Dealing with dissatisfied patients can be difficult. But ensuring your patient has good care and that you've properly documented that care is essential.

Posted in Dental Insights on Tuesday, May 2, 2017

From Dental Insights, Summer 2017

Joe Smith was a retired construction worker in his mid-60s. He had a sporadic dental history and had been treated by a number of local general dentists in the past 10 years. The work consisted of cleanings and some crown and bridgework.

Years before, Joe had lost a front upper tooth, number 8, and had a traditional three-unit bridge to replace the missing tooth. The bridge was now failing, so Joe went to see general dentist Samuel Wilson, DDS, at the urging of his daughter. The daughter was getting married later that year, and she wanted the dental work done before her wedding.

Dr. Wilson had placed implants for many years with good success. He had extensive education and training in implant placement.

Joe’s daughter went along to the first consultation and evaluation appointment in December. Dr. Wilson believed he could replace the existing bridge with a single implant and two separate traditional, individual crowns, all to be completed in time for the wedding. When finances were discussed, it became clear that Joe’s daughter was the decision maker and likely the one paying the bill.

Joe (and his daughter) agreed to have Dr. Wilson do the work, and the case was planned, oral consent was obtained and preparations were made. Before beginning the work, Dr. Wilson performed a cleaning on Joe’s teeth. Documentation of these cleaning services was scant.

The implant was placed in January, and the adjacent traditional crowns were prepared and placed permanently.  Everything appeared to be on track for a successful implant placement and restoration. The implant seemed to be integrating well, and a temporary implant crown was placed. However, starting in February, notes in the chart by the staff stated, “patient is crabby,” and he had asked, “Why is it taking so long to get my (permanent implant) crown?”

Joe would leave the appointment seeming to be satisfied with the coloring, shade, overall fit, and occlusion of the dental work only to call the next day to complain about pain or poor aesthetics. His concerns were primarily related to the temporary implant crown, which was supposed to be similar in shade and shape to the permanent that would be later placed.

Sometime in late February, Joe was eating a steak dinner when the temporary implant crown came out. Joe came in for an emergency visit to recement it. He mentioned he gagged and almost swallowed the temporary implant crown. His daughter, who was at dinner with him, was upset because she did not want something like this to happen at her wedding. Around this time, there were some discussions of evaluating tooth 7 for a restoration to better match the proposed permanent implant crown at 8.

In May, Joe called to say he was having a “problem” with the implant. He came in for an appointment, and Dr. Wilson’s notes state that it appeared the implant was “failing.” Joe and Dr. Wilson apparently, according to Dr. Wilson’s notes, discussed making the permanent implant crown shorter and “redoing” the implant in June. The notes show that Joe then got a new temporary implant crown and there is no indication the implant itself was removed or replaced. The daughter’s wedding was in July, and there were no reported dental issues. (Joe was in the temporary implant crown for the wedding.) In August, the permanent implant crown was placed. Everything looked good and Joe was noted to be “satisfied.” A week later, in mid-August, the permanent implant crown fell off and was recemented.

Joe never returned to Dr. Wilson. About six months later, in January, Joe called to ask for his records. Dr. Wilson’s staff sent him follow-up messages to ask him to return for a follow-up or to let them know why he was unhappy.

When Joe finally spoke with the office receptionist later in February, he told her, “I want my stuff back—I paid for it.” The receptionist advised Joe to sign a release form and provide the name of his new dentist. Joe told them that he “wanted all my stuff,” and his daughter would pick it up. He also indicated that he was in pain, but he did not elaborate before hanging up on the staff. The records and forms were gathered and prepared. Another staff person advised Joe that there would be fees for the copying of the materials.

At the end of February, Joe’s daughter stopped by the office. She was unfriendly to the front desk staff and commented about having to pay a fee for records when Joe had already paid for the dental care. Joe called the office again and spoke to another front office person to complain that he had not received all of his records, including all of the billing information and the lab slips. When the office staff realized they had not provided complete records, they resent the additional information. Joe then filed a disciplinary board complaint, a malpractice claim pro se (without a lawyer) and a Better Business Bureau complaint.

Dr. Wilson called his professional liability carrier, and counsel was assigned. Regarding the disciplinary matter, the licensing authority requested the patient’s records and scheduled an informal conference. Dr. Wilson had to answer questions about the dental care he provided, explain his qualifications and experience, defend the quality of his work, and respond to questions about his office’s billing and recordkeeping practices.

After the informal conference, the disciplinary board chose not to proceed with formal action against Dr. Wilson. However, he was verbally admonished for:

• Poor office practices
• Failure to properly respond to patient complaints
• Lack of follow-up about Joe’s complaints
• Delegating his patient’s ongoing issues to his lower-level (front desk) staff

The Better Business Bureau complaint required a written response to the charges. Dr. Wilson also had to attend a conference that addressed the patient’s complaints about response time.

The civil suit eventually was dismissed because Joe was unable to find a dentist who would substantiate his negligence claims. However, that matter was only resolved seven months later, after several motions to dismiss and the court’s leniency because Joe did not have a lawyer.

What Can We Learn?

Regardless of whether Dr. Wilson’s dental care was appropriate, he could have better recognized the patient’s issues in the early stages. Dr. Wilson’s records could have more effectively conveyed that Joe was hard to satisfy from the beginning. His notes could have been more detailed in describing Joe’s complaints and what was done to address them.

If Dr. Wilson would have consulted with Joe early on, he might have quelled Joe’s displeasure with the progress of his care. Joe’s daughter seemed to be a driving force here, as well. An attempt to talk to the daughter, with Joe’s written permission, may have deterred her from whispering in Joe’s ear. Family members who foot the bill can give rise to conflicting concerns. Any resulting miscommunication creates a likelihood of further actions, as well as HIPAA related problems.

Dr. Wilson’s delegation of Joe’s problems to his lower-level staff complicated the case and created more problems. The fact that Joe was upset should have raised a red flag before he requested his records. If Dr. Wilson or a trusted staff member would have approached Joe and/or the daughter and given them prompt and full access to the records without a fee, it might have calmed the anger levied against Dr. Wilson and the practice. Nonetheless it behooves   practicing dentists to familiarize themselves with their respective dental practice act regarding charging for forwarding dental records. Guidance is often provided as to what can be charged for, which specific expenses are appropriate, and how to quantify the charges.

Additionally, had the records described in detail what Joe said or did (versus describing him as “crabby”), Joe and his daughter may have perceived Dr. Wilson’s care and responsiveness in a better light. Instead these comments, along with the scant and sometimes confusing documentation of the work performed, likely planted the seeds of discontent with Joe and his daughter. Not receiving a complete set of records only served to worsen the problem.

While this matter was resolved positively for Dr. Wilson, it caused a great deal of stress and frustration for him and his staff. Luckily, the case involved only a single implant failure and was likely defensible on the dental care. However, had this been a case with multiple implant failures and a large financial commitment, the matter might not been have resolved as positively.

A prudent practitioner must spend more time on the consultation description, the informed consent process, and the thorough and objective documentation of the preparations and procedures. The dentist must also try to resolve issues with dissatisfied patients.

This case study was written by Linda Hay, J.D. All names used in Dental Insights case studies are fictitious to protect the privacy of the dentist and the patient.

Linda J. Hay is a partner in the Chicago office of HeplerBroom, LLC. Ms. Hay has practiced in the professional liability defense arena for more than 25 years and has tried numerous cases to verdict. She is actively involved in a variety of defense bar, professional liability and risk management organizations. Ms. Hay can be reached at Linda.Hay@heplerbroom.com.