Monday, August 5, 2013

Keeping Your Cool When You're Getting Hot

I am writing this just moments after a patient encounter that set me back. Admittedly, it takes a fair amount to raise my blood pressure. I’d appreciate your feedback on how you would have handled this situation differently, if at all.

A bit of history:

In the morning huddle, I saw a patient on my schedule for a toothache. He had never been seen for treatment in our office. It was brought to my attention that this patient was “the guy that scheduled two weeks ago, then, once seated in the operatory, stated he didn’t have any money for this appointment.” (Yes, he was given fees during the initial phone contact.)He had brought in a bag full of meds and wanted “the doctor to tell him what he could take.”

For the record, the meds were a plethora of friends’ and family’s pain meds and Abx. It was explained to the patient that Dr. DeLacy would have to examine the area and review an x-ray (including what said fees would be) before she could discuss the use of any type of prescription medication. Mr. Patient responded that he didn’t have the any money to do that and asked if she could “just look.”

The patient was dismissed that day, having refused an exam or review.

Flash forward to today. A team member reminded me of the patient and assured me that he had been informed of the fees and he understood his financial responsibilities. “Oh, and by the way, Doc, he needs meds for his dental anxiety too.” As you can imagine, I had to mentally prepare for the patient.

Fortunately, his clinical need was a straight-forward diagnosis. Tooth #29 fx’d approximately 10 months prior. Three weeks ago, it began to ache. The patient had visited the ER and received Abx and T#3. He took “some” of the Abx and now stated that now “it doesn’t hurt that much.” The tooth is restorable with a favorable prognosis. I discussed with the patient the clinical options: clean out as temp fix, RCT/CORE/PMC, or an extraction. I also informed Mr. Patient of the pros and cons of each.

Let me point out that this patient is the type of patient that has a tendency to tell you how his bite is off and that this situation is what is causing the dental decay, etc. Mr. Patient is clearly a clinical expert in dental occlusion, load, and endodontics. He proceeded to explain to me that when it was really “hurting,” he could “suck hard enough to drain blood out of it,” and he didn’t think the root canal was needed. Now knowing the personality type I was dealing with, the next portion of our conversation will likely be familiar.

As I turned to the computer to enter the treatment plan services, the conversation slowed. I assume he is uncomfortable with silences. He began to ramble. It started off generic enough, but quickly turned to a personal attack on myself and the profession that I have committed a significant amount of time and finances to be proudly associated with.

“Doc, this dentistry is a racket. Don’t you do any pro bono work? I mean, there isn’t anything for the poor. I’ve never heard such a situation where you don’t have to do pro bono work to keep your license.”

As hard as I tried not to engage in this line of conversation, I did politely respond that my partner and I do, in fact, selectively choose when we donate our services. I also explained we participate in the tax payer’s state-funded children’s Medicaid program, which means we accept significantly reduced fees for children under age 21. AND, in order to keep our licenses in good standing, we have to continue to take courses and schooling.

“KIDS?!?! Why would they need dental care? They have brand new teeth.”

I took a deep breath and focused on my computer. In that moment, I realized that I could refute and debate for hours, but the beliefs of this patient was that he felt that I shouldn’t charge him anything. He had so kindly informed me earlier that, “The hospitals HAVE to see you, even if you don’t have money. Dentists? Well, they all want your cash UP FRONT!”

I proceeded to, as nicely as I could without screaming or becoming physically violent, inform him of two known clinics that do, in fact, see patients that qualify financially for either no cost or reduced fees. At this point, I had resigned myself that I wasn’t going to gain any ground and it was best to excuse myself. I politely explained that we would give him the fees for dental treatment in our office, if he chooses to have the dental treatment completed in our office.

Maybe I should have attempted to educate him further. Maybe I should have offered to reduce my fee on the exam and the x-ray? Or, maybe I handled it correctly. The problem wasn’t only that he was ignorant on the topics or that he so infuriated me that I wanted to scream, but that I allowed myself to get drawn into a conversation that made me feel I needed to defend myself and my profession. Fortunately now, I have this blog as my outlet and have an acceptable place to “get it all off my chest.” I’m feeling much cooler now; the AC is working again.

Colleen B. DeLacy, DDS


Dr. Andy said...


Do yourself, your staff, and your family a favor: fire this patient.

Look at how your body reacted physically. How will you feel the next time you see his name on your schedule? Will you be happy or anxious? I've learned the hard way, this stuff affects YOUR health.

Would anyone reading this allow me to walk into their house and tell them how to run things? No. Our offices are our second home. Same rules apply.

Write up a nice dismissal letter and mail it off.

Keep a copy. The opportunity WILL come for you to use it again.


Unknown said...

My guess is that is primarily drug-seeking behavior.
It is not your job to defend the profession. Your job in this case is to protect yourself and your staff and patients from harm.
Once, over 25 years ago, a couple of guys came into the office. One complained of a toothache, and sure enough, when I'd sat him down he had an abscessed tooth. But he didn't want me to treat the tooth, he wanted drugs--and he even told me what drugs he wanted.
I refused; he and his bud came into the treatment room and grabbed me. I hauled off, but before I belted this guy I told him to get the hell out of my office.
I was going to forget about it (after I calmed down) but a patient in the waiting room prevailed upon me to call the police. When they arrived, I gave a report, showed the medical history with the patient's name--and was amazed to find that he had used his real name--and the guy had just been released from jail a few days before.
After he left my office, he ran down two doors to the pharmacy, reached over the counter and stole some antihypertensives. The (very nice) pharmacist was concerned the guy would poison himself.
I wonder how many other dentists this guy tried to roll.
If this guy was in any way threatening, please file a police report, so something is down on paper.

Anonymous said...

Since you have not started any treatment on this guy, simply tell him the you and he are not a good match and he'd be better served getting his treatment elsewhere. You actually aren't firing him, since you have no relationship with him to have established treatment that you must continue. The old saying that 5% of our patients give us 95% of our problems is correct. Nip this in the bud and send him packing.

Dr. Lawrence M. said...

Colleen, thankfully the law is behind us when we tell you that you are not forced to accept a patient in your practice. If they are in pain or there is an infection, you are required to ethically begin initial therapy to relieve pain or infection. After that, you have the choice to treat, or not to treat.
This man has definitely alienated himself to a great many people. That is his problem. don't let it be yours.
warm regards,
Larry Stanleigh


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