Kiran Madesha, Legal Advisor, dentalcorp; Kristy Pilatzke, Risk and Compliance Officer, dentalcorp
The dentist-patient relationship is the core of dentistry. Just like in any relationship, there inevitably will be a negative experience, and nearly all dentists will need to dismiss a patient at some point in their careers. Dismissals can be upsetting for patients and stressful for dentists. Regardless of whether you have conducted a patient dismissal previously, it is always good to review and possibly revise your dismissal procedure to ensure you follow the best practices for terminating the relationship. This will help you avoid facing any proceedings for professional misconduct.
When a patient displays a lack of confidence in their dentist’s abilities; fails to adhere to instructed treatment plans; misses appointments; refuses to pay outstanding fees for agreed-upon payments; or exhibits belligerent behaviour, terminating the patient-dentist relationship may be the only option. The dentist has the legal ability to dismiss a patient when the patient-dentist relationship has broken down beyond repair.
The following considerations will help minimize the risks that accompany dismissing a patient from a dental practice.
- Patient dismissal should be a last resort. Circumstances are unique. Dentists have a professional obligation to develop, maintain, and foster positive relationships with their patients. Therefore, it is important not to turn to patient dismissal prematurely. Communication, attentive listening, and displays of empathy can quickly diffuse a situation with a dissatisfied patient. Reasonable efforts must be made to accommodate the patient’s needs.
- Document. Many factors can lead to a patient dismissal. Document any concerns that may suggest a breakdown in the dentist-patient relationship, as well as any efforts made to save this relationship in the patient's records. As with all recordkeeping, documentation should be timely and accurate. Ultimately, dismissal is best achieved through a written letter sent by registered mail with a return receipt or by alternative means that confirms delivery. Include the registered mail receipt and letter in the patient file.
- Provide reasoning. The circumstances leading to your decision may vary, but always remember you must have a reasonable cause for terminating the relationship. Under human rights legislation, you are prohibited from refusing or dismissing patients based on protected classes such as age, race, nationality, disability, gender identity, and family status.
- Close the loop on care. Within reason, fulfill outstanding dental needs prior to dismissal. This does not necessarily mean seeing through an entire treatment plan. However, you also don’t want to expose yourself to an allegation of patient abandonment. For example, it would be prudent to cement a final crown, restore or extract a symptomatic tooth, or insert a permanent denture. If a patient is experiencing severe pain, inflammation, or suffering from a life-threatening condition, that may not be the time to dismiss them. On the other hand, if the patient chooses not to return to the office for the remainder of their treatment, be sure to inform the patient of any currently diagnosed oral condition, as well as any treatment recommendations and risks of not seeking further care.
- Give reasonable notice and be available for emergency care. Regulatory bodies want to ensure there is no interruption in care and promote continuity of care. Therefore, it is crucial to inform the patient you are dismissing of a timeline during which they may seek emergency care at the clinic. Some provinces mandate specific timelines. For instance, in Ontario, the requirement is at least 30 days for emergency care, whereas the dental regulatory authority in British Columbia requires at least 60 days. Timelines may vary depending on whether you are a general practitioner or specialist. Consider your location, availability, and the ease of finding a new practitioner to determine whether it would be prudent to offer more than the minimum time requirement.
- Support the patient in finding a new dentist. Help the patient find a provider who can assist with their current oral healthcare needs, or direct them to a dental association that can help locate a dentist accepting new patients in the area.
- Offer copies of the patient’s records. Inform the patient that upon their request, you will send copies of their clinical notes and records to their new dentist(s). As always, be sure to document any requests to release copies of records or radiographs. While you may be permitted to charge for these copies, evaluate the situation and consider offering to send these copies free of charge.
- Review outstanding balances. You can discuss any financial balances the patient may still owe, or you may waive the patient’s outstanding fees as a gesture of goodwill. Each situation is unique, and your decision will depend on a number of factors such as the success of treatment provided, the financial situation of the patient, the underlying reason for dismissal, and the patient’s history with the clinic.
- Avoid any further contact. Following the termination date, it is critical to inform staff not to schedule further appointments with the dismissed patient. Where patients have exhibited or threatened violence, office personnel should develop protocols to manage unexpected patient visits, especially if there is a potential safety risk. Once the timeline for emergency care has ended, and the patient is fully dismissed from the office, the dentist is under no obligation to accept the patient back into the office for future care.
Unfortunately, not all dismissals go as smoothly as we hope. Should there be a complaint or a lawsuit, seek advice from your provincial professional liability provider, your lawyer, or a more seasoned practitioner.
About the Authors
Kiran Madesha is a licensed lawyer with the Law Society of Ontario and works as a Legal Advisor at dentalcorp on the Compliance team. Kiran holds a Bachelor of Laws degree from the University of Liverpool and a Master of Laws degree with a concentration in Health Law from the University of Toronto.
Kristy Pilatzke is an experienced quality and compliance professional with over 13 years of experience in regulated healthcare industries, from pharmaceuticals manufacturing and specialty pharmacy to acute care. She currently holds the position of Risk and Compliance Officer at dentalcorp. Kristy holds a Master of Science in Healthcare Quality from Queen’s University.