Written evidence submitted by The Cadogan Clinic (IBI0004)

About the Cadogan Clinic:

The Cadogan Clinic is one of the UK’s leading aesthetic and skin health hospitals specialising in cosmetic surgery, regenerative treatments and medical dermatology. Based in the heart of Chelsea, the Cadogan Clinic is now the busiest specialist aesthetic hospital in the country & and increasingly important hub for medical aesthetics. Founded in 2008 by Mr Bryan Mayou, a pioneering plastic surgeon best known for introducing liposuction, microvascular surgery and vascular lasers to the UK, the Cadogan Clinic team comprises over 90 industry-leading consultants; hand-picked for their expertise, published research and innovative approach. The team practise at the vanguard of clinical medicine and are leading authorities within their specialist field.

The Cadogan Clinic has a strong commitment to research and education and is home to the most prestigious surgical fellowship in the UK and the coveted BAAPS/BAPRAS fellowship is now entering its 5th year. This educational post is designed to promote aesthetic excellence, allowing high-performing plastic surgeons to build their cosmetic surgery knowledge whilst advancing clinical research at the Clinic and support the future of safe and responsible cosmetic surgery and non-surgical interventions.

The team at the Cadogan Clinic contribute to the improving of industry standards, including psychological screening as key benefit to all patients and potential patients. Our Consultants follow a stringent pre-operative assessment protocol to ensure any prospective patient is fit, well and suitable for daycase surgery. This includes a mandatory psychological screening test comprising a nine-question self-declaration questionnaire relating to their appearance and how they feel about it. Alongside screening focussing on motivations for surgery by the patient’s surgeon at consultation, this screening tool helps surgeons determine if patients are seeking treatments for the right reasons and highlights any vulnerabilities or mental health issues driving the decision. Patients who don’t meet criteria from the screening test or if any other psychological concerns are determined, the patient will be declined. This is often in conjunction /onward referral to a psychologist specialising in body image disorders. 6% of consultations are rejected at the Cadogan Clinic due to psychological reasons.

Due to the rise in demand for cosmetic procedures, the Cadogan Clinic undertook an intensive review into the use of the preoperative RoFCAR psychological screening tool in a busy private cosmetic surgery clinic to determine the motivations for patients seeking surgery.

The Cadogan Clinic is sending evidence to support the inquiry into the impact of body image on physical and mental health, demonstrating that self-confidence is the main trigger for people seeking cosmetic surgery. Our team supports the call for tighter regulations and more standardised protocols for psychological screening for all aesthetic patients, both surgical and non-surgical and would be delighted to collaborate further with this inquiry.

Separately, the industry uses outcomes data –Q-PROMS under guidance from the Royal College of Surgeons, to assess patient satisfaction with the outcome of the surgical intervention by patient’s own measurement of their health pre- and post-operatively. Published data demonstrates clearly that when suitable candidates for surgery are chosen, these procedures can deliver significant and permanent improvement in both physical and mental health

In CQC registered premises, a similarly high standard of assessment is usually provided for non-surgical interventions as to surgical interventions, although a standardised body image assessment would be welcomed.  The difficulty remains that as a majority of non-surgical aesthetic interventions are provided in non-CQC registered premises it is much more difficult to monitor these standards across the industry. There is still significant value of introducing standardised assessments regardless for those who wish to follow them.

The below study reviews the RoFCAR Psychological screening tool used at the Cadogan Clinic which was led by fellow Mr Andrej Salibi, Consultant Plastic, Reconstructive and Aesthetic Surgeon from January 2019 -December 2020.

Review of the RoFCAR Psychological Screening Tool in a Specialised Day-Case Cosmetic Surgery Hospital

Executive Summary:

Background:

There has been a recent rise in the demand for cosmetic procedures. It is deemed paramount that clinicians psychologically screen patients to ensure they are suitable candidates. We aim to review the use of the preoperative RoFCAR psychological screening tool in a busy private cosmetic surgery clinic.

Methods:

RoFCAR scores from January 2019 until December 2020 were analysed and stratified according to type of aesthetic surgery. Scores above thresholds were identified and percentages were calculated comparing scores of patients undergoing various types of aesthetic surgery

Results:

A total of 740 patients reviewed. 599 patients underwent one operation and 141 had multiple operations. Breast lipofilling was the operation with the highest number of revisions (7/18). Labiaplasty patients appeared to be the most self-conscious with 27.8% scoring above threshold. Patients who underwent breast surgeries were found to be most likely to avoid work, social and sexual activities compared to those who underwent facial surgeries (12.3% vs. 11.9%, 18.0% vs. 15.5% and 29.9% vs. 13.6%, respectively). Lower self confidence in relation to work, social and sexual life appeared to be a prominent feature in all types of operations, with over 50% of all patients scoring above threshold. Predominantly, rhinoplasty patients were most likely to both feel the need to check their appearance (54.1%) and do this more than 5 times a day (39.6%).

Patients undergoing multiple operations were found to be more self-conscious (breast and facial surgery met the threshold in 30% of patients). Similarly, they were found to avoid work related activities and to spend more time looking in the mirror than those who had single operations with 66.7% of pinnaplasty patients spending >30 min at one time or over 2 hours a day.

Conclusion:

This review has established that lack of self-confidence seems to be the main trigger for seeking cosmetic surgery. Patients undergoing facial and breast cosmetic surgery such as in addition to labiaplasty are likely to have psychological vulnerabilities and to meet the roar triggers for professional psychological assessment. Patients who underwent multiple operations/revisions are more self-conscious which may be a trait for a higher psychological risk. However, a postoperative follow up screening is needed to confirm the psychological benefits associated with cosmetic surgery.  

Introduction:

The increased popularity and demand on cosmetic surgery in the recent years has drawn a considerable attention to the importance of patient selection in order to improve outcomes and reduce the incidence of postoperative dissatisfaction1.

It is essential to identify patients with underlying psychological distress related to their appearance and those with unrealistic aims and expectations in order to achieve the goal of cosmetic surgery. 2 Therefore, it has become increasingly evident that the process of preoperative patient assessment and psychological screening is a crucial component of the plastic surgeon’s role. Finding the ideal preoperative screening tool in order to identify patients whom might be at a higher risk for poor postoperative outcomes has attracted a considerable interest from plastic surgeons, psychologists and national bodies in recent years1.

It is well established from the current literature that the systematic, preoperative psychosocial screening of patients seeking cosmetic surgery is essential for a satisfactory aesthetic outcome. Self-reported questionnaires have been widely used prior to cosmetic surgery in order to screen patients for possible psychological issues or inappropriate expectations and motivations. Nevertheless, the purpose of these is not to replace formal psychological assessment, but to assist in identifying those patients that may require a referral to a psychologist prior to their surgery2.

The pursuit of an ideal screening tool to identify patients with psychological or psychiatric disorders, that may influence their desire for cosmetic surgery, has been ongoing since the 1950s. However, formal literature on the psychological evaluation of patients seeking aesthetic surgery was not published until the early 1960s. Most of this literature was a result of integrated efforts of plastic surgeons and clinical psychologists or psychiatrists in order to extrapolate those patients who are inappropriate for surgery or those with unrealistic expectations3.

There is a paucity of data surrounding the use of validated psychological screening tools amongst plastic surgeons. To date, a number of psychological screening tools have been developed in order to improve patient selection in aesthetic surgery, however their use in the clinical setting is still controversial. This is probably related to the poor uptake amongst the wide majority of aesthetic plastic surgeons who receive limited training in the psychological assessment of patients undergoing cosmetic surgery4.

Responding to the imperative to develop an acceptable method for the routine screening and audit of patients seeking and undergoing cosmetic procedures, a team of researchers and clinicians specialising in the field of cosmetic surgery at the Royal Free Hospital and Centre for Appearance Research have developed a suitable instrument for routine use to fulfil these functions (RoFCAR).  The feedback from providers of cosmetic procedures has emphasised the need for a brief (“one-page”) and a user-friendly approach. The RoFCAR screening tool (Appendix1) adopts a two-stage model of screening and assessment.  Stage one involves the routine use (for all prospective patients) of the screening tool, designed to identify psychological factors which are likely to increase the risk of a poor psychological outcome and to indicate those who would benefit from a more thorough psychological assessment. High scoring on the RoFCAR triggers (Appendix 2) a more extensive interview with the surgeon or practice team (which may or may not involve the use of standardised measures). In the case of any concern, the aesthetic surgeon or practitioner can then recommend a more comprehensive psychological assessment (stage two). 

For the subset of prospective patients identified as having psychological risk factors, stage two is conducted by an appropriately trained professional (ideally a clinical psychologist). This assessment involves the administration of standardised measures.

The screening tool comprises key questions derived from large data sets collected from patients undergoing cosmetic surgery and from data collected for audit and research purposes. The questions are firmly grounded in standardised measures of appearance-related distress (e.g., The Derriford Appearance Scale 245) and are in line with the NICE guidelines for screening for Body Dysmorphic Disorder (BDD). Expert opinion and user input has guided the development of the tool and a pilot study conducted in 2012 and funded by The British Association of Aesthetic Plastic Surgeons (BAAPS) confirmed the feasibility of using the tool in routine practice. The tool is also intended to be used as a resource for auditing patient outcomes1.

Aims:

It is well established that psychological assessment tools are important. However, their use in clinical practice is somewhat inconsistent. The literature lacks objective data that explore their practical use in dedicated cosmetic surgery institutions. Research has shown that the majority of patients undergoing cosmetic surgery are satisfied with their outcome. However, there is a substantial subset of patients who do not achieve their aims and expectations following cosmetic procedures6,7. It is therefore important to identify those at risk for a poor post-operative outcome and explore the reasons behind it. Since the vast majority of cosmetic procedures are conducted in the independent sector, the quality and quantity of data is usually limited.

Therefore, this review aims to evaluate the use of the RoFCAR screening tool in patients undergoing aesthetic surgery within The Cadogan Clinic. We also aim to perform a detailed analysis of the individual components of the screening tool in order to develop a better understanding about the subsets of patients with higher scores and whether these demonstrate a trait for potential repeated procedures and/or revisional surgery.

Methods:

All Cadogan Clinic cosmetic surgery patients are first asked to complete a nine-question self-declaration questionnaire relating to their appearance and how they feel about it. The questionnaire (appendix 1) is designed to reveal how each patient feels about their appearance and its current impact on their day to day life, and assess for four main criteria: unrealistic expectations, inappropriate motivations for surgery, underlying psychological disorders (such as BDD) and any other wider risk factors (such as psychological vulnerability).

This questionnaire covers the five basic questions recommended by NICE to help determine whether a patient has a disproportionate preoccupation with their appearance, and an array of further questions as recommended by the generic RoFCAR psychological screening tool. This is completed either before the consultation or during the consultation with the surgeon.

The second element of the preliminary pre-operative screening is the extensive in-consultation assessment of the patient performed by the surgeon. Qualitative information and data is gathered and recorded from all of the patient’s behaviour, communications and interactions with the surgeon and other clinical/administrative staff, and that an overall suitability assessment is made following the consultation.

Guideline criteria as evidence that the patient’s responses to the questionnaire may trigger the need for additional psychological assessment are explained in appendix 2.

Statistical Analysis:

Completed RoFCAR questionnaires together with the operative details of each patient from 01/01/2019 until 31/12/2021 were generated from the clinic database and analysed. Patients with incomplete RoFCAR questionnaires or with unclear procedure code were excluded in order to improve consistency of data.

Data were then stratified according to type of aesthetic surgery. Scores above thresholds were identified and percentages were calculated comparing scores of patients undergoing different types of aesthetic surgery. Further analysis was performed to evaluate percentages of scores for each procedure against the different components of the RoFCAR questionnaire. 

Results:

A total of 740 patients were included. 599 patients underwent a single operation and 141 had multiple operations (revision and/or additional procedures). Rhinoplasty was the most common procedure (207/740) and brachioplasty was the least common surgery (1/740). Breast lipofilling was the operation with the greatest number of revisions (7/18).

Self-consciousness:

Self-consciousness was an important consideration for all patients, regardless of which procedure they underwent. Labiaplasty patients appeared to be the most self-conscious with 27.8% scoring above threshold, closely followed by patients undergoing mastopexy +/- augmentation of which 26.9% scored above threshold. Largely, patients who underwent multiple surgeries were found to be more self-conscious than those who underwent a single operation; breast and facial surgery met the threshold in over 30% of patients.

Avoidance of activities:

Patients who underwent breast surgeries were found to be most likely to avoid work, social and sexual activities compared to those who underwent facial surgeries (12.3% vs. 11.9%, 18.0% vs. 15.5% and 29.9% vs. 13.6%, respectively). Compared to patients undergoing all other types of operation, patients who underwent breast reduction surgery were most likely to avoid work (33.3%) and 40% of these patients reported avoidance of social and sexual activities. Trunk combination operation patients were most likely to avoid social activities (44.0%) and sexual activities (60%). This was closely followed by labiaplasty patients, of whom 58.3% avoided sexual activity. Of all the facial surgeries, pinnaplasty patients were most likely to avoid work, social and sexual activities (31.3%, 25.0% and 31.3%, respectively).

Patients who underwent multiple procedures following their initial surgery such as blepharoplasties, face and neck lifts, pinnaplasties, mastopexies and labiaplasties were more likely to avoid work related activities than those who underwent a single one of these operations. Furthermore, patients who underwent multiple liposuctions and multiple breast, and facial surgeries were more likely to avoid sexual activity than those who underwent single operations.

Self-confidence:

Lower self confidence in relation to work, social and sexual life appeared to be a prominent feature in all types of operations, with over 50% of all patients scoring above threshold. The general trend found was that patients scored higher for reduced self-confidence compared to any other section of the questionnaire. Over 30% of all patients undergoing breast surgeries felt low self-confidence in regard to their social life.  Primary and secondary breast augmentation patients felt the least confident at work (70.7 and 70.6%, respectively) and during social activities (68.7% and 64.7%, respectively). Additionally, patients undergoing facial and breast surgeries had low self-confidence in relation to their sexual life; over 45% of facial surgery patients and 39.0% of breast surgery patients met this threshold.

Mirror checking:

Over 15% of patients who underwent each surgical procedure both felt the need to look in the mirror and did so more than 5 times a day. This trend was prevalent in patients undergoing facial and breast surgeries who felt the greatest need to look in the mirror. Predominantly, rhinoplasty patients were most likely to both feel the need to check their appearance (54.1%) and do this more than 5 times a day (39.6%). Furthermore, 53.3% of breast reduction patients felt obliged to look in the mirror, closely followed by primary breast augmentation patients, of whom 40.4% felt the need to look in the mirror.

Generally, patients who underwent multiple operations were found to spend more time looking in the mirror than those who had single operations, particularly in the context of breast and facial surgery. Most notably, 66.7% of pinnaplasty patients and 50% of labiaplasty patients spent more than 30 mins at one time or over 2 hours in total looking in the mirror every day. A lower proportion of patients spent more than 30 minutes at one time or more than 2 hours a day looking in the mirror despite high proportions of patients feeling the need to look in the mirror and actually looking in the mirror, possibly attributable to patients taking quick glances and instead avoiding looking in the mirror. (Appendices 3-4)

Discussion:

The intention of this review was to explore certain patients’ psychosocial aspects in correlation with the type of aesthetic surgery including the number of operations and/or revisions. A number of psychological screening questionnaires and self reported outcome measures have been proposed to identify the characteristics of body dysmorphia. Many of these were focused on specific body region/surgery and merely adopted by some institutions but not reviewed following their application.

The majority of the normal population have a degree of self-consciousness about some aspects of their appearance. However, some patients who do not suffer from any form of disfigurement have developed a variable intensity of self-consciousness about one or more aspects of their appearance. In this review we found that patients undergoing breast cosmetic surgery appear to score higher when it comes to self-consciousness. There is also a tendency to increased levels of self-consciousness amongst patients who have undertaken multiple operations for either revision or additional cosmetic surgery. This highlights an important point as breast cosmetic surgery is gaining popularity in recent years particularly breast augmentation. However, it opens up further psychosocial risks as demonstrated in one study where patients undertaking breast augmentation had higher mortality related to suicide even though this was not statistically significant.8

Similarly, a trend can be demonstrated in facial surgery whereby patients meet the roar trigger threshold for self-consciousness questions. It appears that pinnaplasty and face/neck lift patients tend to undergo multiple procedures. Surprisingly, rhinoplasty cohort appears on the contrary to be less self-conscious compared to other patients undergoing other types of facial cosmetic surgery. Preoccupation with minor flaws in ones appearance and engagement in repetitive behaviours such as mirror checking are characteristics of BDD.9 It was clear from our results that mirror checking is a prominent feature amongst patients undergoing facial cosmetic surgery. It has been demonstrated that BDD prevalence is higher in facial plastic surgery patients10 which is mirrored in our results whereby pinnaplasty and rhinoplasty patients are likely to check their appearance and spend longer periods looking in the mirror.

It was not surprising to find that patients undergoing labiaplasty were found to be the most self-conscious and very likely to avoid sexual and intimate activities than other groups. However, over two thirds of patients demonstrated higher scores related to avoidance of work and social interaction. This could be explained by the findings of a study by von Soest et al. highlighting that increased levels of distress, depression and anxiety could be a predictor of patients seeking cosmetic surgery which may have an adverse effect on those patients’ psychosocial well being.11 Similarly, Sharp et al. demonstrated that patients seeking labiaplasty in their studied group had lower satisfaction with their lives overall, which may have been impacting on their quality of life.12

It is difficult to demonstrate a direct relationship between revision surgeries or the tendency for requesting multiple cosmetic procedures and heightened self-consciousness or BDD. Whether low self-esteem is a component or trait of BDD remains unclear in the literature. Nevertheless, prolonged and repetitive mirror checking is a well-established component of BDD. In certain types of cosmetic surgery such as rhinoplasty it was found that patients with higher preoperative nasal self-esteem and mood morbidity scores as part of the Standardised Cosmesis and Health Nasal Outcomes Survey (SCHNOS) may be at greater risk of somatisation or BDD which leads to poor postoperative satisfaction and potentially higher revision rates.13 Although our study has certainly not found a direct link between revision surgery and rhinoplasty, it was clear that patients undergoing facial and breast procedures overall have demonstrated a tendency to request multiple operations.

There are several limitations to this review that should be acknowledged. Data collection and analysis did not adjust for confounders or other factors, which may have influenced patients’ responses and scores e.g., patient gender, ethnicity, age, social status, occupation etc.  It is established that such factors may be related to increased levels of self-consciousness in certain groups of patients, which may in turn exhibit psychological predictors of cosmetic surgery.11 It is also important to note that this review was conducted in the context of the current Covid19 pandemic. However, it is difficult to establish whether this has influenced patients’ responses to the RoFCAR questions. The sudden surge of video conferencing may have exacerbated patients’ self-consciousness and awareness of facial appearance.14 Therefore, future studies may have to take this factor into consideration and review the pre and post pandemic scores in order to evaluate whether there is a shift in paradigms. 

Conclusions:

The use of psychological assessment tools is essential not only to identify those patients with unrealistic expectations and potential psychological risks but also to increase the likelihood of patients achieving a positive postoperative outcome. In addition to a thorough consultation and clinical assessment, the RoFCAR was specifically designed to aid plastic surgeons and aesthetic practitioners to screen patients for any psychological factors, which are likely to increase the risk of a poor psychological outcome. This study has provided large objective data and detailed analysis of the individual components of the RoFCAR questionnaire.

These data has demonstrated that patients undergoing facial and breast cosmetic surgery such as pinnaplasty, rhinoplasty, and breast augmentation in addition to labiaplasty are likely to have psychological vulnerabilities and to meet the roar triggers for professional psychological assessment. Although it was not clear whether patients requesting multiple procedures including revisional surgery have a trait for psychological disorders, it was evident that this subset of patients was more self-conscious of their appearance. Overall, patients who underwent breast and facial surgery met this threshold in third of the cases.

The RoFCAR is also designed to provide a clearer understanding of post-procedural psychosocial gains. Patient satisfaction following cosmetic surgery is an important outcome measure. The main limitation to this review is the lack of postoperative data. Further review would be needed to correlate preoperative patient responses with their RoFCAR scores following their cosmetic surgery in order to establish a link with patients’ satisfaction. Another consideration should be drawn to the consequences of the Covid19 pandemic on the psychological predictors of cosmetic surgery.

January 2022

References:

1.                          Paraskeva, N., Clarke, A. and Rumsey, N.The routine psychological screening of

cosmetic surgery patients. Aesthetics. 2014.pp. 28-32.

2.                         Wildgoose P, Scott A, Pusic AL, Cano S, Klassen AF. Psychological Screening Measures for Cosmetic Plastic Surgery Patients: A Systematic Review. Aesthet Surg J. 4 ed. 2013 Jan;33(1):152–9.
3.                         Sarwer DB, Wadden TA, Pertschuk MJ, Whitaker LA. The psychology of cosmetic surgery: a review and reconceptualization. Clin Psychol Rev. 1998 Jan;18(1):1–22.
4.                         Chasapi M, Salibi A. The Psychological Assessment of Aesthetic Patients: Results of a Survey of the British Association of Aesthetic Plastic Surgeons Members. Aesthet Surg J. 2021 May 18;41(6):NP706–8.
5.                         Carr T, Moss T, Harris D. The DAS24: a short form of the Derriford Appearance Scale DAS59 to measure individual responses to living with problems of appearance. Br J Health Psychol. 2005 May;10(Pt 2):285–98.
6.                         Thomas JR, Sclafani AP, Hamilton M, McDonough E. Preoperative identification of psychiatric illness in aesthetic facial surgery patients. Aesthetic Plast Surg. Springer-Verlag; 2001 Jan;25(1):64–7.
7.                         Sarwer DB, Pertschuk MJ, Wadden TA, Whitaker LA. Psychological investigations in cosmetic surgery: a look back and a look ahead. Plast Reconst Surg. 1998 Apr;101(4):1136–42.
8.                         Brinton LA, Lubin JH, Burich MC, Colton T, Hoover RN. Mortality among augmentation mammoplasty patients. Epidemiology. 2001 May;12(3):321–6.
9.                         Veale D, Riley S. Mirror, mirror on the wall, who is the ugliest of them all? The psychopathology of mirror gazing in body dysmorphic disorder. Behav Res Ther. 2001 Dec;39(12):1381–93.
10.                     Dey JK, Ishii M, Phillis M, Byrne PJ, Boahene KDO, Ishii LE. Body dysmorphic disorder in a facial plastic and reconstructive surgery clinic: measuring prevalence, assessing comorbidities, and validating a feasible screening instrument. JAMA Facial Plast Surg. 2015 Mar;17(2):137–43.
11.                     Soest von T, Kvalem IL, Wichstrøm L. Predictors of cosmetic surgery and its effects on psychological factors and mental health: a population-based follow-up study among Norwegian females. Psychol Med. 2012 Mar;42(3):617–26.
12.                     Sharp G, Tiggemann M, Mattiske J. Factors That Influence the Decision to Undergo Labiaplasty: Media, Relationships, and Psychological Well-Being. Aesthet Surg J. 2016 Apr;36(4):469–78.
13.                     Okland TS, Patel P, Liu GS, Most SP. Using Nasal Self-Esteem to Predict Revision in Cosmetic Rhinoplasty. Aesthet Surg J. 2021 May 18;41(6):652–6.
14.                     Cristel RT, Demesh D, Dayan SH. Video Conferencing Impact on Facial Appearance: Looking Beyond the COVID-19 Pandemic. Facial Plast Surg Aesthet Med. 2020 Jul;22(4):238–9.

Appendix 1 – Psychological Screen form

PLASTIC SURGERY PSYCHOLOGICAL SCREENING FORM

Patient Information

How to fill out this form

We would like to know how you feel about your appearance now. You may or may not have had surgery previously. 

Please answer these questions using a 0 - 10 scale, where 0 is “not at all”/ “never” and 10 is “all the time”/ “extremely”.

With regard to the feature for which you REQUESTED surgery:

7. How many times a day do you check your appearance?                                                        

8. On a typical day, how long do you spend looking in the mirror?                                          

9. In what ways do you expect your life to be different after surgery?                            

Consultant Declaration:

*I can confirm that there has been a consultation with this patient.

*I can confirm this patient has been fully informed and has consented to the surgery. 

*After consultation with the patient I can confirm that the surgery is being carried out under the following conditions:

I can confirm that Cadogan Clinic will keep the patient records for a minimum of 7 years               YES   /   NO

*If the surgery is a cosmetic procedure it will be subject to 20% VAT

Signed by:               ___________________________________________________

Surgeon’s name printed: ____________________________________________

Date of signing: ___________________________________________________

Appendix 2 – Roar Triggers for professional Psychological Assessment

If the responses to the questions are as follows these may trigger the need for professional psychological assessment

Appendix 3 - The overall percentage of patients meeting the roar triggers of RoFCAR against the type of operation

Appendix 4 - Percentage of  patients meeting the roar triggers for RoFCAR questions stratified to single vs. mulitple operations.