A reader wrote:
Larry: The other day a 17-year-old patient came into my office. He had been in braces with his general dentist for almost 2 years. He is still Class II on 1 side and needs all new appliances, about 18 to 24 months more of care, and the extraction of 1 premolar. Here’s the problem: the GP in question is my second best referral source. She said that if I take over the case she will agree to debond it and clean it up. She has been fully paid, and the patient’s insurance has been used up. The GP wants me to bill her for whatever my fee is to finish the case. I still have to take full records but from the initial clinical examination and Panorex, the roots look good, as do the hard and soft supporting tissues, and the case is doable. On top of all this, her practice is within 3 miles of mine, and this will be the second case from her that I will have taken over to finish or redo. Here are my questions.
How much should I charge the GP? What do I need to get in writing from both the parent and the GP (and how do I ask for it) to not be responsible for whatever treatment the GP has rendered up to this point? If the GP gets sued over this, am I involved and responsible for anything? What forms or letters do I need to complete or have signed?
Although the fact pattern here may seem extreme in some respects, it is quite real, and it happens more often than we would like. Most of the time the transfer comes from another orthodontist, but regardless of the source, the scenario is almost always as follows. The patient has been in treatment for a given length of time; the patient has often been told that he or she is almost completed, when that is not the case. The appliances in place are not ones we would prefer to use; unfortunately, the patient often has pathology in the form of periodontal compromise, various degrees of decalcification or caries, or some root resorption. Finally, to add insult to injury, the case has been paid up with no insurance left. Is it any wonder that many practitioners don’t accept transfer patients?
In our scenario, the transferee seems lucky. The first doctor will strip and clean up the teeth and is willing to pay for the retreatment. How much is the question, and for that there is no simple answer. From a practice management perspective, you could just treat it like any other case. After you take your records and present the treatment plan, just quote the referring doctor what your normal fee would be. Alternatively, I think I would tell the patient that insofar as transfers like this are concerned, you have an arrangement with the referring doctor, and the fee will not be a concern to the patient. This posture could alleviate many, but not all, potential problems between you and the patient, and between the patient and the previous practitioner.
Another approach might be to extend whatever professional courtesy you would to any referring dentist as if you were treating a member of his or her family.
Although it is certainly ethical (beneficence, justice, professional collegiality, public fiduciary, and so on), it may present some administrative concerns regarding the usual and customary fees being charged, but one could always argue that this is not a usual and customary situation. Regardless, there is no good answer, and the effort should be directed at making the patient as financially comfortable as possible while recognizing and addressing the business concerns of keeping a good referring dentist happy.
Whereas the first question has as its basis practice management considerations, the second deals more with risk management considerations. What special documentation must be acquired to protect oneself from any liability that may be attached to the first doctor’s treatment? The answer is simple: none. You are not liable for anything the first doctor said or did before you accepted the patient. You are, however, responsible for everything going forward. A basic tenet of tort law is that you take your potential plaintiff as you find him. Look at it this way: if a new patient came to your office with a periodontal status that was not compatible with the initiation of orthodontic therapy, you would refer him for treatment until the periodontal status was under control. If the patient had gross caries, you would have them restored before beginning treatment. If the patient had abnormal root morphology, blunted or shortened teeth, or something else, you would develop a treatment plan compatible with his anatomic and physiologic limitations, and the same for edentulous areas with knife-edge ridges. The bottom line is that you take every patient—and every patient is a potential plaintiff—as you find him, and you deal with it accordingly. Would you refuse to treat these patients? Most doctors I know possess professional egos big enough to surmount whatever potential pitfalls loom on the horizon. Well, it’s the same thing with transfer patients. Whatever you find, you diagnose it, plan the treatment, get your informed consent, and you’re off.
If everything is good, and our fact pattern shows that it is (periodontium, root integrity, and so on), then you will treat this patient as you would any Class II subdivision patient, and you will only be responsible for your diagnosis, your recommended treatment plan, and the treatment you render. From a purely clinical perspective, it doesn’t matter why the patient came to you, except for possibly a history of poor cooperation. What does matter is how you choose to play the cards you are dealt.
To minimize your risk exposure, you want to have good beginning records to document exactly how the patient presented—records that will support whatever you choose to do. You want to have good documentation about the treatment plan presented based on the clinical considerations. You want to have good documentation of the patient’s informed consent to the treatment proposed and the patient’s responsibilities going forward. The previous doctor’s problems, whatever they were, are not yours, and you don’t want to make them yours. This is your patient going forward, pure and simple. Just use all the normal forms and letters as you would for every other patient presenting as this patient does. You are taking and treating your new patient as you find him.
This obviously leads to the next question. If the previous dentist gets sued, will you be involved or responsible for anything? Well, you won’t get sued, but you will surely be invited to the party. You will most assuredly be called as a treating physician, a fact witness, who will be asked to testify about the patient’s status when you first saw him, the way the first doctor left him. You will be asked about all aspects of the patient’s presentation, what your treatment plan was, and whether the previous doctor’s treatment affected the treatment you rendered to the patient. The patient’s attorney will try to get you to be an expert witness for the patient, but the defendant’s attorney will try to block that and keep your testimony strictly to the facts. It will make for an interesting day in court for which you will probably not get paid, because you have been subpoenaed to appear. Ain’t life grand?
At this point, you may be asking whether it’s worth accepting transfer patients. Sure, there are headaches associated with many of them, ranging from mild discomforts to migraines. Let’s say you decide that, as a matter of office policy, you don’t accept transfers. It’s your prerogative, right? The doctor-patient relationship is a bilateral consensual one, isn’t it? You know you can’t discriminate about whom you accept or reject, particularly if the patient is a member of a protected class; and the last I heard, mistreated patients or those forced to relocate in the middle of treatment were not members of such a class of persons. However, let’s run this thinking out to its logical conclusion. If you don’t accept transfers and by extension no orthodontist accepts transfers, what happens to the patients who, by circumstances outside their control, have no access to care because no one will accept transfers in the middle of treatment? Can we as a profession tolerate this situation?
I can only tell you that, having been around the block a few times, I have discovered that accepting transfer cases was extremely valuable in my development as a clinician. You must learn to deal with people clinically, financially, emotionally, and most importantly, empathetically and personally. You have to learn how to face, deal with, and ameliorate adverse clinical situations. This is important because it helps you to become a better doctor when addressing these types of problems in your practice—problems that affect all of your patients who are not transfers.
Believe it or not, I have found that transfer patients who have been mistreated and find themselves in a different environment, say in Larryland, wind up being not only grateful for having been taken in, but also a good source of referrals going forward. This is not always true, but then nothing is 100%. These patients are clinically challenging and have taught me that clinical discretion is the better part of egotistical valor. It has taught me how to make lemonade from lemons in the clinical arena. It has taught me the finer art of clinical compromise. It has made me a better doctor if by no other standard of measurement than the ultimate happiness and satisfaction of my patients.
Our writer threw one more fly in the ointment. The transferring doctor is a good referring doctor. In other words, the GP keeps the easy stuff and refers out the rest. If the GP is screwing up the easy stuff, this raises another consideration. This is patient number 2. I don’t know what number constitutes “continually faulty care.” It must be more than a few, but sooner or later our good letter-writer will be forced to make a decision. Our code of ethics places an affirmative obligation on a doctor who witnesses continued instances of substandard care to do something about it. We are granted a license to practice; it is not a right. With that license comes the responsibility of self-regulation. Couple that with the duty we owe to our patients as a private and public fiduciary: using veracity, informed consent, and nonmaleficence. At some point, we have to do something. Oh well, grist for another mill.
One last thought is that almost all orthodontic training programs I’m familiar with don’t accept transfers. Oh, they give a whole bunch of reasons (I don’t happen to buy them, but then who am I to say), but it just seems to me that if these patients are so difficult to deal with in a private practice, we ought to be training our future orthodontic practitioners how to deal with them. Okay, that too is grist for another mill.
I want to thank our writer who was kind enough to share this problem with everyone. We all need to face the unpleasantries of clinical practice now and then. It’s much better when we can face them in print, discuss them among ourselves, and decide what we will do before the fact than it is to stammer and stumble around when the patient is in front of us in the chair. We owe our patients at least that much.