What would you have done?

Dr. Rich Mounce reflects on treating a “reluctant” patient

Recently, I had an interesting clinical and patient management scenario that is worthy of sharing and personal reflection.

We were referred an emergency “consult” patient from a general practitioner to be seen late in the morning. The patient was a healthcare provider and traveling to my office from a considerable distance. The referral was made for a “consult only.” The patient was late in arriving; and by the time paperwork was filled out, it was 11:45 a.m., and our lunch hour begins at noon.

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Clinically, the patient had a failing lower molar endodontic procedure done many years ago. While the specifics of the clinical situation are not strictly germane to the situation described, it is noteworthy that the tooth may have been vertically fractured, and the prognosis was guarded at best. After discussing the procedure, the alternatives, the risks, and answering all the patient’s questions, the patient opted to confirm either vertical fracture or restorability through endodontic treatment. Given the distance the patient had traveled, he asked if we could do the procedure immediately. We agreed, and treatment commenced over the lunch hour. The patient was jovial, alert, and aware, and without indication of anxiety.

The patient was reclined and a topical placed. Upon readying the injection, the patient was asked to recline his head. In the midst of this request, he sat motionless and unresponsive. Asked a second time, after approximately 10 silent seconds, the patient stated he was anxious and wanted to return with oral sedation.

Two doses of an oral sedative were prescribed, one for bedtime the night before and one the morning of the procedure. The patient was instructed to arrive 1 hour prior to the treatment start to take the medication in order for us to observe him in our waiting room. The patient arrived 30 minutes after his scheduled time for the administration of the oral sedative, claiming to have taken the medication 30 minutes prior. He did not call to say he would be late. I refused to treat the patient and would not reschedule him. He was obviously not pleased and clearly articulated his displeasure. I phoned the referring doctor, suspecting that the patient would return there immediately to complain, which he did.

I surveyed a number of my endodontist and general dental friends to get their opinions on how they would manage these circumstances. Interestingly, none of the clinicians surveyed (endodontist or general practitioner) said they would have treated the patient the same day. Almost all of the endodontists stated that they would have dismissed the patient from their practice, and almost all of the general dentists were willing to reschedule the patient for another day and give them another chance.

I did not reschedule the patient because I believe there is an inertia and “flow” to both patient treatment and rapport with patients. All things being equal, treatment is flowing well, or it is not. When it flows well, it’s a beautiful thing, and when, for whatever reason, it is not, one challenging aspect to the treatment environment (among a myriad of possible issues) often leads to other unexpected problems. Said differently, my intuition is that given the history with this patient, had we treated him without him following our protocol or rescheduled him, it is unlikely he would have cooperated with us in the future and given the story a happy ending.

And finally, this situation presents many relevant questions of which several are asked here for the reader to consider: What was the worst thing that could have happened had we treated him despite his being late and having claimed to take the medication? If we rescheduled, aside from my intuition, what other challenges could or would likely arise? What would you have done? These are good questions, among many that could be asked. I welcome your feedback.
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