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South African Dental Journal

versão On-line ISSN 0375-1562
versão impressa ISSN 0011-8516

S. Afr. dent. j. vol.73 no.9 Johannesburg Out. 2018




Dental Protection, Medical Protection Society, advises:



Dealing with difficult patients

Interactions between dentists and their patients can sometimes be challenging. Most of us have had consultations and treatment sessions where the interaction and outcome could have gone better, and are often a matter of regret for either the patient or clinician, or both, occasionally ending with a formal complaint. Dr Alasdair Mckelvie, Head of Dental Services Africa at Dental Protection looks at some of the issues that can bring about difficult interactions with patients and gives tips on how best to deal with these situations.

A recent survey of dental members in South Africa undertaken by Dental Protection revealed that 50% of dentists are experiencing more demanding patients with higher expectations and more than 80% agreed or strongly agreed that patient expectations have increased in the last Ave years.i

It is therefore unsurprising that an increasing number of complaints which have been laid before the Health Professions Council of South Africa (HPCSA) and the South African Dental Association (SADA) Mediator describe situations where the patient expected so much more than they actually experienced.

Patient expectations

Anecdotal evidence from conversations with colleagues suggests that we may be inadvertently increasing the expectation gap, which in turn can cause an increase in complaints. To give an example of this, I was approached by a Dental Protection member at the recent SADA Congress who described a complaint he had recently received and wanted reassurance that he had done the right thing.

The complaint involved a 16 year old teenager who needed four permanent teeth extracted for orthodontic reasons. The extractions had been arranged without a referral letter from the orthodontist and without a pre-extraction consultation to save fees. The father had dropped the teenager off, gone away, and when he returned was unhappy that none of the planned extractions had been completed and three Allings were undertaken instead. The member was not overly worried about the complaint but concerned that the consent given by the teenager would be invalid.

In not insisting that an examination and discussion should take place before any treatment was provided, the dentist created an expectation that this part of the care of the patient was not that important.

Whilst he did explain why the treatment of caries and the re-evaluation of the treatment plan was needed he had already lost the opportunity to manage the father's expectations.


Discussing a recognised complication after the event can often be an uncomfortable conversation, as the patient may say if it is a recognised complication then they should have been warned from the outset in the consent process. Whilst it may not have influenced the decision to press ahead with the treatment, discussions around risk during the consent process makes it much easier to manage the potential fall-out when a risk does materialise.

A common source of disappointment and tension can arise during an endodontic procedure where a fractured endodontic instrument complicates an otherwise straightforward treatment. Not infrequently, the services of an endodontist is required to recover the file and this comes at a cost to either the practitioner or the clinician, depending upon what was discussed in the consent process. Even when used correctly, files will still occasionally break in service.

This would be considered a non-negligent complication if the correct protocols were followed. However, the discussion with the patient becomes more problematic when you try and explain this to them after the event, and mention the additional costs the patient will need to meet.

Breakages are generally associated with carelessness by patients. When they are unaware of the risk and financial consequences, they may blame the clinician and won't expect to be paying for the remedial treatment themselves.


Disputes about the predicted cost of treatment, and an unwillingness to acknowledge that a misunderstanding can exist when an unexpected co-payment is outstanding is often reported in complaints to the HPCSA.

This reflects our survey findings where more than 70% of dentists think that patients are more likely to complain.i In many cases the unexpected co-payment arises from an underpayment made by the medical scheme. In nearly every case it was the patients' expectation that the benefits covered all dental fees and the dentist's expectation that they would be paid properly for the treatment rendered.

Expectation created around the obligations of third party funders, if not properly managed, can undermine the consent procedure.

Underpayment by medical schemes on behalf of their member should never happen when authorisation has been obtained in an ideal world. However they do occur and often lead to a difficult and unexpected conversation with a patient about an account they were not expecting.

In his presentation to the recent SADA Congress, the Dental Mediator, Dr Kobus Barnard, gave an overview of the cases he mediates. Just under half of the complaints he deals with relate to disputes around fees and billing. The solution to this problem generally always comes before the difficult conversation ever becomes necessary and involves informed financial consent.

A legal and ethical obligation places a duty on each practitioner to provide information about treatment costs. If the treatment includes laboratory items or the services of an anaesthetist then these costs need to be discussed as they have an influence on treatment choices. It would also be advisable to discuss with the patient whether there is any co-payment and the approach the practice will take in the event that there is a shortfall payment by the medical scheme.


In nearly all of the cases discussed, the difficult interaction could have been avoided through better communication in the consent process. On the basis that patients continue to measure a clinician's technical ability more by their communication skills than the emergence profile and marginal fit of their restorations, we will all still have days and moments where we have to manage disappointment and unmet expectations in a difficult interaction.

When you And yourself at the start of, or in the middle of, a difficult interaction there are four recognised steps you can take towards achieving a satisfactory solution:

1. Acknowledge there is a problem and try to summarise and gain agreement as to what are the key issues

2. Maintain Arm boundaries and avoid being drawn into point-winning arguments that are not focussed on solutions. Often it is the failure to discuss the elephant in the room and to And some common ground that leads to a further deterioration in the interaction

3. Show compassion and demonstrate you understand why the patient is unhappy

4. Keep your focus on the best outcome for both parties rather than winning the argument.

There are occasions when managing patient expectations becomes a far bigger challenge than the actual treatment itself. if you choose to ignore an unhappy patient you may lose control of the situation, and our experiences show that the patient will select the path of least resistance, often to the HPCSA or beyond to their own attorney.

You can always look to Dental Protection for support and advice on how to approach a challenging situation.

In June 2018 DPS surveyed 173 dentists in South Africa

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