Jim was referred to you by an oral surgeon with whom you have had little previous experience. Jim’s law firm is in your building, so treatment will be as convenient for him as a walk up a few flights of stairs. He had undergone full bonded nonextraction therapy during law school but has always objected to his facial convexity and lip incompetence. The surgeon has recommended bimaxillary surgery, and insurance predetermination for the procedures is pending. Since Jim expects to marry within the year, he and his fiancée are eager to initiate orthodontic preparation for the surgery.

Clinical evaluation reveals slightly crowded arches with lack of incisor contact. You estimate that less than 6 months of preparation will be necessary to ready him for surgery. Although you recommend that he await confirmation of insurance coverage for the surgical procedures before you start orthodontic therapy, Jim insists that you begin your treatment immediately given the time constraint from the upcoming wedding. “Besides,” he adds, “ the surgeon told me that there is a 99% chance that the insurance company will approve the procedures, and he said he’d support me if there is any problem with that.” Jim is delighted as you bracket both arches and begin leveling them. He even takes advantage of your office’s pretreatment payment plan to receive a fee reduction.

As you enter the operatory at Jim’s first monthly adjustment visit, it is obvious that he is agitated and dissatisfied. He received notice that his surgical insurance coverage had been denied just 1 week after you bracketed his teeth. The surgeon never contacted him, and despite repeated calls to the surgeon’s staff, he received no return correspondence. He finally became so desperate to urge the surgeon to file an appeal that he went directly to the surgeon’s office to request it. He shows you a copy of the appeal letter he finally received and draws your attention to the misspellings and fragmented sentences in both the original and appeal letters. “A fourth grader could have done better,” Jim declares. “If this is the level of responsiveness and attention to detail this guy will provide, I want out!” You find yourself at a loss for words because, at least from Jim’s perspective, the skepticism sounds warranted.

Professionalism carries an authentic obligation to maintain both expressed and implied promises as soon as a patient is accepted for care. This obligation comprises the fiduciary relationship and is a corollary to the ethical principle of fidelity. Since there is a disparity of knowledge between a professional and a patient, the fiduciary relationship demands a higher level of trust or expectation than that of an interaction between equals. In a fiduciary relationship, the patient’s interests surpass those of the provider; therefore, the patient must trust the professional’s judgment and dependability for both guidance and treatment. The professional’s promises, assurances, and perspective must remain realistic to maintain the fiduciary obligation and are essential as components of informed consent. Contrast the fiduciary relationship with the mercantile model in which a caveat emptor (“let the buyer beware”) philosophy motivates the merchant in an attempt to sell as many services or products as possible, regardless of the consumer’s benefit. The merchandiser relies on puffery to emphasize or exaggerate the positive aspects of a transaction while omitting the negatives. The merchandiser might make promises that can never be fulfilled but are intended toward “closing the sale,” rather than placing the consumer’s interests or welfare over his own.

The oral surgeon’s fiduciary responsibility is to conscientiously pursue all avenues of insurance remuneration for Jim’s surgery, irrespective of the magnitude of his own benefit from completing the procedure. And now, as a participant in Jim’s care, you are also obligated to facilitate that process in any way possible. You are now all in this together.