RiskBites: Boundary setting for patients who push

Hello, I'm Dr. Annelline Weston, Dental Eagle Consultant at Dental Protection. Welcome to Risk Bites, a series of podcasts created specifically for dental practitioners in Australia. Risk Bites looks at key dental legal risks and issues affecting dental practitioners across Australia and provides helpful advice and guidance on how to steer clear of them, leaving you free to provide safe and high quality dental care for your patients. In this edition, I'm going to be talking with my colleague Helen Harborn, who's Dental Protection's in-house lawyer, about some patients whom we may need to consider setting some boundaries with. So Helen, over to you. Thanks Annelline. Well, I'm assuming that many of our members became a dental practitioner, thinking there would be minimal need for communication with patients. I mean, their mouths are essentially out of commission for communication purposes for the bulk of every consultation. But some aspects of communication are not just necessary. They are vital to ensure the success of your business and/or your individual reputation. I absolutely agree, Helen, and I think that sometimes people underestimate or devalue perhaps the importance of communication. And it's also important to remember that you're never going to be able to please every single patient. That's just the reality of life. We can't be friends with everyone. Absolutely, that's true. And as we are all now well aware, the onset of COVID-19 pandemic has seen a dramatic increase in the worsening of mental health. And with that, we at Dental Protection across the globe have seen a sharp rise in the stress and anxiety levels of both patients and practitioners alike. It is also anticipated that the recent soaring of the cost of living has now added yet another layer of pressure, and it is now at an all-time high. At DPLA, we have certainly noticed an increase in the number of calls relating to managing volatile patients. In my view, the key to managing, or better yet preventing these situations, lies in the quality of our boundary setting. Of course, that is easier said than done, especially for our early career dentists. But there are a number of simple strategies that practitioners can employ, which I will discuss here today. Yeah, I think it's good to have some strategies up us leave for managing these patients who push. So let's begin by exploring the types of boundary pushing patients that we might encounter. Yes, it can be helpful to be alive to the types of patients that you may need to set boundaries with early on. Thankfully for most of our members, the majority of the patients that you will encounter will be either happy or at least satisfied with your treatment. However, you are likely to find there are small percentage of patients who simply cannot be pleased, no matter what you do and how much you try to accommodate them. For the purpose of this podcast, we will call them the perfectionist patients. And of course, many practitioners are themselves perfectionists, so these patients would seem to be right in our wheelhouse at first blush, wouldn't they Helen? But of course, they can be very tricky to manage. They certainly can, and in terms of the perfectionist patients, these are the ones that are simply impossible to please, and most commonly are the patients seeking cosmetic or aesthetic procedures. They are, and they usually come across as pleasant and friendly at the outset, I think, and they may play to our egos by claiming that only you can give them what they want. That's right, but they will also often drop hints of their perfectionism through the following common behaviours that we've seen. They are very specific and detailed about what they want, often to the point of being obsessive, and they may speak critically about previous treating providers. They might use phrases such as "You won't let me down, will you?" or "I know you are the best." Yes, as a clinician, that type of criticism of others and bigging up of me as a professional particularly when they haven't actually met me or had any treatment from me is an immediate red flag. Yes, as it should be, Aniline, other behaviours exhibited can be highlighted when they are describing the outcome of the treatment they desire. They might use words that indicate they expect perfection, such as emphasising wanting to look like a particular celebrity. Of course they might even say jokingly that they expect perfection, but be clear they are not joking. That's correct, Aniline. Well, it has been said there is never a true word than that said ingest. The key issue is that their expectations are not only very high but are usually unrealistic and unachievable. It is very important to set boundaries with these patients very early on. Listen very carefully to what it is that they want and be very clear and firm about what it is that you can actually provide to them. Provide more information in detail than you would for the average patient, especially in regards to the aspects that you know are likely to be unachievable. Don't be vague or leave any room for them to make assumptions. If you do, it is almost guaranteed this will come back to haunt you. If they don't seem happy but still want to proceed, it is advisable to you not to proceed with the treatment. Don't be afraid to suggest to them that they might be best to see the treatment elsewhere and explain the aspects of the treatment that you are not comfortable with. If you are polite and firm with them, then most times this is not a situation that needs to escalate. I have to say it reminds me of a patient of mine who was giving me all these red flags and when I suggested that they had a second opinion, which I do think is a great suggestion to make to these patients before diving into treatment, they called me a coward and said I was too cowardly to treat them. I am not sure what they thought I was going to do with that, but certainly I think suggesting a second opinion is really sensible. Wow, yes, I agree, Analine. If you do make the decision to proceed with treatment for this patient, document your discussions in detail. I cannot stress this point enough. It might take an extra 10 or 15 minutes to document your conversation, but I can assure you that if it turns into a complaint or worse, a legal claim, those detailed notes will be your saving grace. Another very important recommendation in dealing with these patients is do not blur the lines of professionalism. These patients tend to change their mind frequently and want to keep discussing things and might start texting or emailing you to continue the conversation. It's important that you don't fall into this trap. Keep the boundaries very clear. If they want to continue the conversation, ask them to make an appointment or make a time to talk on the phone. Once again, record the details of the discussion. We have unfortunately seen many members fall into this trap and the courts do not look kindly on practitioners that blur these lines. The voluminous text messaging and DM conversations can be provided as evidence of discussion, but their informal nature just doesn't reflect well on the practitioner, particularly if they're peppered with memes, jokes and swear words. Even if it's not the professional who's done that, it just doesn't look great. So, how best would you summarise how to best manage these patients, please Helen? I would say that the key elements to managing these patients successfully are the following. Maintain clear professional boundaries. Provide them with detailed information. Document your discussions and don't be afraid to decline treating them. Making the decision to treat a perfectionist patient without following these guidelines might see you make $10,000 or $20,000 in profit, but the cost of a damages claim is likely to be in the hundreds of thousands of dollars, not to mention the personal cost to the practitioner in stress and lost time. And it doesn't even need to be a legal claim that costs, of course, a complaint to the regulator can still be time consuming and is invariably distressing too. So, what are the patients do you think we should be particularly live to impractise, Helen? There is also another category of patients, thankfully a smaller percentage again, who are simply hardwired to be argumentative and aggressive, and they will undoubtedly push all of your boundaries. To say they are difficult does not aptly describe them, they are more like bullies. Unfortunately, the more you give to them, the more they want and the more they will take. For the purpose of this podcast, I'll refer to them as bully patients. Yeah, these patients made my life quite difficult as a younger practitioner I must say. So, what tips do you have for these Helen? Well, of course, every situation is going to be slightly different, but there are some general tips to bear in mind for handling this particular group of patients. The bully group of patients is quite unique. They can have underpinning mental health issues and usually have a history which has led them to believe that coercion allows them to gain control and get what they want. It can very much be a learned behaviour and that has worked for them in the past. Once triggered, they become obsessed with achieving retribution and will usually stop at nothing until they are satisfied. Some of the types of behaviours these patients typically display are as follows. Calling, end, or emailing every day or even multiple times a day or frequently attending the practice and making demands of any staff members they can get hold of. Yeah, not just that. I find sometimes they ask questions that just simply cannot and should not be answered too. And don't you find that the demands that they're making are usually unreasonable and the timeframes usually even more so. Correct, Elaine. And they will usually threaten to go to a lawyer or make a regulatory complaint or even go to the media. Yeah, it's always a current affair. They almost always say they're going on a current affair and they also contact or threaten to contact their local MP. They do. And these patients need to be handled very carefully in order for you to avoid complete armageddon. So we would recommend adopting the following process. Firstly, decide the best person in your team to deal with this patient. This might not necessarily be the practitioner responsible for that particular patient's treatment. It will depend on the personality of the practitioner, especially if they're quite junior. Borsening a vulnerable practitioner to manage this type of patient on their own will usually be disastrous, not only for the practitioner but for the entire practice. Some people are just better at managing into personal relationships than others. Decide who is the best person in your team to handle this patient and get them involved from the outset. Indeed. And it's important, of course, for that person to remember that they need to manage the patient in a way that's caring, but they also need to be firm because while they want to be understanding, they also don't want to become a doormat. That's exactly right, Elaine. Becoming frustrated or annoyed with a person who is angry will only serve to pour fuel on the fire. Equally, if you are too sympathetic and agreeable, the patient will sense weakness and take full advantage of you, which will also make for a potentially disastrous situation. The key is just to become clear and professional. Express understanding and concern and guide the patient's expectations in a positive direction. You also need to allow for some disruption to your schedule while you manage this patient. The absolute worst possible thing you can do to a bully patient is try to brush them off quickly because you are busy. They will undoubtedly perceive that they are unimportant to you, and this is a major trigger to bully patients. You can't ignore the inevitable, and if you try, the loss of time you'll encounter will undoubtedly be indefinitely multiplied, and if you just take the time to handle the situation intentionally from the outset. Yeah, that's really helpful, Helen. Thank you. And I think we've just crystallised some tips for the whole team's. Can't we? From these patient discussions. The first one being, of course, that no one has to tolerate abuse? That's correct. They don't, and it's important that we encourage and train our staff to calmly and respectfully terminate a call if a patient is being rude, abusive, offensive or unreasonable. Similarly, you can ask them to leave the premises if needed. If a patient is continually attending the practice without an appointment to complain or to reiterate some demand that they have this may be regarded as harassment, and you are within your rights to tell that patient that you will contact the police if they do not desist from that behaviour. Similarly, if a patient is asked to leave the premises and refuses to do so, you can and should call the police. Sage advice indeed, Helen. Thank you. And thank you all for listening, and we do hope this podcast was helpful to you, and we look forward to sharing more guidance with you in the future. If you have any concerns about a particularly patient that you're finding difficult, or you'd like some more assistance with boundary setting, please do give us a call to discuss. If you like dental protection podcasts, and you'd like to hear more, please subscribe and leave a review.