Nonadherent (also called noncompliant) patients are nothing new to the practice of dentistry. When patients won’t adhere to treatment plans and/or refuse needed examinations or treatment, they place the dentist in a very difficult position: trying to maintain a proper balance of respect for patient autonomy while complying with the applicable standard of care. Sometimes, nonadherence results in a poor outcome for the patient. An interesting case from the far west region demonstrates how this can happen.
Dr. Y, a nationally respected dentist, maintained an upscale dental practice in an affluent area of a major city. He had recently hired an associate, Dr. R, who was a dentist new to practice. After an appropriate orientation period, Dr. R was left in charge of the practice while Dr. Y gave a lecture in another region of the country.
One of the practice’s patients was a well-known retired professional athlete who had become a close personal friend of Dr. Y. The patient had suffered numerous injuries during his playing career, requiring many head and neck X-rays and computerized axial tomography (CAT) scans. Because of this extensive radiation, the patient was resistant to having dental screening X-rays unless there was an identified problem.
During Dr. Y’s absence, the patient had a routine recall (prophylactic) visit. Before Dr. R’s oral examination of the patient, the hygienist informed Dr. R that the patient was not only overdue for a recall by about a year, but also he had again refused X-rays (it was now 4 years since his last X-rays). Further, the hygienist explained that only limited time was allocated for the visit, so she concentrated on performing a thorough scaling, but was unable to perform a periodontal screening.
Dr. R recognized that the visit had not been complete, but given that he was new and that the patient was Dr. Y’s friend, he deferred any further treatment and completed his oral examination. Dr. R identified gingival recession on the posterior dentition and advised the patient that a more thorough examination (including X-rays and periodontal probing) was needed at his next appointment.
Approximately 3 months later, as the patient was preparing for a television appearance in another city (he had now become a broadcaster), he developed pain and swelling in the upper left quadrant. A local dentist examined him and diagnosed a deep gingival abscess at tooth 14. The local dentist explained the problem to the patient and offered to do additional X-rays at that time, and the patient agreed. The X-rays identified furcation involvement and periodontal bone loss at all four maxillary molars. The dentist gave the patient amoxicillin so he could get through the broadcast, and then he advised him to contact Dr. Y’s practice as soon as he returned home.
Upon his return, the patient spoke with Dr. Y, who had reviewed the X-rays and agreed with the diagnosis. Dr. Y explained that this is what can happen when thorough examinations are refused. Dr. Y then referred the patient to a periodontist for evaluation and treatment. The periodontist recommended extracting all four maxillary molars, performing sinus lift surgery, and placing four implants. This recommendation displeased the patient, especially since the time required for treatment would affect his ability to broadcast. He sought a second opinion, which concurred with the periodontist’s treatment plan.
The necessary remedial treatment (which was not rendered at Dr. Y’s office) and subsequent healing resulted in the patient having to be furloughed from his broadcasting position for several months, resulting in a substantial loss of income. When the patient sued Dr. Y and Dr. R for malpractice, the case was settled by a payment in the high range, with defense costs in the midrange.
Risk Management Considerations
By Theodore Passineau, JD, HRM, RPLU, CPHRM, FASHRM
This case resulted in a payment in the high range for many reasons involving both nontechnical and technical dentistry. A good place to begin is with the relationships. Most of the failures that occurred in this case were on Dr. Y’s watch. X-rays were not taken and periodontal probing was not conducted for approximately 4 years because Dr. Y allowed the patient to refuse them.
The patient’s strong personality, combined with their personal friendship, led Dr. Y to compromise his standards. Dentists must not let personal feelings excessively influence their professional decisions. The standard of care remains a constant, whether the patient is a stranger or a best friend.
Dr. R was in a somewhat difficult position. Being new to the practice, the last thing he wanted to do was “rock the boat.” This may have constrained him somewhat from being as insistent on further testing as he otherwise might have been. He may also have been concerned that he might make Dr. Y look neglectful if he was too strong in his recommendations. Unfortunately, these considerations do not carry much weight when one is trying to justify his or her actions in a malpractice trial or a Board of Dentistry investigation. Simply, a dentist is individually responsible for his or her own actions or omissions when treating patients.
So, given this patient’s strong personality, what could have been done? The verbal communication with the patient should have been clear and understandable, and it should have been carefully documented in the patient record each time it took place. It may have also been appropriate to memorialize the warning conversation with a follow-up letter to the patient (and a copy of it filed with the patient record). Part of that follow-up letter could have been an admonishment to return to the practice as soon as possible for the singular purpose of testing and evaluation.
If the patient continued to refuse needed evaluation or treatment, obtaining his signature on a “refusal of care” form would be a logical next step. Doing so can sometimes cause the patient to stop and carefully consider the options. If the patient continues to be nonadherent, it may be necessary to dismiss him or her from the practice. The failure to take this last-resort step could expose the doctor (as here) to an allegation of supervised neglect.
The technical failures in this case are obvious. The dentist simply cannot perform an adequate examination without using imaging and instrumentation. These tools not only allow for an accurate assessment of the patient’s current condition, but also they provide valuable documentation of the patient’s course if it needs to be reconstructed for subsequent legal or investigative purposes.
In the end, this patient’s suboptimal outcome could likely have been avoided; it certainly contributed to the large settlement.
The following suggestions may be helpful when dealing with a nonadherent patient:
- It is important to avoid any form of bias when treating patients. This bias can be favorable as well as unfavorable, and either can cloud the dentist’s professional judgment.
- Communication is the basis of all human relationships, and healthcare provider-patient relationships are no exception. Clear, objective, and consistent communication is a must.
- Memorialization of oral communication is an effective risk management tool. A follow-up letter allows the patient to revisit the conversation to ensure he or she understood it. It also provides a permanent record of what was communicated to and recommended for the patient.
- Use of a refusal of care form can sometimes nudge the patient in the direction of care that is truly needed.
- Recognize that a chronically, volitionally nonadherent patient not only represents an elevated risk of a poor outcome to themselves, but also he or she is a significantly elevated liability risk to the dentist. As with many dysfunctional relationships, if it cannot be fixed (or at least be made better), consideration should be given to formally ending it.
When a situation such as the one discussed above arises, it may be beneficial to seek a second opinion. Your MedPro patient safety and risk consultant has many years of experience in dealing with these types of situations and can be a valuable resource.
This world is filled with people with many personalities, perspectives, and preferences. Although it is incumbent on every dentist to understand and respect a patient’s autonomy, the standard of care must still be maintained. Failure to do so disserves the patient, the dentist, and the profession.
Your MedPro patient safety and risk consultant can provide you with a refusal of care form template. Call or email MedPro at 1-800-463-3776 to obtain a copy.
This document does not constitute legal or medical advice and should not be construed as rules or establishing a standard of care. Because the facts applicable to your situation may vary, or the laws applicable in your jurisdiction may differ, please contact your attorney or other professional advisors if you have any questions related to your legal or medical obligations or rights, state or federal laws, contract interpretation, or other legal questions.
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