Dr J: I’m in the middle of treatment on this young female patient who came in the other day with bugs in her hair. I mean, I can see them crawling around. They are small and white. I spoke to the patient and her mother about it, and they said that they are not lice but, rather, are “bugs from our house.” Her doctor has been treating her for the condition with a “special shampoo,” but it has not worked. I feel very uncomfortable being so close to her head with those bugs crawling all around. I’m also worried about my assistants as well as other patients in the office who would be there when this patient comes in for her appointments. I don’t know whether it is ethical or legal to suspend her treatment until the condition is cleared up, but I really have a problem with the potential exposure to myself, my staff, and my other patients. I have a call in to her doctor, but I have not received a call back. Do you have any advice for me from a legal or ethical perspective? Thanks, Dr S, Iowa
Dear Dr S: The 1 piece of information I’m missing is whether mom, dad, or any siblings have also become hosts to these critters, or are these stay-at-home bugs? Regardless, let’s make a giant assumption that these bugs do indeed possess little tiny passports and can freely travel from host to host. Acting on this assumption, we can analyze the matter this way. Obviously, since she is in the middle of treatment, a doctor-patient relationship already exists. With that in mind, what you are seeking to do is to unilaterally suspend, discontinue, or terminate the doctor-patient relationship. Let’s look into each of these and also look at the reasons that one can legally do each one.
Starting with when the doctor wants to unilaterally terminate the doctor-patient relationship completely, patients owe us 5 duties, responsibilities, and or obligations under the doctor-patient contract: (1) to act in their own best interests by following your professional advice, instructions, or recommendations; (2) to keep their appointments allowing treatment to proceed in an orderly and uninterrupted manner; (3) to be forthright regarding administrative questions such as their health history, financial or insurance information, employment history, and so on; (4) to pay for professional services rendered in an agreed-upon manner; and (5) to conform to accepted modes of behavior while visiting our offices. When patients breach these responsibilities, we have a legal basis with which to terminate the doctor-patient relationship. It could easily be construed that coming to a doctor’s office with a communicable condition and insisting on treatment (because “it’s okay, her doctor is treating her”) is certainly not within the definition of conforming to accepted modes of behavior. Although I am not advocating doing so, if you desire to unilaterally terminate the doctor-patient relationship based on the above scenario, you would probably be within you legal rights if you gave the patient adequate notice and an opportunity, reasonable time, to “cure” the situation. The protocol for doing so has been well established in other columns of mine; additionally, the American Association of Orthodontists also has adequate resources such as form letters that you can download. However, unilateral termination of the doctor-patient relationship is not the best way to deal with this problem because you might still have to see the patient during the reasonable amount of time you have set within which she must seek suitable alternative care.
As to discontinuing active treatment, you have a right to unilaterally make that decision based on the patient’s best interests. For instance, if you see caries, periodontal disease, or decalcifications developing, you can decide that the risk-benefit ratio for this patient does not favor continuing active orthodontic treatment, and subsequently you might decide that the patient’s best interests are actually served by discontinuing active treatment. The doctor-patient relationship still exists, and you are faced with the problem of retaining the result at that time in some form. This doesn’t help you in the present situation, since we would not be discontinuing treatment based on the best interests of this patient; even if we were, she would still have to come in for whatever retention modality you want to use.
This leaves the alternative of suspending active treatment. Although many practice-management gurus advocate doing this for patients who are “fiscally irresponsible,” I have always had an issue with relegating a patient to orthodontic purgatory for nonclinical reasons. The key factor here is the temporal aspect of this forced ostracism. Certainly, a few weeks is no problem, but, once you get to a few months, I start to have reservations. Past that point on a time line, there is no defense to a claim of constructive abandonment that might be filed against you. Looking at our scenario from a public health perspective, the number 1 tenet is that patients who harbor transmissible diseases or maladies should be restricted from contact with the public at large until the condition in question is no longer transmissible. With this in mind, a short suspension of treatment is a viable method of dealing with this problem; during this time, the patient’s condition must be treated and cured, and medical clearance obtained. If this cannot be accomplished, you would then be faced with no option but to unilaterally terminate the doctor-patient relationship.
So much for the legal perspective. What does our Code of Ethics say? Not very much, I’m afraid. Principle VI states that “Members shall be dedicated to generating public confidence in the orthodontic specialty by improving the quality and availability of orthodontic care to the public.” Advisory Opinion A states: “Members may exercise discretion in selecting a patient into their practice, provided that they shall not refuse to accept a patient because of the patient’s race, creed, color, sex, national origin, disability, HIV seropositive status, or other legally recognized protected class.” Finally, Advisory Opinion B notes that “It is not unethical to withdraw from treating a case when the option exists, provided that advance written notice to the patient or responsible party is given to allow for another orthodontist to be secured.”
According to this document, it is certainly arguable that withholding treatment from someone with a transmissible health problem improves the quality and availability of orthodontic care to the public. The first Advisory Opinion allows us to refuse treatment to lice-infested patients because they are not members of any recognized legally protected class of persons, whereas Advisory Opinion B allows us to withdraw from attending to a patient’s care if the proper protocol is followed as previously discussed. Our code aside, our Hippocratic oath requires that we first do no harm. Preventing the spread of this malady to the public more than meets this ethical mandate.
As the Queen of Hearts declared, “Off with her head.”
So, where do we draw the line? We have all dealt with patients who are nice enough to call and say that they have the flu, plague, or whatever. We thank them for informing us, tell them not to come in, wish them a speedy recovery, and reschedule them a week or 2 out; no problem. But, what about the patient who is not so nice? You know, the ones who have the common cold or worse. The ones who believe it’s a good thing to share and spread things around. Don’t we all know friends, neighbors, staff, and (if we are honest) many of us, and I include myself, who have at 1 time or another gone into the office, a little under the weather, because to reschedule several days of patients would be tantamount to stopping the world from spinning on its axis. I know, we wear masks so that we don’t contaminate others in the office—staff and patients alike. Whom are we trying to kid?
Coming back to our reader’s problem, we use disposable headrest covers. Well, some of us do anyway. Okay, so maybe that addresses the problem in the chair. Sure, we wear disposable gowns, or some of us do. That takes care of brushing up against the patient’s head during adjustments. But, how about kids whose legs don’t reach the ground when they sit in our beautiful fabric-upholstered chairs in the waiting room when the back of their heads touch the seat backs because they haven’t reached their maximum upper body height yet? Now, consider the unknown numbers of patients who will unwittingly and unknowingly follow them throughout the day by sitting in those chairs. We delude ourselves by believing that all of our patients have at least a respectable degree of personal hygiene. We have to suffer from this delusion; otherwise, medical and dental commerce as we know it would come to a screeching halt. Or would it?
What if we stopped making our waiting rooms look like hotel lobbies? You know, we could have our decor more reflective of real health care facilities—such as vinyl or tile floors, plastic chairs, wooden benches, and so on. You know, do whatever you can to make the place germ or bug resistant. Oh, wait, I forgot, if we do that, then we lose the competitive edge because our reception areas are not as cozy, comfortable, warm, and inviting as our practice management gurus tell us they should be. Shame on me for forgetting such things.
The bottom line is that we make a decision. We actually perform a risk-benefit analysis, at whatever conscious or subconscious level, on the public health considerations inherent in how we design and furnish our health care facilities, our places of public accommodation, our businesses. We decide that the benefits far outweigh the risks when it comes to certain furnishings, when it comes to choices about working when we are under the weather, and when it comes to seeing patients who might have tiny critters engaging in a hoedown in and around their follicles. We each must decide where to draw the line; in the greater scheme of the world, there are a lot of lines out there. I guess in the end, this matter just bugs me a little.