Macadamias, pistachios, and filberts

Thanks to all of you who wrote in with questions or problems. Several of our readers sent the following related incidents. They all deal with the issue of how we are supposed to deal with Mrs Macadamia, her daughter Pistachio, and her son Filbert—you know, this family of nuts that we want to get rid of. I have condensed their e-mails to save trees.

  • The patient was an adult with a routine problem. At the third visit, she claimed that her hair was falling out as a result of the braces. She demanded MSDS sheets on everything we used. She refused an early debond or a referral to an MD specialist. She only allowed me, not my assistants, to treat her, and each visit averaged 45 minutes. Fifteen months later, when the treatment was finished (during treatment, she sought 3 second opinions about her progress, and everyone agreed that everything was fine), she refused to have the braces removed.

  • At this point, I knew I had a problem. I called my malpractice carrier (AAOIC), which gave me the dismissal protocol to follow, and I sent the dismissal letter by e-mail, by return receipt requested, and in a plain white envelope (with a certificate of mailing). She came into the office a week later refusing to be referred elsewhere and made a stink. It got ugly, and my receptionist had to call the police. Now for the rest of the story.

  • She spent the next 9 to 12 months trashing me on the Internet. I was the devil, I stole her money, all those patients who wrote good posts were being snowed, and so on. I tried to get the posts pulled but to no avail (free speech and all that). My only alternative was to file a complaint with the Federal Bureau of Investigation for cyberbullying (I didn’t do this, but maybe I should have). She reported me to the Better Business Bureau and the state dental board (both investigated and dismissed all of her allegations).

  • Is there a way to manage this kind of thing? It’s been almost a year, and she has finally gone away, but, of course, the negative posts are still there. I worked long and hard to build my practice from scratch only to see my most prized possession, my reputation, trashed.

  • How should we prevent this type of thing from happening, how do we protect our businesses, and how should we react to this damaging kind of harassment?

    Thanks, T. L.

  • I don’t know about others, but I am seeing more patients who try to dictate treatment for themselves or their kids. In a way, the Internet and Internet aficionados have seemingly created a new breed of patient who feels totally empowered by whatever information they have picked up on the Internet. The other day, I had a second-opinion patient come in. She had been in treatment 2.5 years with her general dentist and another 2.5 years with another orthodontist, and was fearful that she would lose her teeth. She wasn’t in bad shape, but what are we to do about patients (or parents) who dictate treatment, how do we flag these patients early on, and how do we terminate their care once we discover them?

    Thanks, D. M.

  • One of my patients has concerns about her alignment, occlusion, embrasures, tilting, angulation, and so on, as well as the clinical changes from visit to visit. I can’t understand how she perceives such small details. The patient demands that after each visit we send her progress photos. Do I have to send her the photos? If not, what reason can I give that will not make her upset? Finally, can I send the photos in small resolution?

    Thanks, J. B.


First, remember that if no doctor-patient relationship exists, then this fact alone makes both you and the patient nonplayers in this little game called professional practice. It would appear that our first reader was a little slow picking up on some of the warning signs. If the relationship had been terminated a lot sooner (read that as “the minute the little hairs on the back of your neck assume an erectile position”), this fiasco might not have crescendoed as it did. There is a story in Harvey Penick’s Little Red Book: Lessons and Teachings From a Lifetime of Golf , wherein a Texas oil magnate offers Penick any amount of money for one of Penick’s lessons on how to get out of a sand trap. Penick evaluates his swing and says “I can teach you how to get out of a sand trap, but it will take 2 lessons.” The oilman asks why 2 lessons are required. Penick retorts that the second lesson will be how to get out of the trap. The first one will be how not to get into it.

When you have patients come in armed with a notebook—today it would be an iPad—and write down everything you say; when they go for second, third, and fourth opinions; when they start self-diagnosing and questioning everything you say and do; when they start dictating treatment; when they complain about things like rotations and axial inclinations that are off, and things that you can’t see with magnifying loupes, these are all warning signs. Big yellow flags: caution, danger, quicksand ahead.

Remember the 5 duties our patients owe us inherent in the doctor-patient relationship: (1) instructions (including recommendations and referrals) will be followed, (2) appointments will be kept, (3) they will pay you for professional services rendered, (4) they will respond fully and truthfully to administrative inquiries, and (5) they will conform to accepted modes of behavior and office protocol. When patients breach any of these duties, you have the right—a right that should often be implemented sooner rather than later—to terminate the doctor-patient relationship. Learn to do it if you don’t already know how: it’s important.

For a lot of reasons, I don’t envy those in private practice today. It is a different world surrounded by a different atmosphere: this atmosphere is called cyberspace. Word of mouth has been replaced by word of post. Reach and frequency have been supplanted by audience and engagement. It’s like the Wild West of old. There are few laws protecting today’s doctors from the slings and arrows launched at us through cyberspace. The greatest online threats to one’s professional reputation are (1) negative mass media coverage (newspapers, television, and radio); (2) negative patient, consumer, and customer online complaints; and (3) negative word-of-mouth postings. Unless one can prove malice or wanton indifference to the truth, free speech reigns. Those who are most technically savvy and who have nothing but time on their hands can ruin a professional’s life and reputation.

Howard Luks stated that “The solution to pollution is dilution.” In other words, have overwhelming numbers of good posts as opposed to negative ones. Since you can’t fix what you don’t know about, you must monitor what is said about you every day, often several times a day. Sign up with Google Alert because it relates not only to your name, but to that of your partners, associates, and your PC, LLC, or whatever. Bad reviews, comments, and posts are inevitable and will be made not only by dissatisfied patients but also by disgruntled employees. Since the best defense is a good offense, first, choose your windmills wisely. When a negative post comes along, your response should be the high road. Don’t fight in public. Instead, explain and apologize if appropriate. Never ignore a negative post. Be concerned and professional; if you can’t be, fake it. You must generate continuing, accurate, and positive content by yourself and your staff by constantly asking your patients to post positive comments, experiences, reviews, and so on. Post all positive professional, personal, and community activities such as awards won, talks, articles published, presentations given, church activities, team sponsorships, all of it. If you’re going to blog, these posts should be done on your Web site. Link your blog to your home page, Facebook page, and Twitter account. Do not post fake or artificial reviews, because they can be spotted via algorithms.

For years now, I have been preaching that one of your most important hires will be a media consultant or an Internet reputation protection company. I can’t stress this point enough: it’s that important. Think of this person as a professional spin doctor. If you delegate this task to one of your assistants who is supposedly tech savvy because she is always surfing, tweeting, and liking something or someone every chance she gets, you are setting yourself up for a big fall. Instead, opt for professionals who do this for a living. They use software and programs that monitor the Internet. They check out every hit. They immediately deal with the company sponsoring the post. They stop or at least address trouble in its tracks, as soon as it happens. You must incorporate an expense line relating to this into your budget.

Finally, I make a public and open plea to the American Association of Orthodontists. Direct the Council on Orthodontic Practice to give regional seminars on how to deal with this issue. Our members are craving it and need guidance regarding this matter. Find a few really good speakers on Internet reputation protection and put them on the circuit. Of course, many of them will have a conflict of interest because this is what they do for a living, but the bottom line is that as long as they disclose their interest and we as an organization don’t endorse any specific vendor, we are at least giving our members direction and ideas to enable them to deal with this problem as they see fit. Oh yeah, to all you program directors out there: this is something that should be included in your practice management seminars, again by people who know what they are talking about. If we are going to send students out into the arena of private practice, we need to give them all the skills they need, not just the clinical ones. We need to provide them with appropriate nutcrackers to deal with all of our Macadamias, Pistachios, and Filberts. A few lectures on the psychologic makeup of such patients and how to deal with them wouldn’t hurt, either.

What are we to do with the patients who want their photographs at the end of every visit? Photographs are part of a patient’s dental record. Patients are entitled to a copy of their records upon request. Period. In one of my former lives as a program director, I required photos of every patient at every visit; it made for great teaching. I won’t express an opinion as to whether the same philosophy should apply to private practice. But remember that every image you produce during your normal ministrations, either photographic or radiographic, becomes part of the patient’s record to which they are entitled. However, a patient cannot require you to take orthodontic records that you would not normally take during the regular course of business. If you don’t have it, you can’t produce it. If you’ve got it, patients have a right to a copy of it.

There is also nothing wrong with developing an office policy along the lines of dismissing patients who constantly put your treatment decisions and every visit’s clinical results under a microscope. If you think that your clinical judgment is being affected by such behavior, you have every right to terminate the doctor-patient relationship based on that. Merely letting such patients know that you will be happy to comply with their requests, and that your office policy in such cases is to terminate the doctor-patient relationship because of its negative effect on your clinical judgment, might be enough for them to shy away from the following through on the request. It is not a perfect world, and there might be no good way to let these patients down easy or without repercussions. The “BUT” in this situation is that you are picking up, fairly early on, that this could be a problem patient, and terminating his or her care could be, for you, the appropriate price to pay for aspirin to make this type of headache go away. The last word is, don’t distort the records; this could be construed as records alteration and could result, when all the stars and planets are aligned just the wrong way, in some sort of administrative sanction taken against your license. If you acquire a piece of diagnostic data, ensure that it is of clinically acceptable quality, kept, and subsequently transmitted in that same good format.

This issue will only get worse before it gets better. I say this because today’s patients are e-patients. What are they, you might ask? E-patients are the decision makers as well as the potential referral sources; 140,000,000 people access the Internet for health care information EVERY MONTH. What criteria do they look for or use in selecting a health care provider? They look for brand identification or affiliation; your reputation in the community; patient testimonials that are highly ranked, as is your office location; other factors such as price, helpfulness, and courtesy of staff, office décor, and cleanliness; temporal considerations such as travel time, wait time, on time, and overall length of treatment time; as well as the attractiveness and empathy of the doctor and office staff. What about your professional SKEEE (skill, knowledge, education, experience, expertise)? As they say in Brooklyn, fuggedaboudit.

Finally, e-patients are educated, empowered, engaged. I hope, in the ideal world, that they become your emissaries. Just remember, in the world of cyber orthodontics, they can also become your enemies.

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Apr 6, 2017 | Posted by in Orthodontics | Comments Off on Macadamias, pistachios, and filberts
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