By Marc Leffler, DDS, Esq. for MedPro Group

Background Facts

Dr. R was a restorative dentist practicing in a rural town in the American mountains, with only 2 other dentists within a 30-minute drive, and no dentists with sophisticated restorative capabilities closer than nearly 4 hours. A 51-year-old healthy woman, B, presented to Dr. R, having recently moved into the area. Her dental history was complex, due primarily to her having suffered significant facial trauma some years ago in a motor vehicle accident, which led to the loss of 6 maxillary teeth. She had been restored from that time with various removable upper partial dentures, but she remained unhappy with her appearance and her ability to function. Luckily, her mandibular teeth were essentially unharmed in the accident, so the lower jaw had a full complement of teeth, other than 2 third molars which were extracted as a young adult and a second molar that vertically fractured after root canal therapy, necessitating its removal.

She sought Dr. R’s opinion as to whether she could have a fixed prosthesis for her upper. After evaluating her clinically and radiographically, Dr. R took alginate impressions and a basic bite, which were poured up and mounted while B left for a short lunch before returning. Dr. R determined that she was a good candidate for implants, upon which a full-arch restoration could be fabricated. B immediately rejected the idea of implants after seeing her brother have what she described as an “awful experience” with implants, so she asked Dr. R for another option. He suggested a 13-unit maxillary “roundhouse” bridge, which would involve the preparation for abutments of all remaining upper teeth, and joining them with pontics which would cover the spaces left by the missing teeth. He explained that, after the teeth were prepared, which he planned to do on one long visit, he would place a temporary bridge, which would remain in place while the remaining steps of bridge fabrication —impressions, bite registration, and laboratory creation of the final prosthesis, followed by potentially several try-in visits to idealize the occlusion – were completed. B liked the concept and wanted to proceed.

Dr. R asked his office manager to meet with B that same day, to go over the fees and set up a payment schedule. The total fee quoted was $30,000, which accounted for everything, regardless of how many adjustments were necessary after insertion. The manager presented B with a “financial agreement”, which set forth the total fee and the payment schedule, which required 3 equal payments at the times of tooth preparation, final impressions, and cementation. The agreement noted, in bold lettering, that B understood that Dr. R would absolutely not proceed with subsequent steps until payments were up-to-date all along the way. B and the manager thoroughly discussed all aspects of the agreement, and B signed the form. Before leaving, she scheduled the first appointment.

Approximately 2 weeks later, B presented to the office and handed a check for $10,000 to the front desk. Dr. R treated B for an entire afternoon, during which time he prepared all of the maxillary teeth and placed a laboratory-processed provisional, which he relined before temporarily cementing it. On her way out, B scheduled her next visit for close to a month later.

At that following visit, she again provided the staff with a second $10,000 check, before spending most of the morning with Dr. R, as he fine-tuned the preparations, completed final impression making, and adjusted and temporarily recemented the provisional appliance once again. He asked B to wait for the office to contact her before next coming in, so that he would be certain that the lab would have adequate time to fabricate the final product. Several weeks later, the office called B and left a voicemail which advised her that she could set up an appointment for insertion. B did not respond, so the office manager repeated the process of calling.

Days later, B called the office, very upset, and asked to speak directly with Dr. R. She tearfully told Dr. R that her husband had lost his job, so she could not afford to make the final $10,000 payment, and she did not anticipate being able to do so in the near future because of a tight job market in her husband’s industry. Dr. R firmly, but professionally, reiterated his policy of taking no further steps until all payments due were made. He encouraged her to return with payment as soon as possible so that he could complete the work.

As of almost 7 months after the laboratory had fabricated the bridge, B’s husband was still out of work, and her temporary bridge was beginning to crack, thereby making eating difficult for her. She called the office manager, asking to be seen to have a new temporary bridge placed, or at least to have the current one repaired, but was told that no further treatment would be provided to her without further payment. When coincidentally speaking with an attorney cousin of hers by phone, she explained the dental situation, her deteriorating mouth, and Dr. R’s refusal to finish the treatment he had started, or even render emergency care. The cousin was outraged by Dr. R’s position, and offered some solutions, including that she speak with a malpractice attorney for advice; but in the interim, he suggested that she drive to a medical center a good distance away, which had a dental clinic that would hopefully repair the temporary for an inexpensive sum.

B followed her cousin’s advice and was able to have the needed repairs at an affordable price. She also spoke to a malpractice attorney, who contacted a dentist friend to get a sense of whether B had an actionable case. In the end, B was told that Dr. R had not seemingly performed any actual treatment which departed from the standard of care, but that he had abandoned her by being unwilling to complete the midstream treatment, and by being unwilling to even perform emergency repairs to maintain her mouth in a healthy state as a stopgap measure. By this time, B was extremely angry with Dr. R, so she wanted to act in any way she could against Dr. R; the only way, according to the malpractice attorney, was to file a complaint with the state’s dental board, explaining the situation in detail and seeking that Dr. R be penalized in some way.

Once B’s husband became employed again and their other outstanding bills were resolved, B was in a position to pay for the completion of her work, now a year-and-a-half after she last saw Dr. R. But she refused to go back to Dr. R because she felt betrayed by him and because her board complaint was ongoing, so she found the closest restorative dentist to her—still quite a distance away—who was willing to pick up the in-progress treatment and complete the roundhouse for less money than B would have paid Dr. R. She ended up very happy with her new bridge, although it took much longer than anticipated and with more stress than expected.

Board Actions

A board investigator interviewed B to get all details she had to offer, and also gathered all of Dr. R’s records, radiographs, billing statements, phone memos, lab prescriptions and receipts, and the financial agreement along with the attached notes of the office manager. Once all of this evidence was reviewed by board members, an interview with Dr. R was scheduled.

Dr. R appeared for his interview with an attorney retained by his malpractice carrier, as was provided for under the terms of policy. Dr. R did not dispute what had been said by B [and as is described in this case study], but instead held firm to his position that he had entered into a financial contract with his patient, which she was unable to fulfill monetarily, so he felt that he was under no obligation to provide any work for which he was not paid, regardless of the stage of treatment.

Board members deliberated as to how to resolve the complaint of B, and they then levied severe sanctions against Dr. R, with detailed explanations to go along. Dr. R was fined heavily, given a 2-year suspension of which all but 4 months were stayed, and mandated to take 8 hours of coursework on the subject of professional ethics.

The board’s explanations clearly set forth the rationale behind the actions. Dr. R was obligated not to leave his patient in an unstable dental state once he began treatment, regardless of financial agreements or her inability to pay as treatment progressed; doing so, determined the board, constituted an abandonment of B, subjecting her to potential bodily harm as a result, and violating his professional duty of non-malfeasance (“do no harm”). The board found Dr. R’s unwillingness to perform even basic repairs on the provisional was an aggravating factor which raised the severity of the sanctions. And the board pointed to the fact that Dr. R was the only dentist in the area and its reasonably close surroundings to be able to handle a case of this type, so his refusal to continue treatment placed a burden on B which was greater than had there been other local dentists able to competently treat her.

Finally, the board explained, for the apparent purpose of education, that Dr. R would have been well within his rights to have refused to treat B from the start if he believed that he was incapable of performing appropriate treatment on her, if she had insisted upon having treatment performed which Dr. R had believed to be inappropriate, if he felt that she would not be an adequately compliant patient, if she had acted personally inappropriately toward him or his staff, or if she was unwilling to pay the fee he requested; but once he accepted B as a patient, and began treatment, he placed himself into a position of unbending ethical obligations toward her which overrode all other considerations.

Takeaways

Dentists are professionals, whose “customers” are patients, and who, consequently, are entitled to have ethical standards upheld in all circumstances. When those ethics are violated by the dentist, they are subject to severe sanctions, up to the possible loss of license. These principles should be viewed entirely differently from departures from the standards of care of treatment—mistakes in performance or errors in judgment—which might cause physical injury. The difference can be viewed as a matter of intent and professionalism: Dr. R fully intended to take the unprofessional actions/inactions that he did, and that is what led to the severity of what the board meted out.

Dentists do well to realize that any situation which prevents them from being able to complete work that has begun puts them at risk for a claim of abandonment, with the penalties that carries if demonstrated. So, any time that they leave the employ of an office, or any time they wish to dismiss a patient for any of a variety of reasons, deep consideration as to how the impacted patients will be affected must take place, with plans put in place to protect those patients. Even if patients are terminated without ongoing work in progress, they should be told of their conditions in detail, advised that they ought to seek dental care elsewhere as soon as is practicable, and be provided with emergency care by the terminating dentist for a reasonable period of time.

Dental malpractice claims are resolved by money, which is usually paid by a malpractice insurance carrier, but abandonment claims leave the dentist holding the whole bag, exactly as they have done to their abandoned patient.

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