In this second installment of How to Effectively Treat the Difficult Patient, we examine other situations that arise when treating patients who present challenges beyond their dental conditions. This article, originally printed in The Scope: Dental Edition, was written by Donnaline Richman, Esq. and Marilyn Schatz, Esq. of Mercado May-Skinner (MMS) and Keith Vaverchak of MLMIC.
Click here to read How to Effectively Treat Difficult Dental Patients: Part 1.
Dental Patients Who Complain About Treatment
Patients who lodge complaints about their care and treatment with a third party, such as a hospital, insurance company or governmental agency (e.g., Medicaid or the New York State Office of Professional Discipline [OPD]), create an awkward situation. The patient may have chosen not to discuss their concerns about treatment with the dentist and, instead, decided to write a formal complaint letter. Sometimes, it is not the patient who makes the complaint, but rather a spouse, adult child or other family member.
No matter where it originates, receipt of a complaint letter places the dentist in an uncomfortable and defensive position. It may not be wise to continue to treat the patient if he or she is dissatisfied. Consciously or unconsciously, the dentist may be inclined to order additional, or even unnecessary, testing or procedures merely to satisfy the patient’s demands or protect himself/herself from litigation or government investigation.
If a dentist does receive a complaint letter that alleges sub-standard quality of care received and requests compensation for an injury (i.e., a claim letter), the dentist should contact MLMIC Insurance Company. MLMIC will investigate the patient’s claim and develop an appropriate response and/or resolution to the complaint. If the patient’s letter does not ask for monetary compensation, but simply raises concerns about the quality of care, attorneys at MMS Law are available to assist the dentist in preparing a written response.
Dental Patients Who Fail to Pay Bills
Dentists often ask whether they may discharge a patient who fails to pay for services rendered. The answer is yes, as long as there is no dental reason that would preclude discharge. These patients may also fail to keep their appointments due to their inability to pay. If the patient misses an appointment, and his/her dental condition warrants follow-up care, appropriate steps must be taken to ensure that the patient is counseled about receiving the required care and the consequences of the failure to obtain it. Warning letters should be sent about missed appointments that describe the patient’s condition, the need for continued treatment and what could happen if treatment is not received.
Only after such steps have been taken may the patient be discharged from the practice. Note that the dentist-patient relationship does not automatically end when a patient’s bill is sent to an agency for collection. The dentist’s responsibility for the patient’s care only ends when the patient has been formally discharged.
Dental Patients Who Threaten to Sue or Consult an Attorney
If the patient not only complains about treatment but threatens to bring a lawsuit, or if the patient has consulted an attorney, clearly the dentist/patient relationship has been seriously disrupted. The dentist’s first awareness of attorney involvement may occur when he or she receives a request for the patient’s dental record. Since it is not always clear why an attorney is requesting the record, many dentists rely upon instinct to alert them to a potential liability issue. If there is any inkling that the patient is contemplating a malpractice lawsuit, it may make it uncomfortable for the dentist to continue to treat the patient.
Surprisingly, some patients wish to continue seeing a dentist they have sued, but it is not in the best interests of either the patient or the dentist to continue the relationship. Patients who have sued, or who have consulted an attorney with the intention of commencing a lawsuit, often cancel or fail to keep scheduled appointments, particularly after their attorneys have requested their dental records. They may be noncompliant with treatment recommendations or fail to communicate about dental issues. Dentists may feel compelled to practice “defensive” dentistry, ordering inappropriate tests and procedures. The dentist may believe that continuing the relationship will help him/her “look better to the jury,” which, generally, is not true.
Once a patient has commenced a malpractice suit, the dentist-patient relationship, based upon mutual trust, has been seriously compromised. The patient should be discharged from care, or, if his/her condition requires it, the patient may be transferred to another practice. If the patient’s dentist is in a group practice, the patient should be discharged from the care of all dental providers in the group.
Intoxicated/Impaired Dental Patients
When a patient or family member comes to the office drunk or otherwise intoxicated, he/she may be uncooperative and disruptive and can be asked to leave the premises. The dentist may be concerned about the patient’s ability to drive and may question whether he/she should call the police to prevent an accident. These same questions arise when a patient who has received an anesthetic or sedative in the office insists on driving home, despite clear warnings not to do so. Regrettably, a dentist’s office cannot call the police to stop the patient from driving without a patient’s consent, since this would be a breach of the patient’s right of confidentiality.
Handling these situations involves skillful persuasion. First, the patient should be assessed to determine whether there is another cause for the behavior that can be treated, or if he/she has recovered sufficiently to drive safely. If the dentist feels the patient is unable to drive safely, the dentist should attempt to persuade the patient to remain until he/she is safe to drive, offer to send the patient home in taxi or car service, or call a family member of the patient to provide transportation. The counseling efforts and actions taken must be documented in the patient’s dental record. If clinically appropriate, the patient may be discharged from the practice.
Dental Patients Who Lack Capacity
Patients with decreased cognition, dementia or those who reside in a New York State Office for People With Developmental Disabilities (OPWDD) facility can be difficult to treat. Concerns may include cooperation, safety and informed consent. When dealing with patients who lack capacity, proper staffing and allocating adequate time are important so that these patients may be treated safely. It can also be difficult to discern if such patients have a legal guardian or other person who has the right to provide consent. A patient may have multiple family members who disagree about the patient’s care, but do not have the legal authority to make healthcare decisions. Individuals entitled to make healthcare decisions, such as providing consent for treatment, include healthcare proxy agents, legal guardians or, for a patient from an OPWDD-regulated facility, an involved family member.
Patients who lack capacity pose special legal issues involving appropriate delegation and documentation of decision-making authority. If you have a situation that requires evaluation of such authority, you should contact legal counsel.
Dental Patients Who Act in a Seductive Manner
Some patients send love letters, exhibit unusual or flirtatious behavior or use sexual innuendos when speaking to their dentist. In some instances, the patient may not even be aware that this behavior is inappropriate.
A dentist should have a chaperone present in the room when it is appropriate. The presence of the chaperone must be documented in the patient’s dental record. (MMS Law can provide sample language that can be used to document the presence of a chaperone.) This is particularly important for patients who act in a seductive manner.
A patient who acts inappropriately toward his or her dentist may have underlying emotional or psychological issues. There is a very real risk that the patient may make allegations of sexual misconduct when their advances are rebuffed by the dentist. Such allegations can destroy a dentist’s career and result in disciplinary action by the OPD. The use of a chaperone can help a dentist avoid such allegations. If a patient alleges that sexual misconduct has occurred, the patient must be discharged immediately, if appropriate, to protect the dentist’s license and reputation.
Discharging a Dental Patient From Care
As pointed out in this discussion, a dentist is not required to continue caring for a patient whose behavior makes the dentist uncomfortable. A patient may be discharged from care if they do not have an urgent or emergent dental condition or do not require continuous care without a gap.
In some situations, the dentist may find that the patient cannot be discharged, or that the dentist must first arrange for a seamless transition to another provider. The dentist must consider the patient’s ability to obtain the same type of care in a timely manner within a reasonable geographic distance. In some specialties, 30 days’ notice may be insufficient.
If the patient can be discharged, any existing appointments must first be cancelled. The dentist must then promptly send a letter to the patient stating that he/she is discharged from the entire practice. Once the discharge letter has been sent, all office staff must be made aware of that fact so that the patient is not inadvertently given a new appointment.
The wording of the discharge letter may be important. In cases where the patient has failed to pay for treatment, it is usual for the letter to state nonpayment as the reason for discharge. In other cases, especially when the discharge is due to the patient’s disruptive behavior, or if there is a potential lawsuit against the dentist, the discharge letter may be more general and may state simply that there has been a disruption in the dentist-patient relationship. This general, noncommittal statement may help avoid or minimize an unpleasant confrontation. If further evaluation, care and treatment are indicated, the discharge letter must emphasize the importance of seeking such care and state the consequences for failing to obtain it.
Interactions between dental practitioners and patients can sometimes present challenging dilemmas. Angry, rude, unhappy and anxious patients can be disruptive to the office. The ability to positively address patients’ concerns is an essential component of a successful dental practice.
It is strongly recommended that dentists implement appropriate strategies to manage difficult patient encounters in order to reach amicable resolutions. Successful communication and listening skills are required to avoid and diffuse strained relations. Anxieties can be reduced by empathizing with patients in a calm and understanding manner. Dentists should acknowledge grievances, frustrations and concerns by demonstrating understanding without being dismissive or disrespectful, knowing when to compromise and always maintaining professionalism.
Effective skills are essential to address stressful relations between dentists and patients. MLMIC professionals have the experience and requisite expertise to assist in the management of these uncomfortable circumstances. Please do not hesitate to contact us should the need arise. By properly managing these situations, dentists can maintain good relationships with their patients, provide effective care and protect their reputation.
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