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 other- wise might have been. He may also have been concerned he might make Dr. Y look neglect- ful if he was too strong in his recommenda- tions. 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 also have been appropriate to memo- rialize 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 admon- ishment 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 some- times 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 obvi- ous. The dentist simply cannot perform an adequate examination without using imag- ing and instrumentation. These tools not only allow for an accurate assessment of the patient’s current condition, but also they pro- vide valuable documentation of the patient’s


• Recognize a chronically, volitionally nonadherent patient not only repre- sents 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 experi- ence in dealing with these types of situations and can be a valuable resource.


The ADA has a new tool to help you communicate with patients, “Dental Communication: Letters, Templates and Forms.” One of the chapters specifically covers “Treatment Letters”, including Consequences of Delayed Treatment, among others. Learn more/order at bit.ly/3t3Gjt1. Save 10 percent with promo code 21010B.


course if it needs to be reconstructed for subsequent legal or investigative purposes.


In the end, this patient’s suboptimal outcome likely could have been avoided; it certainly contributed to the large settlement.


SUMMARY SUGGESTIONS


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 profes- sional judgment.


• Communication is the basis of all human relationships, and healthcare provider-patient relationships are no ex- ception. 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 com- municated to and recommended for the patient.


• Use of a refusal of care form can some- times nudge the patient in the direction of care that is truly needed.


CONCLUSION


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 still must be maintained. Failure to do so disserves the patient, the dentist and the profession.


Your MedPro patient safety and risk consul- tant can provide you with a refusal of care form template. Call or email MedPro at 800- 463-3776 to obtain a copy. f


As the nation’s leading dental malpractice insurance carrier, MedPro Group has unparalleled success in defending malpractice claims and providing patient safety & risk solutions. MedPro, the endorsed malpractice provide of MDA, is the nation’s highest-rated malpractice carrier, rated A++ by A.M. Best. The Berkshire Hathaway business has been defending dentists’ assets and reputations since 1899 and will continue to for years to come.


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.


MedPro Group is the marketing name used to refer to the insurance operations of The Medical Protective Company, Princeton Insurance Company, PLICO, Inc. and MedPro RRG Risk Retention Group. All insurance products are underwritten and administered by these and other Berkshire Hathaway affiliates, including National Fire & Marine Insurance Company. Product availability is based upon business and/or regulatory approval and/or may differ among companies. © 2020 MedPro Group Inc. All rights reserved.


ISSUE 2 | MAR/APR 2021 | focus 19


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