A Dismissal Case Study

his hand on his head and inexplicably mumbling to himself the words “larger restroom.” The patient then proceeded to share with the staff that he had taken a pill for anxiety in the office parking lot shortly before checkin. Staff alerted the periodontist of this situation.

The call: The office manager of a periodontal office contacted the Advice Line to discuss whether they had enough grounds to dismiss a new patient. Rather than being referred by their general dentist, the patient in question found the specialist on the web and presented for a consultation regarding periodontal issues.

After conducting a complete examination, the periodontist diagnosed mild to moderate periodontal disease and recommended scaling and root planing on all four quadrants.

The patient initially scheduled an appointment to begin treatment. However, in the next few months, he repeatedly canceled and rescheduled his appointments. When the office was finally able to reach the patient by phone, he expressed that he had other dental concerns and that he was seeking care at a general dentist’s office.

Months later, the patient finally appeared at the periodontal office for an appointment. After checking in, he asked if he could use the restroom. On his way out of the restroom, staff noticed that the patient was banging continued on page 4 continued from page 3

During his discussion with the dentist, the patient shared that he was taking prescription anti-anxiety medications, but he did not share which medications had been prescribed or the dosage. The periodontist noticed the patient’s cognitive abilities appeared significantly affected as he mumbled with slurred speech. Given the patient’s altered state, the dentist informed the patient that they would be postponing treatment.

The patient became upset with this change of plans and proceeded to grab his keys and attempted to leave the office. The office staff tried explaining the reason for postponing treatment, but the patient refused to listen, becoming combative and using profanity. The office staff reached out to the patient’s mother, who was listed as his emergency contact on his medical history form. The patient’s mother asked the office staff to prevent the patient from leaving and to not provide any treatment, stating she would come pick him up. The patient's mother also requested that the office cancel any upcoming appointments for her son.

A few days following this incident, the patient called the office demanding to know why he was not treated. The patient had no recollection of the events that occurred during his previous visit.

The advice: The Risk Management analyst commended the office for withholding treatment and taking the appropriate steps to ensure patient safety, considering the patient’s altered state. The analyst advised the periodontist to consider patient

Know When It's Time to Consider Dismissal

Unsure whether to pursue dismissal?

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 fails to pay for services rendered.

• The patient tries to take dental care into their own hands through actions such as trying to self-adjust a prosthesis or orthodontic appliance.

• The patient has not been in for an extended amount of time. Consider dismissal if the patient has not been seen in 24 months (about two years).

• The patient is disruptive to your practice, such as constantly being late for appointments or causing conflicts with other patients.

• The patient exhibits abusive or threatening behavior to any member of the dental team or other patients. You have a duty to protect the safety of everyone in your practice.

Patients may not be dismissed or discriminated against based on limited dismissal. Even though the patient was still receiving treatment, there were adequate grounds for dismissal due to the patient’s erratic behavior and escalating abrasive treatment of staff members. The periodontist was reminded to fully document interactions and communication in the patient’s file. The analyst also guided the dentist in composing a letter to the patient providing a 30-day notice of dismissal, which allowed reasonable time for the patient to find a new periodontist.

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Preparing for Dismissal

Most dismissal cases should not be rushed. The exception is when the patient in question is a safety threat. You have a duty to protect the wellbeing of everyone in your practice. Carefully document the occurrence prior to proceeding with the dismissal.

Otherwise, before taking action to dismiss a patient from your practice, you should make well-documented attempts to communicate concerns to the patient about potential consequences of their behavior. Try to learn and understand why the patient is not complying with treatment or paying bills and address any underlying issues that may be contributing to their behavior. For example, if a patient is noncompliant due to fear or anxiety, you may be able to address their concerns and help them feel more comfortable with treatment. In other cases, patients may be going through a difficult time in their lives that is affecting their behavior, and they may benefit from additional support and understanding.

If, after your attempts to communicate and address the issue, the problematic behavior continues, follow the proper steps of dismissal. When dismissing a patient, provide a formal written notice stating that you are withdrawing care and requiring the patient to find another provider. They should allow a reasonable amount of time for the patient to find another dentist (30, 60, or 90 days). Additionally, give two viable referrals, such as the local dental society, local dental schools or a managed care plan. Mail the confidential written notice to the patient by both first-class and certified mail with a return receipt requested. Risk Management analysts can provide guidance on the dismissal process and letters along with resources to protect dentists before finalizing the separation.

Special Consideration: Orthodontic Patients

Exclusive consideration must be given to cases involving patients undergoing treatment such as orthodontics. In situations where patients elect to discontinue treatment and establish care elsewhere or there is a behavioral problem with a patient midtreatment, automatic dismissal is not recommended. Allowing the patient to remain in appliances without ensuring the patient will be monitored could expose you to accusations of patient abandonment or other liability risks. Furthermore, there is increased potential for the patient to experience relapse, broken brackets, loose wires, decay, decalcification, etc. If the patient dismisses themselves or if the dismissal is a last resort due to nonpayment or other concerns, offer to remove the appliances and provide retainers to maintain existing tooth positions and any orthodontic tooth movement achieved, if appropriate.

No two cases are the same when it comes to patient dismissals. There is a reason they are the most frequently cited cause of calls to TDIC’s Advice Line. Since dismissals can be fraught with safety and ethical considerations, make sure to lean on the expert advice of a Risk Management analyst before initiating a patient dismissal.