Chairside with Derick Tagawa, DDS, FACD
OP: What is your definition of a difficult patient?
Tagawa: When I say difficult patient, I also include parents of patients. In fact, most of the difficult people in my practice are parents, not patients. My definition of a difficult patient is someone who is challenging to manage (as opposed to difficult to treat) for clinical, administrative, and/or interpersonal reasons. These patients may or may not complete their treatment on time, and the treatment results are often compromised or not up to expectations. Generally, difficult patients require more practice resources (such as doctor and staff time, and emotional energy) than all other patients combined.
OP: What percentage of your and your staff’s time do these patients take up?
Tagawa: It feels like the 2%–3% of my patients who fall in the “difficult” category take about 20% of my practice’s time and other resources. As much extra time as these cases can take, I insist that myself and my entire team do what it takes to see that the patient gets the best possible treatment and service.
OP: How do you interact differently with a difficult patient?
Tagawa: Taking a deep breath, taking a moment away from the pressures of a busy schedule, visualizing a great interaction for this meeting, and counting to 10 before seeing the patient are all ways I interact differently with difficult patients even before I see them. Active listening and paraphrasing are powerful tools that help me deal with difficult patients. I admit that I am not so skilled in the use of these tools that I can do my best without practicing these skills through role-playing.
Treatment time is the most common ongoing patient concern during the course of orthodontic treatment. Giving a realistic treatment-time estimate is a good way to address this concern at the start of treatment. At the first treatment appointment, my staff calculates the “estimated deband date” and writes it at the top of the chart. From that point on, whenever patients ask when their treatment will be finished, all staff and doctors show the patient this area of the chart.
Depending on the progress of treatment, the “estimated deband date” may be revised. Sometimes, treatment time is revised downward. Most revisions, however, are made in an upward direction. In general, the sooner in treatment that these revisions are made, the less patient disappointment is created.
I rate treatment progress at every routine appointment, and if there is any change in the estimated completion date, a conference is either held or scheduled. Instances of missed appointments, lack of elastic or headgear wear, or poor oral hygiene are related to an increase in the estimated treatment time by revising the chart right in front of the patient. This is done with an understanding (not punitive) attitude.
A key to keeping patients happy during treatment that is taking longer than anticipated is to give them choices. This makes them “stakeholders” in their treatment, not “bystanders.” Common choices given to patients are:
1) stay with the original treatment plan, but commit to compliance;
2) change the treatment plan to use noncompliance devices (such as a fixed Class II corrector spring);
3) change the treatment plan to extract teeth in nonextraction cases when appropriate;
4) discontinue treatment, enter retention, and face the possibility of retreatment in the future.
It is critical that the risks, benefits, and alternatives of treatment be thoroughly discussed with the patient and documented on the chart. It helps me a lot in the long run to acknowledge with difficult patients that our relationship hasn’t been the best, or that we haven’t seen eye to eye about solutions to various issues. I also state that my intent is never to create negative relationships, but that I cannot be all things to all people. For risk-management purposes, this conversation is documented.
OP: How do you approach ending treatment?
Tagawa: By the time I feel compelled to ask a patient to leave my practice, I have exhausted every means I (and my staff) can think of to resolve any issues, complaints, or problems in treatment. If possible and appropriate, I prefer a face-to-face meeting. In this meeting, I acknowledge that the doctor-patient relationship has deteriorated to the point that a change in orthodontists is required. I state that this change is in the best interests of both the patient and myself. I then describe the treatment results to date and the treatment that remains to be done, and recommend the steps I think should be taken to complete the treatment. I then bid the patient farewell and good luck. It makes it easier that this conference is generally short, unemotional, and to the point.
My office manager handles the details of the transfer of records, prorates the account, and issues a refund check if needed. The chart is carefully documented, and a letter of dismissal from the practice is mailed to the patient by certified mail, return requested, and via first-class mail. The letter details in writing what was said in the dismissal conference. The format of this letter contains all of the items recommended by our malpractice insurance carrier.
Derick Tagawa, DDS, FACD, has a private practice in Brea, Calif. He can be reached at [email protected].