Patient Selection: An Important Risk Management Tool

Of the hundreds of professional liability claims The Dentists Insurance Company addresses annually, many could have been avoided or mitigated had the dentist been more cautious about choosing which patients to accept into care.

“Prevention is the best strategy to avoid risk,” said Taiba Solaiman, TDIC senior risk management analyst. “Being selective in the patients you see goes a long way in avoiding trouble down the road.”

New Patients

Dentists are not obligated to accept all patients into their practice (barring discrimination). Those you do select to make up your patient base should be those with whom you can form productive, healthy doctor-patient relationships.

Some signs to look out for when meeting a new patient include the following:

• Patients who arrive for the initial exam complaining about the past several dentists they’ve seen, especially if it’s within a short time frame. This may indicate the patient is hard to please, so there’s a high likelihood they won’t be satisfied with your treatment either.
• Patients who attempt to dictate treatment or who do not follow treatment recommendations. Patients cannot consent to negligent treatment. You are required to follow the standard of care and failing to do so can set you up for a liability claim.
• Patients who refuse to disclose the name of their former dentists. For continuity of care purposes, it is standard practice to contact previous dentists for dental history. Treating patients without knowing their complete dental history can put you at risk. Investigation into the patient’s treatment history can provide invaluable insights on the patient you are considering accepting into your practice.

Emergency Patients

For patients who present for emergency treatment, it is recommended to discuss the limited scope of the relationship prior to treatment. The patient should understand that you are not establishing a doctor-patient relationship beyond their emergency care. The ethical standard for emergency services for patients who are not patients of record is to make “reasonable arrangements for their emergency care,” according to the ADA Principles of Ethics and Code of Professional Conduct. To facilitate meeting this standard, consider maintaining a list of phone numbers of clinics and dental societies to provide to the emergency patients without an established dental provider.

After the completion of emergency care, document the treatment and refer the patient back to his or her established dentist. If you decide to keep the patient, understand that there is a duty to provide care until one of the parties officially terminates the relationship.

Second-Opinion Patients

Patients often present to dental offices seeking a second opinion on recommended treatment from another dentist. Some patients simply want to compare prices. Some want to confirm that a treatment is truly needed. Others may be trying to build a case against another dentist. If you are unsure about a patient’s motives, it is acceptable to ask questions. For every patient who presents for a second opinion, raise questions such as:

• What brings you here today?
• How did you choose my office?
• Are you currently under the care of another dentist?
• When was your last dental visit?
• Why are you seeking a second opinion?

If a patient refuses to answer these questions, consider carefully whether you want to accept this patient into your practice. Avoiding these questions can be a red flag. Let the patient know that refusing to answer these simple questions prevents you from providing a thorough assessment and suggest that they seek a second opinion elsewhere.

If you choose to proceed with the exam and notice questionable dentistry, consider that the patient could have omitted facts or withheld important information. Refrain from making commentary or making disparaging comments. Let the patient know that it is difficult to make an accurate assessment based on limited information.

When providing an assessment related to care previously provided by another dentist, Solaiman said only state the facts and refrain from making subjective comments.

Noncompliant Patients

Dentists have a right to refuse to treat noncompliant patients. If you allow patients to remain in your practice despite their failure to follow a recommended treatment plan, you could be at risk for allegations of supervised neglect. You are responsible to provide dentistry within the standard of care and a patient’s refusal of a specific treatment, such as refusing to have diagnostic radiographs taken, does not allow a dentist to practice below the standard of care. Depending on the circumstances, dentists should be aware of continuing treatment when the patient’s refusal jeopardizes the possibility for a successful outcome or the patient’s health, in which case terminating care may be the only reasonable option. Occasionally, some dismissed patients may want to return to your practice; however, it is not advisable to accept them back.

“Old habits can be hard to break and it is not worth exposing yourself to the same liability risks that caused dismissal in the first place,” Solaiman said. Rather, refer them to a local dental society or their insurance company so they can access a provider directory.

Patient Dismissal

When circumstances dictate a dismissal is necessary, you must first thoughtfully consider potential risk and act in accordance with ethical standards of treatment. In addition to state laws and any Dental Practice Act requirements, ADA’s Code of Ethics can guide your decision. Your local dental association should offer guidance on the laws regarding treatment within your state.

Some common and acceptable indicators that a dentist may need to consider dismissing a patient from care are:

• The patient is noncompliant with treatment recommendations or attempts to dictate treatment.
• The patient tries to take dental care into their own hands through actions such as attempting to adjust a prosthesis or orthodontic appliance.
• The patient has not been in for an extended amount of time and/or regularly misses scheduled appointment. Consider dismissal if the patient has not been seen in 24 months. You can use the Failed Appointment Sample Form to notify a patient they are in jeopardy of dismissal.
• The patient demonstrates abrasive behavior or makes inappropriate comments to the dental team or other patients. In such cases, practice owners must intervene. As employers, they are obligated to provide a safe working environment for their staff and patients, one in which no one is fearful for their own safety.

TDIC policyholders have access to specialized expertise through the Risk Management Advice Line. Analysts will guide you through the process of dismissal to make sure all appropriate actions are taken to ensure an ethical dismissal, including advice on patients mid-treatment and providing sample dismissal letters.

Treating Friends and Relatives

Dentists often want to help friends or relatives by providing affordable dental care. Occasionally, dentists feel obligated to take on these patients despite their better judgement. Uncomfortable scenarios can turn into high-risk scenarios, so keep in mind that you have the same responsibilities regarding documentation, care and treatment of friends and family members as you would with any other patient.

Patient and case selection is an essential component of a dental practice. While it can be difficult to walk away from a perceived financial gain for the practice, the end result could be more costly than the anticipated benefit. Trust your instincts and have the courage to walk away from a patient or treatment plan that makes you uncomfortable.

If you find yourself facing an uncomfortable or uncertain situation, contact TDIC’s Risk Management Advice Line.

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.