Facing reality: Communicating and managing achievable aesthetic outcomes

There is a great deal of satisfaction in seeing dramatic before and after images, and even more so when your efforts are responsible for positive change. The ability to create transformative improvements in oral health and appearance is frequently cited by dentists and orthodontists as the most satisfying aspect of their profession.

While many patients are just as pleased with their treatment outcomes as their provider is, occasionally there are patients who claim that the reconstructive work did not meet their expectations. Through thoughtful communication, dentists have opportunities to mitigate patient complaints and manage expectations for increased patient satisfaction.

The Dentists Insurance Company (TDIC) Risk Management Advice Line, which provides guidance to TDIC policyholders and dental association members, regularly receives calls regarding patients who have expressed dissatisfaction with the outcomes of their reconstructive treatments. The following case study illustrates how TDIC’s Risk Management analysts have advised callers to respond.

A case study in reconstruction and realistic outcomes

A dentist called the Advice Line with questions about how to manage a dissatisfied patient. After the dentist had completed Invisalign treatment, the adult patient insisted that the result was not representative of the outcome promised by the dentist.

The patient demanded that the dentist retreat the case at no charge. The dentist explained that it was unnecessary to spend additional time and money to retreat the case when the outcome was both clinically acceptable and represented the original desired outcome expressed by the patient.

During the Advice Line call, the dentist shared their perspective that the patient’s expectations had changed over the course of treatment and became more specific regarding desired tooth rotation and position. The dentist sought advice on how to best communicate with the patient. How could the dentist illustrate that the patient’s desired result changed over the course of treatment as well as explain that her expectations simply could not be clinically achieved with the original treatment plan? The result the patient desired would involve changing the size and shape of her natural teeth, but she refused to consider cosmetic options such as veneers.

The Risk Management analyst recommended that the dentist perform a review of the patient’s chart, assessing the documentation on file including a signed consent for treatment, the treatment plan and the stated potential outcome. These records should substantiate the dentist’s claim that the patient had been fully informed of the original treatment plan and had consented to treatment for the stated outcome.

The analyst also advised the dentist to suggest the patient seek a second opinion, including a report from the consulting provider. If another orthodontist expressed an opinion that was not in agreement with the treating dentist’s plan, then the dentist should reach out again to the Advice Line to discuss options for optimally managing the situation.

If the patient refused to seek a second opinion, then the dentist could choose to inform the patient that they were respectfully declining to retreat the case. The analyst agreed that despite the patients’ insistence that the result could and should be improved, the dentist should oversee the treatment and not be influenced by the patient’s statements. However, the dentist should still review the chart and be prepared to defend the case if the patient decided to take further action. Again, the Advice Line analyst offered to assist the dentist further if that occurred.

TDIC’s experts point to poor communication being the greatest cause of litigation, not poor dentistry. Complaints are best addressed and resolved when effective communication tools have been utilized before, during and after treatment through appropriate case selection, detailed treatment planning and thoughtful handling of crucial conversations.

Patient selection

Careful case selection is one of the most important aspects to consider when it comes to protecting against potential risk. Barring discrimination, dentists are not obligated to accept all patients into their practices. It’s imperative to educate patients during the selection process by using pamphlets and before and after photos. Not every procedure is right for every patient; explaining that in a compassionate manner may be necessary.

Those cases you do select to treat should be with patients with whom you can form productive, healthy provider-patient relationships. The scope of treatment required should not exceed that which you can successfully, effectively and safely provide.

“We try to look at every possible angle when it comes to patient interactions, and a lot of issues can be traced back to patient selection,” said Taiba Solaiman, one of TDIC ‘s senior risk management analysts. “Patient demeanor is important information in patient selection.” Solaiman says dentists often have an uneasy feeling about certain patients but may put their instincts aside in favor of potential income or simply trying to make patients happy.

Take time to get to know potential patients and learn more about their motivation for seeking care. Some “red flags” that should indicate caution when accepting a patient for reconstructive treatment include:

• Excessive complaining or criticism of former dentists.
• Long, complex dental history with multiple providers.
• Inability to receive or convey constructive feedback.
• Requests for specific prescriptions.
• Overly rigid treatment controls and restrictions or citing research that is clinically unsupported.
• Unrealistic time or treatment expectations.
• Providing photos of celebrity’s or model’s smiles (or their own from years ago) that are unachievable outcomes.

Along with evaluating the patient’s personality, demeanor and treatment expectations, dentists should carefully consider what is an achievable outcome for each individual. In general, reconstructive results are affected by jaw size, musculature, variable biological responses and patient compliance. Share the most realistic potential outcome with the patient based upon known barriers to treatment.

Treatment plans

Providing detailed treatment plans that outline the options discussed, the risks and the associated costs can help prevent miscommunication between patient and provider about anticipated outcomes. Communicate the scope and limitation of treatment to patients before reconstruction begins. This is most effectively documented when patients are given detailed treatment plans with copies included in the patient’s chart.

Additional documentation associated with the treatment plan should include the patient’s signed acknowledgment of their receipt and understanding of the plan and their consent for treatment. Include pretreatment records such as photos, study models and diagnostic wax-ups. If the treatment plan changes course midtreatment, a revised treatment plan should be printed and signed by the patient before proceeding.

Addressing complaints

Despite your best efforts to offer patients realistic treatment outcomes and detailed treatment plans, some patients will still be dissatisfied. Whether or not you feel a patient’s complaint is reasonable or has merit, taking the time to listen and respond in a meaningful way is a personal touch that takes only a few minutes, but can make a world of difference.

Risk management analysts emphasize that a process of listening to and recognizing complaints does not mean that dentists are admitting liability. It is common for dentists to mistakenly believe that acknowledgement of a complaint equals agreement and therefore validates a patient’s claim. In actuality, documentation that a dentist responded to the patient’s complaint reflects that the dentist was responsive to the patient and viewed their concerns seriously.

Often these matters arise when a patient believes they didn’t receive adequate information about their treatment such as warnings about potential risks or other treatment options. Expressing concern for their frustration and attempting to address those specifics helps diminish the damage with both the patient and any source of resolution, such as the dental board. Also, referencing back to your treatment notes and informed consent forms that the patient signed can demonstrate the thoroughness of your efforts to educate the patient. In the event of a claim, this will demonstrate to anyone who reviews the case that the patient was listened to and treated with respect, rather than ignored or dismissed.

TDIC experts offer these guidelines for handling patient complaints:

• Discussions about patients’ clinical concerns should not be left to staff. If the complaint is made via phone or email, the treating dentist should extend an invitation or make time for a face-to-face meeting with the patient as soon as possible to address the patient’s concerns.
• When meeting to discuss a patient complaint, active listening helps the patient feel respected. Practice active listening by avoiding distractions, establishing eye contact with the patient and adding comments that elicit additional information.
• Demonstrate comprehension by paraphrasing concerns in your own words. Restate what you understand the patient’s complaint to be. Avoid the tendency to include evaluations of what the patient is telling you.
• Provide education. Help patients understand the scope and feasible outcomes with educational tools such as pamphlets, models and other resources.
• Carefully document all the patient’s concerns and how they were addressed. TDIC recognizes that when faced with an unhappy patient, these conversations can be difficult and often come down to thoughtful and considerate responses that avoid escalation of the matter. TDIC’s current online seminar offers policyholders the opportunity to enhance communication and documentation skills to assist dentists with these difficult conversations.

Take time to review the patient’s case thoroughly before offering resolutions to the complaint. If necessary, explain to the patient that you need time to review and give a specific timeframe when you will be prepared to address their concern (for example, 48 hours).

Fortunately, most patients will be thrilled by their new smile and the likelihood of a dissatisfied patient can be mitigated through considerate patient selection, detailed treatment plans and documentation. When complaints do arise, take time to listen and respectfully consider the patient’s concerns. TDIC’s Risk Management analysts are available to help through the Risk Management Advice Line and can provide resources and suggestions on how to best resolve patient complaints.

TDIC’s Risk Management Advice Line is a benefit to TDIC policyholders. To schedule a consultation with an experienced risk management analyst, visit tdicinsurance.com/RMconsult or call 1.877.269.8844.