Over many years of practice, I have encountered numerous patients who were difficult to treat. I probably could label them "problem patients." Early in my prosthodontic career, it was difficult to identify this type of patient, or to know what to do with them when I unknowingly had accepted them into the practice. I often accepted problem patients, only to suffer both psychological distress and clinical failure.
With time, identifying these patients became less daunting. However, it has taken many years of practice to achieve relative competency in treating them or in finding someone else to treat them. Early identification of problem patients is essential, and an organized plan of dealing with such patients is necessary.
This article describes several identifiable characteristics of problem patients and discusses ways to treat these patients with minimum disruption to your practice.
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IDENTIFIABLE CHARACTERISTICS OF PROBLEM PATIENTS
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History of treatment by many practitioners.
These patients may have sought treatment from numerous dentists, physicians or dental specialists. Some patients bring with them several dentures or occlusal splints. They may have a history of repeated retreatment of crowns or veneers. If an adequate health history and a history of health practitioners previously visited are not obtained, unsuspecting practitioners can be misled by these problem patients.
Negative attitudes toward previous practitioners.
On accomplishing a thorough examination, the dentist may find that the patient’s mouth testifies to relatively good treatment by a previous practitioner, but the patient continues to complain that the previous treatment was poor. The patient complains of the previous dentist’s various negative characteristics, but he or she may make you feel that maybe you can satisfy the often ambiguous clinical challenges.
Pushy and irritable personality.
Some patients mistakenly feel that the more demanding they are, the better care they will receive. As you know, the reverse is true. Often, you may be influenced to do your best to satisfy their demands, but their demands may not be in their best interest. This characteristic is identifiable early in the patient encounter. Rather than allowing yourself to become irritated, you should take a deep breath and listen to the patient’s complaints. If the demands become more unrealistic, the possibility of a satisfactory patient-doctor relationship diminishes, and the need for other plans for treating the patient becomes evident.
The patient is rude to the staff, but calm and respectful with the doctor.
Your team should be advised to inform you of a problematic personality before you spend time with the patient. Most staff members can tell if the patient is going to be difficult to treat after only a few minutes with them. If relations with the staff member become tense, it is likely that the same negative attitudes will develop with the dentist.
History of legal activity.
You need to have a question on your new-patient questionnaire about the patient’s past legal activity. Unless the patient is overtly dishonest, he or she will report if there has been a past legal encounter with other health practitioners. I have treated many of these in my career. One person had sued 23 other practitioners, including me. Early in my career, I was naive enough to think I could solve this patient’s oral problems. I was wrong. It is well to identify these patients early on in treatment. The major challenge is determining what to do with them.
Apparent clinical knowledge beyond the normal.
Some patients are quite knowledgeable of dental terms and techniques. This knowledge can be an advantage or can become a genuine problem. I have treated patients who appeared to know as much about dental materials and techniques as do most dentists, or who at least expressed themselves in a knowledgeable manner. It is good to be careful with these people, since they may have extraordinary dental knowledge because of an obsession with or abnormal interest in their dental problems.
Health history is mostly negative.
If the patient’s health history reveals chronic, negative problems, this may indicate that the patient is difficult to treat or has a difficult personality. It is highly likely that you are destined to become another practitioner with whom the patient will become dissatisfied. Make sure you discuss the patient’s questionnaire responses with him or her to legitimize and understand the case before considering treatment.
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TREATING THE APPARENT PROBLEM PATIENT
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Identifying the potential problem patient is not as difficult as deciding how to treat him or her. What should be done with a patient who fits the previously described characteristics?
The diagnostic appointment.
This type of patient should receive more conversation time in the diagnostic appointment than would a normal patient. The dentist or staff member interviewing the patient should thoroughly discuss with the patient as many of the described negative characteristics as time will permit. The patient should be allowed to express himself or herself about the matters of concern. By taking this additional time, the dentist is able to assess the patient’s problems more accurately and to make a decision concerning the patient’s treatment. Rather than jump into treatment too soon, practitioners are wise to spend extra time at the diagnostic appointment, because it can help alleviate future problems. The psychological needs of this type of patient may be far more demanding and potentially threatening than the clinical needs.
Contact previous practitioners who have treated the patient.
After having treated more of these types of patients than I like to admit, I can testify that simple five-minute phone calls to previous practitioners are an excellent investment of time. You may find that the patient’s apparent problem was really the previous dentist’s problem, and that you should not anticipate a psychological challenge. On the other hand, you may find that the patient truly is a problem patient. Recently, I had an unfortunate encounter with a patient who had been treated by several excellent, nationally renowned practitioners. After phone calls to these dentists, I discovered an upsetting fact: the patient in question had several court restraining orders as a result of her threatening activities with dentists. Previous dentists actually had called the local police, as I did, to assist in restraining the patient and removing her from their offices. Although this is an extreme case, it demonstrates the desirability of contacting former practitioners.
Educate the patient about all aspects of the treatment.
If these patients understand the procedures to be accomplished, there is less likelihood there will be confrontations at a later time. I suggest using slides, models, pictures, casts, books, an intraoral TV camera and any other educational mode available in your practice to upgrade patient education.
Make sure you obtain written acknowledgment of informed consent.
Be certain that you have explained thoroughly the procedures you are planning and any potential complications that may arise. Then obtain written acknowledgment of informed consent from the suspected problem patient. This practice, which requires only a few minutes, may be highly important if future challenges occur with the patient.
Be realistic with the patient.
Tell this patient exactly what to expect. Educate the patient or her so that he or she has realistic expectations. Do not let him or her visualize a treatment result that is not achievable.
Accomplish a simple clinical task on the patient to test your suspicions.
Seating a temporary removable partial denture, or flipper, in our office usually requires about five or 10 minutes. While treating a problem patient recently, a very competent dental assistant and I spent almost three hours seating the temporary partial denture. At the conclusion of this arduous appointment, I had a candid conversation with the patient. During this discussion, I told this problem patient that our personalities were quite different, and I thought that some other colleagues would have a better chance of satisfying her needs. I referred her to three other practitioners.
Make a record of every aspect of the procedures accomplished.
If challenges occur at a later time, complete record-keeping will be important. Educate your dental hygienists and dental assistants to keep thorough records with every patient.
Accomplish only enough therapy to relieve patient pain.
This concept allows you to satisfy your professional responsibility but does not get you involved with complicated procedures, which almost certainly become a headache with these problem patients.
Refer to other practitioners any procedure with which you feel uncomfortable.
Patients who may be problem patients are not subjects on whom you should attempt procedures you are just learning. Refer them to someone who has more experience than you do.
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MAKING CORRECT DECISIONS ABOUT TREATING THE POTENTIAL PROBLEM PATIENT
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It has been my experience that at any one time in a typical practice, there are at least a few problem patients. Some of them turn out to be relatively normal, while others are almost untreatable. We are in a health profession, and we have an obligation to provide services to all. Someone must treat these people. If all of us referred every potential problem patient, they would not receive treatment. I feel that it is our responsibility to attempt to blend these patients into our practices and make them into acceptable patients, but I realize that this task is almost impossible with some.
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SUMMARY
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Problem patients exist in all dental practices. In this article, I have described methods of identifying these people and assisting them in becoming acceptable patients. I also have made suggestions to reduce the inconveniences encountered when treating problem patients.
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IDENTIFIABLE CHARACTERISTICS OF...
TREATING THE APPARENT PROBLEM...
