Why Preoperative Consultations Matter: A Case for Better Planning in Dermatologic Surgery

In this candid discussion, Daniel Eisen, MD, shares real-world experiences highlighting the critical role of preoperative consultations in improving patient satisfaction, managing expectations, and streamlining surgical workflow. From missed biopsy sites to unexpected reconstructions, the message is clear: Proper preparation prevents poor performance.

Dr Eisen is the director of dermatologic surgery and head of the micrographic and dermatologic oncology fellowship program at the University of California Davis Medical Center in Sacramento, CA. He is board-certified in dermatology and a fellow of the American College of Mohs Surgery.

Your session contrasts preoperative consultations with same-day consultations. Can you share a real-world example where one clearly outperformed the other in optimizing workflow or patient satisfaction?
I have examples of this almost every day. I try to do preoperative consultations whenever possible. I think there’s so much advantage to it, but patient circumstances sometimes get in the way. Some people drive 4-plus hours to get here—it’s unreasonable to ask them to drive 8hours just for a consultation and then return for the procedure. Others may have disabilities, rely on medical vans, or need specialized transportation.

About a month ago, I had a patient with a nasal tip skin cancer—one of the most challenging areas to reconstruct. He declined the offer of a prior consultation. I spoke with him about the procedure and explained the likely reconstruction approach. He ended up losing most of his nasal tip, and we used a nasal flap to reconstruct it. Cosmetically, the result was good, but he was still unhappy.

Even though I explained the procedure before we started, he hadn’t had the chance to go home and process it. Once you're in the office, it’s like being on a conveyor belt—patients don’t want to reschedule or come back, so they often feel pressured to proceed. Even with a good outcome, he wasn’t satisfied because he wasn’t mentally prepared. Had he done the preoperative consult, he might have chosen sedation, or we could have involved another consultant for general anesthesia. But with same-day procedures, there’s no time to deliberate.

Even when patients seem surprised about what needs to be done, I encourage them to go home and think about it. Some do, but most don’t, and they often end up dissatisfied. It’s just not what they expected. Like the saying goes: “Happiness is reality minus expectations.” If you expect something like a shave biopsy and leave with part of your forehead attached to your nose, it’s going to be disappointing.

In your experience, how do preoperative vs same-day consultations affect surgical workflow and patient understanding?
It’s significant. There’s rarely extra time in the schedule for extended discussions. Some patients don’t even know where their biopsy site is. Without the consultation, we may have difficulty identifying it, which slows everything down. Some patients may be very anxious and need medication. If we don’t have it on hand, someone has to go get it. Or maybe they need antibiotics, or another surgical consultant. You’re unprepared without that initial consult.

There’s a quote I like: “Proper preparation prevents poor performance.” That’s what my high school English teacher always said. If you haven’t planned something, you’ve planned to fail. Consultations allow you to catch things missed in referrals. Sometimes patients show up with biopsies indicating actinic keratosis, and they’re scheduled for Mohs surgery—totally inappropriate. Planning makes the workflow smoother, and patients are more satisfied.

The outpatient surgical literature supports this: Preoperative consultations reduce cancellations, improve outcomes, and boost satisfaction. There’s no reason dermatologic surgery should be any different.

Have you found that specific patient populations—older individuals, those with complex histories, or patients undergoing Mohs surgery—benefit more from one approach?
I think everyone benefits from a separate-day preoperative consultation. But if someone has had the procedure 10 times and knows what to expect, it may just be another medical visit among many. If they decline the consultation, that’s fine—I believe in patient autonomy. Still, they’re at higher risk for being dissatisfied, but we have to be reasonable. We’re here for our patients.

Is there anything else you would like to share with colleagues regarding pre-operative consultations?
Having a checklist helps so nothing gets missed. We ask: Do you have a heart valve? Do you need antibiotics before dental procedures? Are you anxious? Some anxious patients talk a lot, and you won’t know unless you ask.

It’s also important to involve the family. Sometimes they’re left in the waiting room—that’s a missed opportunity. If the patient doesn’t communicate well, or doesn’t want to worry their family, that can actually increase anxiety.

I like shared decision-making. I encourage patients to go home, think about it, talk to their families, or even get other consults—like radiation therapy—even if I don’t think it’s the best choice. It’s not about what I’d want; it’s about what they want. My job is to give them the tools and information to make a decision they feel good about. If they feel good, then I feel good.