When a procedure fails, your patient will still hold you in high regard if you have great bedside manner. You will be better protected from legal redress if you have a proper informed consent and you have communicated the possibility of failure before the treatment. Even with these protections, you still want to express your concern and show compassion. In my specialty, that conversation could go like this:

“I’m so sorry the root canal treatment hasn’t worked out for you. We tried everything possible and, unfortunately, your case was one of the ten percent that just doesn’t heal.”

It is best to stop at this point and wait for the patient’s reaction. If they accept your statement, you should proceed with one of the following solutions:

“I’m going to make arrangements for you to have the tooth removed.”

or

“I’m going to contact your dentist and let him know that he will have to make arrangements to replace this tooth.”

or

“I want you to contact your dentist so he can make arrangements for you to have this tooth removed and replaced.”

If the patient exhibits any feeling of discontent you proceed:

 “I’m sure you remember we discussed the chance of success when we chose to give it a try.”

Notice, blame is not assigned, and you remind the patient that this was what you discussed before treatment was chosen.

Sometimes the belligerent patient will deny ever having such a discussion, at which point it is time to pull out the diagram you drew explaining the treatment, or mention that it was noted in the consent they read before deciding upon treatment.

It is difficult to express compassion for a belligerent patient, but you must continue to be apologetic and explain the situation again, if necessary.

Every practitioner knows what types of failures occur in their particular field and you must have explanations for the most common questions you can expect to hear.

“Why didn’t the scar fade? It looks worse than before!”

“As I explained before we decided to try this procedure, we can’t predict how anyone is going to heal. Some people heal over invisibly and others develop heavy scarring. In your case, we have more of the scarring.”

“How come I have more pain after the back operation than before?”

“I’m sure you remember our conversation about how we usually get a great response to this type of surgery, while other times it just doesn’t work out. When there’s scarring around the nerve root, it can put pressure on the nerves in the same manner that the herniated disk did before the operation.”

For every procedure you perform, you must have a complete understanding of any and all complications, so that your explanations are confident, clear, legitimate, and offer comfort. Patients don’t like to hear, “I’ve never seen anything like this before.” That is not an acceptable response to their concerns. It makes them think you are incompetent. It shows no compassion. It is poor bedside manner.

Even if you have never seen anything like that before, try to have a good answer to help the patient deal with their concerns. This is often the case with an emotionally disturbed, petulant, or chronic pain patient.

“But doctor, ever since you removed my bunion, I noticed that my urine is green and my hair is thinning.”

Although I’m not a podiatrist, I’m fairly certain those symptoms have nothing to do with the operation. Rather than getting defensive and saying, “I never heard of anything like that before,” take a deep breath and try, “I’m very concerned about those symptoms you just described, especially because they have nothing to do with removing your bunion. I want you to get in touch with your medical doctor concerning this matter. I’d be happy to discuss your case in detail, if he/she wants to speak with me.”

If you’re the patient’s medical doctor, or if you’re the specialist their medical doctor sent them to, you may say you want to get a second opinion. Remember: Every patient wants a solution. Don’t be afraid to refer them to one of your colleagues.

In this manner you offer a solution without making light of their concerns or appearing defensive, which many patients interpret as incompetence or lack of compassion. Best of all, you get them into the care of someone who may be able to offer help.

Complicated cases require a cadre of specialists whom you can rely upon.

A pain specialist is a must-have for every practitioner, since we all see chronic pain patients or challenging pain management cases. Attempting to treat these patients without the proper expertise will be a disservice to the patient, your staff, and yourself.

It is also important to have a psychologist/psychiatrist for referral, but making psychiatric referrals are difficult. Patients don’t like to think their problem is in their mind. The slightest mention of a psychological cause of symptoms can make the patient defensive and harbor feelings that you are not compassionate to their needs. Quite often they will doubt your expertise and seek care from other practitioners until they find one who will offer them one treatment or another, though often useless.

When you do suspect a psychological etiology, you may attempt to ease your patient into accepting a psychiatric referral: “After trying all of the methods and techniques I have at my disposal, it may be best to consider seeing a pain specialist or neurologist.”

These doctors will rule out an organic etiology and make the psychiatric referral if necessary. When the patient sees, yet, another doctor who can’t help them, they may finally accept the possibility that they have a psychological problem.

Since neurologists and pain specialists treat many chronic pain patients and many undiagnosed ailments, they often utilize the same antidepressants used by psychiatrists and achieve a high level of success. And when required, they have much more experience making the psychiatric referral.

The Referral Process

All too many practitioners think making referrals makes them look inadequate. That is a dangerous attitude as the patient may not receive appropriate care, and the doctor places himself in jeopardy of legal redress for performing services that didn’t meet the standard of care.

Making referrals shows your concern and is perceived as being compassionate as long as you do it in the appropriate manner.

It’s Not Only What you Say, but How You Say It

Referrals can be perceived in two different ways:

1. NEGATIVELY: You don’t want to deal with the problem, you’re incompetent in your field, or you don’t care about your patients.
2. POSITIVELY: You are genuinely concerned for the well-being of your patients, placing their best interest above all else.

The distinction between caring and callous does not only lie in what you say, but how you say it.

Wrong way:

"Mrs. Smith, I've never seen anything like this before. I'm almost to the point that I don't think it's your tooth that's causing the problem. I'm just not sure what it is. Doing anymore here will be a waste of time. I want to send you to a specialist."

Right way:

“Mrs. Smith, I am so sorry to see that your pain hasn’t responded to any of the treatment I’ve done. While I can’t determine why it hasn’t gotten better, you most certainly have a problem, and we have to find an answer to your problem. I want you to see a doctor who specializes in hidden sources of pain. He’s very good at finding why some symptoms don’t respond to the usual treatments.”

 A variation:

“Mrs. Smith, everything we have tried is just not working. I want you to get better, and I want you to see someone who specializes in more complicated cases like yours. I’m going to send you to a doctor who has a great deal of success in cases that don’t respond to conventional treatment.”

This manner of referral sets up a pathway for success with the potential for placebo effect by mentioning how the new doctor has a “great deal of success.” The key is to communicate compassion while maintaining your credibility. You must always be cognizant of how you are perceived by your patients.

Sometimes doctors who show great compassion and empathy become a magnet for chronic pain patients and lonely old folks. This type of patient has finally found someone who will listen to them, and they have no intention of getting better as it would end the relationship. When you refer these types of patients (after a reasonable attempt to help them), you avoid this dependency situation. If you fail to recognize this pattern, you will enable this dysfunctional behavior and you will not have time to see many patients each day.