You Lost Me at Hello. Red Flags.

With 26 years of practice under my belt, one of the most valuable lessons I’ve learned is when to NOT treat a patient.  Just ten days ago, I blogged about a very nice new patient:  You Had Me at Hello.  With a more recent patient, it was “You lost me at hello.”   Sort of.  It was really at “good bye.”

As a group, dentists tend to take on all comers.  We want to treat everyone… probably for a couple of reasons.  First, many of us want everyone to like us.  Everyone should like me, right?  Just ask my mom!  Who wouldn’t like you?  Well, as we get older, we learn not everyone will like us.  Even better, as we get older, we learn not to care that not everyone will like us.

Secondly, I submit that most dentists will take on all comers, because he or she simply wants the income.  If we’re honest, we are all driven by the desire to make money.  Nothing wrong with that….  Who works for free?  But, when that desire supersedes all other factors, we can get into trouble.

Listen to that little voice!

I’ve only been “sued” once.  It never went to court.  It was settled by my insurance company.  The dental issue isn’t really relevant (though it was minor).  What IS relevant is that I KNEW I shouldn’t have treated the patient.  I KNEW IT!  I actually dismissed her before beginning treatment because of the red flags she was waving in my face.  She had already written a (big) check for the treatment plan in full, and I sent it back to her.  But, then she came back, crying and begging me to treat her.  She went on about how I was “the best,” and that she only wanted ME to treat her.  And, I caved.  Big mistake.  Lesson learned.

The dissatisfied patient.

A few weeks ago, I met a new patient who was in distress after her experience at a “McDentist” corporate office.  She had a 3-unit bridge prepped and temped.  The teeth were hurting her and her jaw was sore.  She wasn’t happy, and she was adamant about not going back to that office.  She reported a history of TMD issues.  I referred her to an endodontist for evaluation and we made her an NTI to deprogram her spastic muscles (she specifically requested the NTI, as she had one previously).

She presented with teeth #’s 10 – 16 missing on the upper left side.  She also missing #’s 2 and 4 on the upper right.  There was a temp bridge #3 – 5.  She has moderate localized periodontal disease in the lower anterior sextant.

Flags be a-wavin’!

Today, she came back for a comprehensive examination.  She began by standing up out of the chair (red flag) to tell me about how she disagrees with the endodontist’s recommendation to do root canal therapy on one of the teeth.  She then said, “I want you to do the bridge, then we’ll do implants over here…and then…”

I invited her to take a seat in the chair.  She then told me the temporary bridge was out (and at home).  So, teeth #s 3 and 5 were exposed preps.  She explained that she wants to get her work done right away.  She wants a bridge put on those teeth as soon as possible, and she reiterated her disagreement with the endodontist (red flag).  I had not yet received a report from the endodontist.  I explained that if a tooth has been diagnosed as needing root canal therapy, I wouldn’t want to put a bridge on it before the RCT.  She looked at me with a facial expression of contempt and said, “I can disagree with the endodontist.”

I replied, “Yes, you can.  But, I have to be able to defend my treatment decisions.  Since I haven’t heard from him, yet, let me find out more before we make any decisions.”

“So, you have a problem putting a bridge there?” 

No.  I’m not saying that.  I just don’t know, yet.   I need more information.  Would you like to continue with our examination?

“I’m not sure.  If you’re not going to do the bridge…”  (red flag)

Again, I don’t know, yet.  Why don’t we gather all the information and then we can come up with our plan?

“OK.”

Phew!  So, we do our exam… charting…. perio probing… oral cancer screening…. TMJ screening….

She has a hard time opening and closing.  Open and closing is very uncoordinated.  Her muscles are all over the place.  Palpation of the joints and muscles shows they are tender.  She tells me that she hasn’t been wearing the NTI.

I sit her up to go over my findings.  I explain that we can make a new temporary to get the exposed / prepped teeth covered up and comfortable.  I’ll call the endodontist to get his diagnosis on #3.  Then I explain that we should start with mounted models and bite records, since we’d be rebuilding her bite.  Again, I get the, “Are you crazy?” look (flag).  Furthermore, I recommend that she see my colleague who focuses on treating TMD issues.  He’s very knowledgeable and my “go to” guy.   We need to sort out her TMD issues before we rebuild her occlusion.  I also mention getting an MRI.  I get the stink eye again (flag).

She even says, “I don’t think we’re seeing eye-to-eye (flag).”

I agreed, “Apparently not.  But, this is what I would do if you were my sister.”

In the end, she asked for my TMD guy’s card.  I am betting I’ll never hear from her again.  And, if I do, I’m referring the case to a prosthodontist.  Too many flags.

In discussion with my team, they also agreed that there are too many flags.

I’ve learned to trust my instincts.  I’ve also learned to listen to my team.  They know!  If your team is telling you there is danger ahead, you should listen to them, even if you’re not seeing it.  The patient who is dissatisfied by the last dentist, is likely predisposed to feel the same way about you.

To everything… turn, turn, turn.

I like to make money.  I need to make money.  Don’t we all?  This could be a great case.  But, it needs to be done right.  I also need to retain my sanity, stomach lining, and heart muscle.  It’s just not worth it.  I’ve got too many nice, appreciative, trusting patients to deal with those with unreasonable expectations.  Whenever a patient pushes you into treatment and your little voice is telling you, “slow down,” you should pause for the cause.  If the patient won’t listen and doesn’t appreciate your concern and measured approach, it’s time to move on.

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