Now that you’ve completed your residency, the impact of your growing expenses has become a reality. You have been engaged for 2 years, and you have promised your fiancée that you would marry once you received your orthodontic certificate. You’ll need to buy a car because of your employment in a distant town, and those school loans are looming. You have accepted a position at a dental maintenance organization (DMO) near the Army base where your fiancée will be stationed for another year. It’s a high-volume practice, obviously understaffed and quite harried. After about 4 months of practice at the DMO, you notice that the Cromwell family is one of several that seem to have vanished from your practice. You had taken a liking to the Cromwells because they are from your hometown and cheerfully traveled a great distance to see you. When you ask the business staff about their whereabouts, you are told curtly that they were dismissed because they lost their insurance coverage and their account was delinquent. You ask the manager whether the family was made aware of this problem, and she replies that the company’s policy is that any patient whose account reaches 60 days in arrears is summarily dismissed.

You acknowledge that you are a member of a business entity, but as a professional, you also recognize a high level of responsibility toward your patients. You wonder what you can and should do to intercede.

The fiduciary relationship is a corollary of the ethical principle of fidelity (the maintenance of promises). The fiduciary relationship is based on the patient’s trust that the provider will exert an adequate level of professional competence and a high degree of morality in treatment delivery. Professional competence is essential because of the great discrepancy of knowledge between the patient and the doctor. Morality involves the doctor’s responsibility to place the patient’s interests above his or her own.

This role can place the doctor in a difficult predicament. By failing to satisfy their account balance with the DMO, the Cromwells have violated their contract and have not fulfilled their responsibility of fidelity. No practitioner should work without remuneration, but is the fiduciary relationship violated if the DMO prevents the orthodontist from providing care because the family has failed to pay?

The office staff should have approached the patient long before the account fell into arrears, regardless of their workload. Perhaps an extended contract might have facilitated timely payments, even without insurance coverage. If there is any concern that the stressed business staff might neglect to inform the patient, the orthodontist should attempt to communicate this option himself. Although this action might contradict the advice of business management professionals, the patient must be offered options to prevent the unfortunate turn of events. The orthodontist should have a sufficient level of morality, as a component of his fiduciary responsibility, to have the professional motivation to offer the family options so that care can proceed.

If the Cromwells are still unable to comply, they should be offered an alternative source of care. They should receive the opportunity to transfer to a different orthodontist, with access to your services for emergency treatment for a short period of time. The options for alternative providers need not be a specific person or institution. A copy of the patient’s diagnostic records should be sent to the new provider upon the patient’s consent. Although a copying fee is appropriate, the original orthodontist should not refuse to transfer the records despite the account status or if the patient fails to pay the reproduction fee. And the original provider should refrain from making disparaging remarks about the family when communicating with the new provider. If all efforts to collect are fruitless, the account can be referred to a collection agency or legal service.

Each of us needs to manage our own assets. Orthodontists are no exception, but our fiduciary responsibility places us above the realm of a routine retail transaction.