In every orthodontic practice there are a small number of patients or their relatives whose behaviour can test your reserves of goodwill. But while it might be tempting to tell these individuals that you will no longer provide treatment, doing so can make matters worse. Leo Briggs offers some advice on how to manage challenging behaviour

Every orthodontist relishes a clinical challenge, but challenging behaviour by patients or their relatives can be time consuming to deal with and in extreme cases, even threatening. Examples include:

•    Non-compliance with treatment such as refusing to follow oral hygiene advice or not wearing their retainer as instructed
•    Disruptive behaviour such as being late for their appointment or failing to show up at all
•    Vexatious complaints
•    Aggressive, abusive or violent behaviour
•    Refusal to pay bills.
Faced with a difficult patient or relative, one option can be to stop providing treatment to the patient. However, this is not always the end of the matter. Aggrieved ex-patients have been known to make a complaint, contact the local newspaper or post their feelings on social media. You could also be criticised by the GDC if you are unable to justify your decision. The GDC’s Standards for the Dental Team says that ending a professional relationship with a patient should be rare.
While removing the patient should be a last resort, particularly with an orthodontic patient who may be undergoing a long term and complex course of treatment, there are other steps you can take to try to address this issue.

Spell out the problem

The patient or relative may not realise their behaviour is a cause for concern. Where possible, give them a chance to change: explain the problem, explore any difficulties they might be experiencing and follow this conversation up in writing. It can also help to consider the behaviour in context. An apology might be enough for everyone to move on.

Stay calm

Dealing with an aggressive person takes care, judgement and self-control. Try to remain calm, listen to what the person is saying and ask open-ended questions. Reassure them and acknowledge their grievances. If someone is physically violent, leave the room and call for help. Training staff in conflict resolution and dealing with aggressive behaviour is advisable. NHS Protect offers online and in-house courses.

Discuss your treatment plan

If you are concerned that a patient’s behaviour is compromising their dental health or jeopardising the chances of a positive treatment outcome, discuss this directly with them or, in the case of younger child patients, their parent if it is appropriate to do so. It may be that they are struggling to follow your advice or they have become disillusioned so be prepared to reassess your plan together to ensure it meets their best interests. If you believe their expectations are unrealistic, it would be better to address this sooner rather than later. But if removal is the only realistic option, you must:

Be able to justify your decision

You must be satisfied that your decision to stop treating a patient is fair. In particular, the GDC warns dental professionals they ‘should not stop providing a service … solely because of a complaint the patient has made about you and your team’. It makes sense to keep a careful record of the events that led to your decision, including any efforts you made to warn the patient about their behaviour.

Write to the patient

The GDC says you must inform the patient in writing, explaining your reasons and ‘take steps to ensure that arrangements are made promptly’ for their continuing care’ e.g. explain that you will write to their general dental practitioner and ask them to arrange a referral to an alternative orthodontist.

Meet your contractual obligations

Where there is an ‘irrevocable breakdown’ in your relationship with an NHS patient, the National Health Service (General Dental Services Contracts) Regulations say you must inform the patient and notify the Local Area Team, usually by forwarding to them a copy of your letter to the patient. If a patient has been violent, you should first report this to the police and then inform the LAT who will inform the patient.

Refusing to see a patient because of the behaviour of a parent

This is a very difficult situation to deal with because the relationship between the clinician and dentist may not have broken down. It might be necessary to find out if someone else can accompany the patient if it is inappropriate for the parent to return to your practice.

Get dento-legal advice

The DDU can support you when dealing with difficult or challenging behaviour from patients. We can advise you on whether a refusal to treat may be justifiable and review the wording of warning letters to patients. We can also assist with responding to patient complaints.