struggle with whether to make the leap and undergo a particular surgery, I have been known to say: “I have never had a patient say: “Put the skin back; I wish I never had the surgery!”
One of us has to be awake: When a patient is clearly desirous of taking over control of the surgical plan, I will politely explain: “Well, one of us is going to have to be awake at surgery, and one of us is going to have to be asleep - and it would appear that you are the one that wants to be awake…”
What shouldn’t happen: When describing the incalculable value of surgery - safely delivered, I will add: “ You are paying as much for what should happen as much as what shouldn’t.”
Your Biggest decision whilst asleep: When patients legitimately voice the daunting nature of a looming surgery, I will reword their emotion thus: “This upcoming surgery will be the biggest decision you will ever make…asleep!”
The What and The Why: Patients may come to you knowing what procedure they need you perform as a surgeon, but they should leave your office knowing why you do the procedure you do.
A Reason for Everything: Every thinking surgeon should have a reason for everything they do and a reason for everything they don’t do - in order to be a surgeon with guiding principles rather than simply a technician with common tools.
Principles before Techniques: A surgeon without guiding principles is nothing more than a technician with common tools. And a corollary is that every teaching surgeon must teach girding principles - not just methods.
I don’t know: When patients attempt to pin me down about results, I purposefully keep the exact aesthetic outcome purposefully amorphous - such as the ultimate size in breast augmentations and the precise shape in aesthetic rhinoplasties -because we all honestly don’t know for sure.
Ups and Downs: Whenever the patient describes their successful recovery despite the ups and downs, I will share the following insight: “If I had told you everything about the post-operative course, you would probably not have undergone the surgery!
Safetyomics: A practice principle that will bring the surgeon more patients, ultimately, than the most titillating surgical video ever seen on TikTok.
“It’s a 30-Year Program”: A Surgical Residency may be a 6-year or so program, but surgical practice is a 30-year endeavor. Experience is everything.
The Surgeon’s “Learning Curve”: The surgeon yearning toward “better” has the risk of stalling some years into practice when all become too comfortable - when a surgeon’s hands go on “auto-pilot”. Instead, the surgeon must install as many change agents as possible - by writing, speaking, teaching - to help re-vitalize - to inspirationally defibrillate, as it were - the surgeon into continuing to learn, to move up their learning curve.
Price Tag: The cost of a surgery should not be a measure by how long and arduous it is, but rather by how efficacious and safe it is…
Compassionomics: It takes less than 40 seconds to hold the patient’s hand, look them in the eye and say: “I will be here for you. I will be with you every step of the way. I will keep you safe” - probably one the most meaninful 40 seconds in the patient’s life and one of the most efficacious 40 seconds in your career. Ironically, it takes about the same precious 40 seconds for you explain to the patient why you don’t have the time…
Complication Whisperers: We should strive to be complication whisperers: for complications inform our future surgeries.
Reverse Dsymorphia Syndrome: When the surgeon, rather than the patient, exhibits their own brand of dysmorphia with a resulting startling, discomfiting gallery of overly pulled faces, overly augmented breasts, and overly elevated brows. Hence the neologism, “reverse dysmorphia syndrome”
The Surgical Checklist: Too Little, Too Late: Unless a comprehensive checklist is instituted and followed, anything less is simply too little, too late. Instead, the checklist must cover the entire breadth of the patient’s care, from consult, through surgery, to recovery, and must include every clinically relevant action to prevent the greatest number of errors of omission - the “to do’s” and errors of commission - the “not to do’s.” Otherwise, checking off just a few boxes impatiently and only as the surgeon is about to make an incision is simply too little, too late.
The Patient as a Faberge Egg: Going to a surgeon, being examined by a surgeon, being operated upon by a surgeon is one of the most anxiety-ridden…and risky, human experiences. And nothing - not even drugs - can entirely alleviate these dreads and dangers. But carrying the patient from diagnosis to healed, like a Faberge egg goes a long way to ferry the patient through this veritable tunnel of terrors that is surgery.
The Skin we leave behind: When describing the inevitable - and dare I say to all my illustrious colleagues - universal - fact of life is that when conducting any rejuvenating surgery where skin is removed, by defintion, the skin we leave behind is no better than what we take away. So your face, your breasts, your abdomen will sag - albeit usually only a modest amount - again. And a corrollary…
Operating on another species: To those surgeons who claim - and present - superhuman before and after results - I say: “In all deference, unless you are operating on another species…”
“Concierge” Medicine: Anyone can wake up tomorrow and declare themselves a Concierge doctor. There is simply no vetting process, no certification, no monitoring of this supposed “concierge” care. And until such time as there is that world is truly the Wild West! As I like to say to my patients who boast about their procurement of a “concierge doctor” and how doing so has gamed the system: “I’d rather it take some effort to reach a great physician than have a mediocre one on speed dial!”
Take a Pause: As my old Professor would say when confronted with a dicriminating but indecisive patien - what I like to call a state of “analysis paralysis”t: You should recommend they take a pause about deciding upon any kind of elective surgery because: “the more you “push” the patient away, the more they will want to come back”!
Some more than others: When patients hear of my passion and commitment to safety and my deliberate respect to “do no harm”, balancing of safety with results, I am often asked: “But dont’a all surgeons think this way?”. And I respond “Yes, you are right, but kindly, some surgeons more than others!”...
The more you “push” them away: If a patient has reservations about a surgery, fight instinct: because actually the more you “push” them away - recommend they take a pause to think about it or get a second opinion etc - the more they will come back!
Analysis Paralysis: When a patient can’t land on a choice for surgery, tell it like it is and say, compassionately: “You have some analysis paralysis - so it’s time for you to take a pause from trying to decide.”
Gun Laws in Surgery: When a patient is too anxious to have their surgery right away - sometimes even ready to book before the consult - it is effective to remind the patient that buying a surgery should be akin to buying a gun with a mandatory 2-week waiting period before doing so!
Wear a White Coat: Buck the masses - wear a white coat: to remind yourself and your patient that you are not only a surgeon, but a physician as well!
Starting Practice: If and when you are unsure what directions you should take when starting your practice, I always tell the chief residents and young attendings: “The best strategy: just look around your community, see what everyone else is doing, and do the opposite!”.
More to come!!!
