The Shady Patient
Dr Alex David has a general practice in a Midwestern city. Most of his patients are middle-class business and professional people. Late one afternoon, Mr. William Worthy entered Dr David's waiting room, unannounced, as a referral from the chiropractor next door. He said that he had been in an automobile accident the day before that resulted in back and dental injuries. He wanted a dental examination for his insurance company and then, presumably, he would follow up with treatment.
Superimposed on this entirely straightforward story were the disturbing appearance and behavior of Mr. Worthy and the two thug like men who accompanied him. Dr David thought all three of them looked like trouble. Mr. Worthy in particular was irritable, agitated, and threatening, and he wanted medication, specifically Valium. While Dr. David was interviewing Mr. Worthy, his friends left the waiting room and entered the treatment area. They wandered through the hall, entering several operatories. Their unauthorized entry and their suspicious demeanor alarmed the office staff and Dr David. After two or three requests, Mr. Worthy's friends re-entered the waiting room.
At his first opportunity, Dr David called the chiropractor, who confirmed the basic story. The chiropractor said that he, too, had been concerned when the trio had entered his office. He therefore had called the hospital where Mr. Worthy was treated following the accident, but everything checked out.
When Dr David found time to examine Mr. Worthy, the patient's anxiety and tense oral musculature made the examination difficult. Mr. Worthy jumped at every touch. He said he had a lot of pain in his teeth but could not be specific as to location. He again stated his need for Valium to help him relax, and Dr David reluctantly saw his point.
The examination itself was inconclusive. Several cusps were fractured. Electric pulp testing and thermal tests were ambiguous, and it was hard to interpret percussion. Other pathoses (caries and periodontal disease) existed that were not related to the trauma. Radiographs did not help either. Altogether, the picture was confusing. Dr David thought the pain could be from the fractured cusps, but the amount of pain did not coincide with the clinical picture. On the other hand, he knew that the full consequences of trauma are often not seen until much later.
Dr David decided to prescribe a small amount of Valium to cover the next 5 days, and he agreed to see Mr. Worthy again at that time. Dr David was concerned about drug dependency, but Mr. Worthy denied regular use of Valium or any other drug. Dr David's hope was that the pain response was primarily due to anxiety and would be substantially modified by the Valium and by time. His plan for the next visit was to seal the exposed dentin on the fractured cusps to confirm the source of the pain. If that did not help, referral to an endodontist was the next step. Long-range management of the fractures would involve restorative procedures and root planing to start to control the periodontal disease.
The plan was acceptable to Mr. Worthy, and he agreed to return in 5 days. Two days later, Mr. Worthy called Dr David to say he was in real pain and demanded more Valium. Dr David considered what to do. He really did not have time in his schedule to see Mr. Worthy that day, but he also did not want to prescribe more Valium. What he really wanted was to not accept Mr. Worthy into his practice because of his suspicious and fear-provoking demeanor. However, large parts of the story seemed legitimate. Dr David admitted that if Mr. Worthy had shown up in a three-piece suit and alone, instead of in dirty chinos and a leather jacket and with his disreputable friends, he would have a much different outlook on this case.
Likewise with the first case, let’s follow a process:
- Determine the alternatives. Should he refuse treatment? Pass him off to an endodontist? Prescribe Valium by phone? Rearrange everything to see him asap? Other options?
- Determine the professional obligations and views of others: the ADA code says, “dentists shall be obliged to make reasonable arrangements for the emergency care of their patients of record.” Discuss that in light of this case. What is “reasonable?”
- Determine the ethical considerations: Discuss the various principles in light of the options listed above in #1 and other alternatives you have thought of.
- What should we do? Rank the alternatives.
- Choose a course of action.