Is the customer always right?

The era of paternalism in healthcare has long since passed and modern clinical practice is based on patients being presented with options and exercising choice.

We all recognise the need to respect patient autonomy and the freedom individuals have to choose the particular care they receive. But where does this leave the clinician when the patient’s choice is at odds with the advice provided? Is the customer always right? Should the clinician go against their own better judgment or recommendations to accommodate the patient’s preference? It can be a conundrum when the patient has a set view of what they want and insists that the clinician delivers this.
Increasingly, members of the public have an awareness of their individual ‘rights’. This can lead to a feeling of entitlement, which then translates into unrealistic expectations and demands. In the dental arena this can manifest as a patient insisting on a particular form of treatment on the basis that it is their mouth and their teeth so they are entitled to tell the dentist what they want done. Clinicians spend their careers caring for patients. It is in their nature to address problems and help patients in whatever way they can. Paradoxically, this commitment to helping others can create problems if it is not securely bound to the ability to step back and take an objective view of the issue to be addressed.
There is a difference between what is in the patient’s interests in terms of treatment and what treatment the patient may be interested in having. There are many instances of dentists ending up in difficulties and being on the receiving end of complaints simply as a result of well-intentioned, but perhaps ill-considered, efforts to accommodate a patient’s wishes, which may actually be counter to their best interests.

Shared decision-making is key
In an age of increasing patient awareness of what is out there, and ever-increasing expectations of what can be done, there is sometimes an element of confusion between a patient consenting to a particular treatment and a patient demanding a particular treatment. While it is true that the patient has the right to give or withhold consent for a particular treatment, this is about granting permission. It is about giving the green light to go ahead in a particular direction. It does not mean that the dentist is compelled to provide the treatment in question, merely that they are permitted to.
It is no more appropriate for a patient to demand a certain treatment than it is for the dentist to impose this. The key factor is shared decision-making, not capitulation to a demand from one side or the other. There needs to be agreement about treatment that both are happy with.
For example, a patient requires an extraction but due to a fear of needles is adamant that they will only have treatment as long as no injections are involved. The patient may be insistent that it is their choice, but it is up to the dentist to decide whether they consider that it would be safe and appropriate care to proceed without local anaesthesia. The tooth may be grossly mobile or firmly embedded, and the dentist is the one who is best placed to understand the implications of the clinical presentation. If it is inadvisable to proceed, the dentist should not go against this sound clinical judgement.
Other scenarios include the patient who does not wish to have dentures and insists that the dentist restores periodontally involved teeth with crown and bridgework, which the dentist feels is ill advised and doomed to fail, but which they agree to provide in order to accommodate the patient’s wishes. It may be well intended, but the dentist can expect little thanks when the inevitable happens. Similarly, a dentist who ‘has a go’ at trying to preserve a hopelessly compromised and unrestorable tooth in response to a patient’s plea to save this, can often find that the patient holds them responsible when the tooth is lost. Far from receiving gratitude for their efforts, the clinician can find that they are blamed for not having delivered the outcome that the patient wanted and which the patient claims was ‘promised’.

Balancing wishes and responsibilities
The important fact to bear in mind is that although a patient may have personal wishes, which the clinician obviously needs to take account of and respect, the clinician also has professional responsibilities, which dictate how care should be provided. These include doing no harm and acting to protect the patient’s interests. Providing care that runs counter to the dentist’s own judgement is not responsible treatment. Yes, the patient wants you to and yes, you could proceed, but should you? It is one thing to say that as long as the patient consents then the risk of failure should be ‘on them’, but this may not stand up dento-legally. It is not unusual for there to be an outbreak of selective patient amnesia or understanding when the outcome is not good. For patients to claim that they were not warned or were advised appropriately is not uncommon.
It also happens that a disappointed patient will say that if the chances of success were so slim, then why did the dentist do the treatment in the first place? There are all too many cases where dentists say that they knew that the treatment was unlikely to be successful but they proceeded with it because they wanted to do something to help the patient. Unfortunately, the limited prospect of success is often not made sufficiently clear, and the dentist ends up being blamed for an outcome that would have been inevitable in any case.

The best policy
The best way to help is just to be honest. Correcting an unrealistic expectation rather than catering to it is not always easy in the moment, but often saves more grief for the patient and the dentist in the long run. The dentist has not just the skill, but knowledge, and both have to be used to best serve patients. Explaining why something is a bad idea and clarifying the basis for declining to provide a particular treatment is the best way to help a patient. Conversely, building up a patient’s expectations (even inadvertently) only to then dash them is not the best way to treat patients or instil confidence in your approach to care.
It is wise to stop and consider if a patient seems intent on following a treatment path about which you have reservations, and down which you would not recommend travelling.
Patient autonomy must be respected, of course, as you cannot proceed without the appropriate permission, but this is not the same as handing over responsibility to the patient and passively accepting direction. If there are inner alarm bells sounding it is well worth putting on the brakes and pulling over. The treatment journey requires both dentist and patient to agree on the destination and how you are going to get there.

Dr Martin Foster
BDS MPH DipHSM
Martin is Dentolegal Consultant at Dental Protection