Dentists have the right to dismiss unruly patients, but when done without due diligence, practitioners are vulnerable to wrongful abandonment and discrimination lawsuits. Know when and how to end a provider-patient relationship.

By Ty M. Galvin, D.D.S. and Michael A. Gile, D.D.S.

Are you obligated to continue treating a patient who repeatedly misses appointments, argues over treatment, disputes financial agreements or is increasingly rude to your staff?

While “patient divorce” may carry a stigma, the well-being of the doctor, staff and patient are worth the uncomfortable dismissal process. It is within a dentist’s full right to dismiss a patient if the dismissal is not for a legally impermissible discriminatory reason.^[1]

As health professionals, we believe in our duty of care to our patients. This can make the decision to dismiss one particularly challenging but is a key component of doing our jobs well and providing optimal care to all.

When is it appropriate to dismiss a patient?

First and foremost, you cannot dismiss a patient based on their race, gender, national origin, disability, religion, genetic information or age. Practitioners are responsible for accommodating disabilities, such as providing interpreters for individuals who are hard of hearing during their treatment, for example.

It is a person’s behavior toward you and those within your office which will drive a decision to separate. Here are three key reasons to dismiss a patient:

1. They are abusive to others within your office. Your first responsibility as a dentist and employer is to your patients and staff. When another patient becomes verbally or physically abusive, or sexually inappropriate to your team or toward fellow patients, they are a liability to your practice.

Case in point: When a young patient’s crown fell off days after treatment, instead of calmly requesting a replacement, one mother berated the dentist’s staff and threatened to ruin the office’s reputation. After a new crown was cemented, completing the treatment, the child and mother were dismissed from the practice due to harassment, libel and extortion of the office staff.

2. They continuously miss appointments or refuse the recommended treatment. Refusal can take a variety of forms, from not scheduling follow up appointments to dictating the type of materials you use. Before you dismiss these patients, you can inquire about concerns or fears that may be causing them to ghost or implement policies like charging for no-shows.

Case in point: A new patient comes in for a replacement of four crowns. The patient refuses the dentist’s standard process and recommendations, insists on the use of a different lab and porcelain fused to metal crowns instead of zirconium. If the procedures have not been started, the patient can be dismissed on account of dictating treatment other than what the dentist recommends.

3. They refuse to pay for performed treatments. A common cause for dismissal is nonpayment. In these instances, it is important to distinguish between patients who cannot pay and will not pay. Providing payment plans is one way to accommodate those who need assistance, but a refusal to make these payments is also reason for dismissal.

Case in point: A patient commits to a quadrant of dentistry including two crowns and a filling.  The patient agrees to financial arrangements but refuses to pay after the treatment is completed and tells the office staff “The work is already done, what are you going to do about it?”

Real concern happens when a difficult patient’s non-compliant behavior escalates. Paying attention and noting incidents can help track behavior and indicate the need for dismissal. Comprehensive chart documentation can support your decision should it lead to a claim.

The dos and don’ts of dismissing a patient

A successful “patient divorce” occurs when the patient does not leave the relationship angry and litigious. Here are best practices for ending the relationship quickly and without further incident.

DO:

• Have the right documentation. If a patient should ever dispute their dismissal, you’ll need objective documentation of all incidents to substantiate your decision. This includes any emails, voicemails or texts from the patient as well as records of any outreach to them concerning their behavior. Keep these in their chart so they can be easily sourced.
• Consult your State Board guidelines. States may have specific requirements around dismissing patients including how many days you must provide emergency care after dismissal.
• Send a discharge notification letter by regular and certified mail. This maintains a one-way communication, void of dispute. Phone calls and emails are not recommended as they encourage potentially argumentative discussions. It is also best practice to include notes within this communication detailing additional care you recommend for the patient, as to avoid any accusations of abandonment.
• Continue care for 30 days from the date of the notification letter. Remember, check your state for additional requirements.
• Be courteous but concise. Practitioners are not required to provide a specific reason for service termination. Instead, recommend resources for finding a new dental office and explain how you will transfer medical records when appropriate.

DON’T:

• Admit to not meeting the patient’s needs. It’s instinctual to apologize when you’re in uncomfortable situations or to avoid conflict. However, you don’t want to confuse the situation with malpractice.
• Recommend another dentist. It’s better not to be blamed for another unsuccessful doctor-patient relationship. Keep your recommendations to resources such as the patient’s friends, family, social media and the internet to guide their search.
• End a relationship in the middle of a treatment phase. The patient’s wellbeing takes priority. Make sure to time the discharge as to not endanger the patient’s oral health.

We all have those patients on the schedule that cause stress for the doctor and staff. While ending a relationship is never easy, dismissing a challenging patient can not only be a relief for the entire team, but it also likely puts the patient in a situation where they can receive better care.

When you follow the recommendations on when and how to end a relationship with a difficult patient, you’re building an environment more conducive to helping your other patients and keeping you and your staff safe. 

For more information on protecting your practice in difficult situations, contact PPP Risk Management.

This information is intended for informational purposes only. Nothing contained in this publication is, nor is intended to be, legal or dental advice. Professional Protector Plan for Dentists is not liable for any injury, loss, damage or expense arising out of or in connection with the use of this information.

^[1] American Dental Association “Patient dismissal: Guidelines for Practice Success | Managing Patients | Patient Relations,” 2023.