One of our readers e-mailed me and finished by asking questions that at 1 time or another have plagued many of us. He wrote the following.
Larry: I just finished a clear aligner patient and got what I thought was a very nice esthetic result. However, teeth 5 and 28 were not in a really good cusp/fossa relationship as the lingual cusp of 5 was occluding on the lingual slope of the buccal cusp of 28. The patient’s general dentist sees her, I get a call, and he says “I do aligner therapy, too.” He proceeds to tell me that he wants me to move 5 more palatally and 28 more buccally to create a better cusp to fossa relationship prior to restorative work. In my opinion, the patient will not like the esthetics of 5 being moved palatally and appearing sunken in when she smiles. Must I treat to a treatment plan I don’t love? Can I transfer her aligner therapy to the GP? If the GP didn’t do aligner therapy, could I refuse to treat her? I welcome any thoughts you might have on this matter.
The decision to accept the final occlusion as stated by our reader, as described, is a clinical one; without knowing the full details, the case cannot be addressed. Therefore, we can move on to the other questions. Must our reader conform to or provide a treatment plan with which he doesn’t agree? Matthies v Mastromonaco, 709 A2d 238 (N.J. App. Div. 1998), would lead us to believe that, based on practitioner autonomy, we can answer in the negative. In that case, the court stated the following.
If a patient selects a course of treatment, even from among reasonable alternatives, which physician regards as inappropriate or disagreeable, physician is free to refuse to participate and to withdraw from case upon providing reasonable assurances that basic treatment and care will continue, and in such circumstances, there can be no liability for refusal.
Although not exactly on point, St. John v. Pope , 901 SW 2d 420 (Tex. 1995), is close to answering our reader’s second question, which was whether he could refer the patient to the general practitioner to treat as the general practitioner wanted. If a practitioner does not feel competent to treat a particular patient for whatever reason, the St. John case noted the following.
…professionals do not owe a duty to exercise their particular talents, knowledge, and skill on behalf of every person they encounter in the course of the day. As is true of all callings, physicians are not obligated to practice their profession or render services to everyone who asks.
…a physician may decline treatment and thereby decline to create a physician-patient relationship, even on the basis of an erroneous conclusion that the patient’s condition is beyond his or her ability to treat.
The last question posed was whether he was free to withdraw and refuse to treat the patient any further. Tierney v University of Michigan Regents , Docket #239690 (Aug 5, 2003), provides guidance regarding this issue. The court echoed the sentiments of most other jurisdictions, all of which hold that “The physician has a definite right to withdraw from the case provided he gives the patient reasonable notice so as to enable him to secure other medical attendance. Such a withdrawal does not constitute an abandonment.”
Commentary
Today, it is not uncommon to have patients who attempt to dictate to providers how they wish to be treated. From nonextraction to demanding that certain types of appliances be used, our patients think nothing of challenging our recommendations and trying to direct our ministrations. Their bases for doing so stems from an enhanced notion of patient autonomy fostered by information and data acquired through various online resources. At times, it almost borders on acquiescing to committing malpractice. Even when patients attempt to induce the practitioner to follow their wishes, with the caveat that they will sign a release if their choice of therapy or approach turns out poorly, the doctor cannot permit this to happen. In United States v George , 239 F.Supp. 752 (D.Conn. 1965), the court was blunt when it stated the following.
…the doctor’s conscience and professional oath must also be respected. In the present case the patient voluntarily submitted himself to and insisted upon medical care. Simultaneously he sought to dictate to treating physicians a course of treatment amounting to medical malpractice. To require these doctors to ignore the mandates of their own conscience, even in the name of free religious exercise, cannot be justified under these circumstances. The patient may knowingly decline treatment, but he may not demand mistreatment . (emphasis added)
You have practitioner autonomy at least to the same extent that the patient is an autonomous individual. As long as you don’t engage in illegal discrimination, you are free to accept who you want to accept as a patient; free to treat how you want to treat, as long as you are not committing a battery on the patient; free to terminate a patient from your practice upon following specific protocol; and free to refer patients to other practitioners if you believe that the patient’s interests would be better served by doing so. The problem is that these legal freedoms come with a cost. The cost is that they sometimes conflict with certain bioethical tenets, but more often, they run afoul of “tried and true” practice management principles (read that as “not being in your best financial interests”). I’m not going to espouse which tenet should trump the other—legal, ethical, or financial. It’s a free country. A man’s gotta do what a man’s gotta do. Oh yeah, that applies to women, too.
So, what should our reader take away from all of this? First, if the general practitioner thinks he can do a better job or if he wants to do something different, let him. As long as you have determined that the end result of your treatment was within acceptable parameters and met the standard of care, don’t let your ego get in the way of someone else’s ego. There will always be those who think they can do better. Sometimes they can; most of the time they cannot.
Can our reader refuse to treat the patient further? Absolutely. If you don’t believe that treatment is warranted, if you don’t see what the patient is complaining about, if you believe that the patient will not be best served by undergoing whatever he wishes to undergo, don’t render treatment. Refer him to someone else; after he has left, say good riddance to yourself. Pat yourself on the back; you have just avoided a problem.
Should you render treatment that the patient wants, but that you believe is the wrong thing? Never! Don’t do it. Don’t do the ortho and compromise the orthognathics. Don’t do the ortho and compromise the perio. Don’t render treatment that will put the patient in a worse position than where he is. Wait, doesn’t obtaining informed consent negate that concern? Usually, no. What about limited treatment? Performing limited treatment is fine as long as (1) it is limited and (2) it is not harmful to the patient. Remember the primacy of nonmaleficence: above all, do no harm.
You can’t be everything to everyone. Just do the best that you can do. Hopefully, that will jibe with what the patient will let you do. And be yourself. Most of the time, you have no choice in the matter, particularly since everyone else is already taken.
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