The Tipping Point: Setting patient expectations - a compliment or red flag?

There is a moment in every case where a disgruntled patient becomes a complainant. The Tipping Point is a series of cases and commentary that highlight that very moment.

Maintaining professional boundaries can be challenging when a patient begins to cross them in light of a breakdown in communication. 

Case study

Dr G worked as a locum dentist. While working in a recent practice he treated a patient, Mrs B, for a check-up and filling. Mrs B was very complimentary of his skill, treatment and care. Mrs B had a history of periodontal disease and poor service, and she was very impressed and extremely happy to find a general dentist who she believed would be able to provide her with the care she needed at a reasonable price. Over the course of their appointment Mrs B continued to shower Dr G with praise. 

On completion of Mrs B’s appointment, a broad discussion was had about her ongoing periodontal treatment needs. Mrs B expressed dissatisfaction with many of her previous periodontal practitioners and had high hopes for continuation of her care with Dr G, and enquired if this was possible. Although Dr G explained he was only working temporarily in the practice as locum, he did give Mrs B his business card with contact details upon departure.

The following Saturday, while out with friends, Dr G received a phone call from Mrs B wanting to discuss her recent treatment and periodontal condition, stating she respected his professional opinion and was most impressed with his clinical skillset and caring disposition. Over the course of a 30-minute conversation Dr G explained that he was currently not working in a practice but would keep her updated once he became settled in a permanent location. 

Not long after Dr G had commenced working at a local practice, he received a call from the practice manager where he had previously completed a locum position. They were enquiring on Mrs B’s behalf if continuation of her periodontal treatment was possible, which he happily confirmed it was.

When Mrs B phoned to schedule her appointment with Dr G she expressed discontent about the treatment fees and advised she would not consent for any periodontal analysis on the day, explaining she would bring records from her previous periodontal treatment (with the specialist) and she believed this would suffice. When Mrs B attended her appointment with Dr G, he explained that in order to provide a comprehensive treatment plan and periodontal treatment he would need to assess Mrs B’s current periodontal condition, which would require Dr G to complete a thorough periodontal analysis. Mrs B again declined and was keen to get her cleaning appointment underway. 

During the course of completing Mrs B’s general clean, Dr G noted several isolated and deep probing depths and became concerned by Mrs B’s refusal for baseline periodontal records. He also began to question Mrs B’s motivation for completing her treatment with him and was equally concerned that Mrs B had unrealistic expectations about her treatment. When he raised these concerns with Mrs B, she produced a periodontal chart from previous treatment some two years earlier and was adamant that this should suffice. 

Dr G was concerned that Mrs B’s desire to be treated by him was motivated by cost and her aversion to specialist treatment fees. Bearing in mind the complexity of Mrs B’s periodontal health, her refusal for baseline assessment and very high treatment expectations, Dr G advised Mrs B that specialist referral and treatment was required. Dr G also explained that specialist treatment and care would enable Mrs B to achieve a more predictable outcome. 

The Tipping Point

Mrs B was not happy: she continued to question Dr G and alleged that Dr G had told her he could complete her treatment. She sent messages insisting that Dr G call her outside office hours to discuss these concerns and when this did not happen, she became angry. She had spoken with Dr G outside office hours previously and she believed he was now avoiding her calls. Despite Dr G’s best efforts to explain via phone calls and emails the reason and rationale for referral, Mrs B was not having it. 

When it was clear that Dr G would not provide the treatment she required, she then expected him to facilitate immediate access to specialist treatment, which was unreasonable, given all appointments were scheduled at the discretion of the periodontist. Dr G tried to assist Mrs B where he could, only to be sent demanding emails and text messages questioning Dr G’s professional capabilities and his duty of care.

Naturally, this matter resulted in a complaint to the regulator, and while this was swiftly dismissed, it further compounded the stress Dr G was under.

Learning points

While Dr G had only ever intended to provide appropriate treatment and care for Mrs B, when he provided his contact details and encouraged her to contact him, thereafter answering her call outside office hours, he had inadvertently set a precedent and expectation of being available to Mrs B at her convenience. 

When Dr G had agreed to manage her care, Mrs B had expected and assumed that he would be able to maintain her periodontal health and referral for specialist care would not be required.

Setting clear professional and personal boundaries with patients, while managing their expectations, can be challenging but is an essential requirement when managing any therapeutic relationship. 

Potential red flags that might test our professional boundaries with our patients, their treatment and their care are often shared in the context of our conversations and discussions, and frequently only identified as such, with the benefit of hindsight. 

This matter provides us with a timely reminder that professional boundaries serve to protect patient and practitioner alike, providing a blueprint of reasonable and appropriate interaction and expectation.