The other day I read Imtiaz's article about case acceptance (http://www.speareducation.com/spear-review/2015/10/the-most-misleading-statistic-in-dentistry). Imtiaz points out that when we commit to comprehensive dentistry in philosophy, we have to reconsider the definition of "case acceptance." In having the courage and confidence to work through the patient-oriented treatment planning concepts that we learn at Spear Education, we also have to accept that we will get a whole lot of "no's" in the process to comprehensive dentistry before we get a "yes" for a big case.

We have to have faith in what we believe about dentistry and in our diagnostic skills and our ethical approach to developing an appropriate plan with our patient. I have developed a sort of mantra from a conversation I had many years ago with Dr. Garry DeWood, who told me, "There's only really one treatment plan for each patient; if you don't know what that is before you present it, you haven't asked enough questions." When we listen carefully to what our patients tell us and develop the treatment plan that meets their physical health needs as well as their desires, we have to have faith in presenting our findings. However, we also must have faith enough to stop when the patient--or his wife--builds a brick wall...maybe to the point of ceasing the doctor/patient relationship.

Two days ago, I had a co-diagnosis appointment with a patient who in two previous discussions had clearly told me that he wanted to know what could be done to improve his bite along with a lengthy lists of complaints about his previous dentist who had done some CEREC crowns and a few bonded composites after orthodontics. The complaints, of course, were a red flag. At his first interview, we discussed at length the indication for mounted study models in order to achieve a thorough understanding of his functional concerns, to which he consented. During his examination, we spent a long time listening and recording his complaints, mostly which dealth with his key statement, "I don't know where to bite my teeth together because nothing feels solid." Since his joint and muscle findings were unremarkable and load test was negative, we proceded with jaw records, PVS impressions, and mounting of study models. He had generalized attrition and non-carious cervical lesions, multiple vertical fractures, and several destabilizing posterior interferences, with a 1mm lateral and posterior slide to MIP. During the review of findings at the co-dx appointment, where his wife was present, I informed him that the work he had done appears to have been reasonable, but it likely is not adequate to address his complaints. We discussed the indication for a full mouth reconstruction (ortho had already been completed reasonably), and we also discussed the possibility of basic care, which would involve an FPD or implant to replace tooth #19. I explained, however, that I would not be willing to proceed with restoring #19 and a fractured crown #3 without an occlusal adjustment first because of the existing occlusal instability, which was one of his chief complaints. He asked me to develop a treatment plan for a full reconstruction and also an alternative to address the single crown and FPD option, and we reschedule him for a treatment consultation in a week. His wife kept interrupting during the meeting saying "This has already been done" "They said they couldn't open his bite with his back teeth," "He had the braces to open his bite and fix it," "We didn't know what was being done," etc. I tried to refocus to the current situation while not condemning the previous dentist, saying "I understand. However, it seems that your [the patient's] complaints may be different now than the were previously."

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Last evening, the patient's wife called my office and demanded to speak with me. When I answered the phone as "Dr. Huff," the patient's wife responded, "I refuse to call you 'Doctor,' KEVIN." I knew I was in for an ear chewing. All I could do was let her blast me for everything from not getting all of the previous dentist's records so I would do what that dentist wanted to accusing me for billing for models that should be part of treatment, which is what her insurance company had told her. This went on for nearly 15 minutes. After she had completed her rant, I sat silent for about a minute with dead space on the phone. I'm a firm believer that in these situations, the first person to speak tends to lose. When she asked if I was still there, I said, "Yes, ma'am. I am just waiting to make sure that you are finished. If you are, would you mind allowing me to address each point you raised individually?" She allowed me to address each of her concerns, which I did with confidence yet grace despite her continual interruptions with "yeah, I knew you'd say that," etc.

When I was finished addressing her concerns, I said, "Would I be able to talk with your husband to make sure that he shares your concerns because he is, in fact, my patient? If so, then it really does seem that it would be best for me to refund the funds for the occlusal analysis and study models and agree to part ways since it is clear to me that I have not earned your trust." She paused, almost shocked by what I had said, and then said, "Well, I guess you should if you have to."

Her final words before she hung up the phone on me were, "What gets me most is that you never even asked me what I wanted." Ding! Ding! Now the truth finally appeared.... She was the decision maker and she didn't perceive the value, despite her husbands desire for optimal care!

I called the patient. My conversation was very amicable, and he ended up thanking me for refunding the money. He said reluctantly, "I guess I'll have to go somewhere and just get the bridge done." I sensed that he is being forced by his wife, which is something that is completely out of my control. However, I feel that I did everything appropriately. Incidentally, despite being accused of being a "used car salesman" by the wife, I still have not presented a treatment solution. Unfortunately, he will never hear what could be done. I suspect, that he ended up where he is because of similar pressures being applied to previous dentists.

My question is this.... How do you handle situations like this? I know there is no right answer, but I would like to understand how others think.

Thank you.

Kevin

PS: For thoroughness, here are the occlusal photos of the diagnostic mounting, where blue is centric and red is eccentric:

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