Carrying the Consequences of Our Patients’ Decisions
Written by: Dr. Maggie Augustyn, FAGD, FICOI, FAAIP
For many new dentists, the journey into practice is marked by an overwhelming need to be perfect, to please every patient, and to prove their worth in a profession that demands so much. Perfectionism becomes a double-edged sword, driving them to excel but also leaving them vulnerable to exhaustion and self-doubt. Impostor syndrome creeps in, whispering that they’re not good enough, that they don’t belong, and that every mistake is proof they’ve chosen the wrong path. They second-guess their decision to become dentists altogether, wondering if the weight of their patients’ expectations and decisions is simply too much to bear. This burden—of carrying more than they’re meant to—can feel crushing, and it’s a reality I’ve faced myself. One patient encounter, in particular, forced me to confront these feelings and reflect on how much of this weight is self-imposed and how much is simply part of being human.
Act 1: Agitation in the Air
As I walked into the operatory, I overheard the patient berating my assistant. “This is the second time now that you’ve put your hands in my mouth without warning me. I had my eyes closed and didn’t know you were coming at me.” Her voice was elevated, eminent, and important; she was relentless. She said that same sentence at least three times now. In my head, I was thinking: Can you come to the dentist, sit in a chair, lean back, and not expect someone to place their hands in your mouth? Denise, the dental assistant, profusely apologized, still holding the gauze that so insulted Doreen. The patient’s agitation was contagious.
Act 2: Precision Under Pressure
I walked in and said, “Hi, let me take a look.” I confirmed with the patient that the anesthetic had already had a profound effect. Swiftly, I evaluated the teeth for remaining cement, confirmed that the milled provisional bridge had been cleaned off, and irrigated the intaglio with alcohol. I placed bond and adhesive cement along with the bridge on the tooth, then flossed. I used my finger and a cotton roll to move around the bridge and wiped off any remaining cement. I flossed again. The patient began to sigh and moan. I used an uncooperative bridge threader. The patient moaned again. I light-cured, scaled lightly, and instructed the assistant to finish light-curing and cleaning off to confirm that no pieces were left behind. The patient signed with agitation. Within five minutes or so, while working in another operatory, a sticky note was placed in front of me: “Room 1 wants to talk to you.” Of course, she does, was my own moan in my own head.
When Emotions Speak Louder
I walked in neither aggravated nor compassionate. It was the end of the business day for all of us, including the patient. Doreen began: “You berated me about not taking Xanax, you were going way too fast, and treated me like an animal.” And so, now the rumble began: “Like an animal, you say?” I spoke. I couldn’t stop the words coming out of my mouth. The voice inside my head kept going: I wonder what kind of animal she was thinking of… did I treat her like cattle? I can’t imagine cattle would be treated this well. Or did I treat her like a pet animal? The latter is probably more accurate. To be honest, I don’t remember exactly what other words she used to communicate her distaste for my care. Having heard my response, she got up and left, and I expect that she will not return. There is, however, a strong chance that Google might in some way get roped into this.
The Prequel: Building Bridges, Not Just Teeth
This woman presented to our office for the first time, having taken a long hiatus from dental care. Her blood pressure was 171/100. I tell all my patients that if their blood pressure is 180/120, when it adds up to 300, they’re in a hypertensive crisis, and technically, I should call an ambulance. She knew her BP was high but also said that, despite her doctor’s recommendation, she was not compliant with both of her BP medications because she didn’t need them. She did say that she had dental anxiety and that the last time she had a tooth extraction, she “yelled.”
I spent more time than most during this limited oral exam and invited her to come for a comprehensive evaluation. Months later, her husband called my private cell phone after hours. Doreen was in pain and was specifically requesting that antibiotics be called in. Again, I spent at least 30, if not 45, minutes on the phone with both of them. I explained that I do not prescribe antibiotics blindly, especially when there are no systemic signs of an infection, specifically quoting fever and malaise. The patient’s husband stated that she had neither. I discussed the overuse of antibiotics and antibiotic resistance. I discussed the potential for tooth fracture, which should not be treated with an antibiotic, as an example of what could be causing the pain.
I suggested the use of alternating acetaminophen and ibuprofen if medical conditions did not prohibit it. I discussed the possibility of going to the ER if the patient’s swelling interfered with her breathing. The patient returned to the office the following Monday and received a referral to an oral surgeon for multiple extractions, including the fractured tooth, with sedation. She was then instructed to return, as she had chosen to replace the missing tooth with a bridge. Our interactions up to this point had been pleasant and even upbeat. Doreen wasn’t an easy patient to work on, but she was one that I felt honored to serve.
Is it Her or is it Me?
Most people, when they enter a room, match the energy already present. As I mentioned at the beginning of the article, Doreen’s irritation was contagious. I witnessed her berating my assistant not just for doing her job (and doing it well, I might add) but for doing something that was to be expected at the dental office. It is also likely that, as I watched my assistant be criticized, I became defensive myself. This is not something that every provider or practice owner does, but I desperately wanted to take my assistant’s side. The way I saw it, this patient’s complaint didn’t have as much merit as she was giving it credit for. Denise was gentle, kind, and extremely accommodating. My feeling was that my assistant did not deserve to have the patient explode on her like that. And so, as I entered the room, I matched the energy of the patient, not the energy of Denise. I, admittedly, did not cower, holding up the outdated version of “the customer is always right.”
When Pressure Feels Like Pain
Anxious people, anxious patients, have a disproportionate reaction to very normal things. They are in a state of hypervigilance, and thus, depending on how deep that state goes or how anxious they become, they react with extreme intensity. Pressure becomes pain. A slight touch or rub feels like 10 or 100 times the pressure. They make noises they can’t often control, including screaming, crying, and yelling. This is what Doreen admitted to when she told us about her last extraction. Anxious patients need a tremendous amount of patience and compassion. Its lack can bring on an even more disproportionate reaction and can send them further into their anxiety shell. The lack of compassion, or a perceived negative experience in the dental chair, can also make a patient not want to return to the dentist—any dentist—and can sometimes go years without care.
And here is the thing… I know this. I have lived in my own shell of anxiety, and I am a pro at spotting it in others. I have written extensively about our need, as providers and dentists, to exercise compassion toward those who suffer. That particular article took the cover of the AGD Impact in 2024. I have even gone as far as to say that relationship building with patients takes precedence over medicinal management. I have many patients in my care who have been able to forgo medicinal anti-anxiety treatment because of the compassion that I am able to extend towards them. So, then the question becomes, if I know all of this, if I believe it, if I know how to exercise this, why did I fail in exercising this compassion towards her?
When Reflection Reveals Regret
As I recounted the encounter moments later in my private office, I felt myself physically shaking. Physically shaking. Introspectively, I was attempting to identify my emotions. Was it anger? Irritation? A mama bear reaction toward my team? Did I have a bad day? I really dove deep to try and work this out in my head. Sure, I was angry; how can you not be when someone accuses you of treating them like an animal? But anger wasn’t overwhelming; it might have accounted for only 5% of my emotions. Yes, I was irritated and protective. She accused me of berating her, even though she had just done the same thing to my assistant. This might have been 25%. But my reaction, first and foremost, was an answer to the energy she had laid out in the room. She was demanding, unyielding, and rude. It was viral, and I caught that. I allowed her emotions and her display to affect me. Her expectation was that every human in the vicinity would allow that kind of behavior, forgive that kind of demeanor in her, because she was anxious. And I failed her expectations. We all did. Ergo, her display didn’t change, and neither did mine. Could I have done better? Absolutely. Do I have regrets on how I treated her? Pause. Maybe.
Carrying the Consequences of Another
I do a significant amount of surgery in my office. At least 75% of patients do not fill out their medical history intake form properly. Very few of them actually list the medications they take. When I ask for the list, they often roll their eyes, questioning my “desire” for it. They don’t look at it as a need on my part but rather a quirky wish. They often dismiss me for “just wanting their teeth cleaned.” Yesterday, I heard one patient say, with an A1c reading of 13, “I’m pretty sure I’ll be just fine.” And I answered her, with what might have been perceived as a lack of kindness, “I can’t take your word for it; I have to determine that for myself.”
This week alone, I wrote three letters of medical clearance for patients who take bisphosphonates. I have a patient who has periodontal disease and needs an extraction. I have another who has an infected fractured upper incisor and is in need of not just tooth removal but also a replacement. I asked both of these patients if, prior to the use of the bisphosphonates, they were informed of the dental consequences of taking that medication. The periodontal disease patient stated that she was told to see a dentist but she just didn’t. The second had no recollection of such a conversation.
Every time I get a letter back from the physician, it states that the patient will not interrupt care (infusion of bisphosphonates), that the benefits outweigh the risks (for bone fractures), and that it is left to the dentist to decide whether to perform the procedure. They essentially refuse any liability, but shouldn’t they share it? I stare at these letters and consider the consequences of taking these medications. And when I get myself all rolled up in that predicament, and think of all the things that could go in the direction of MRONJ, I quickly interrupt myself.
“Hold on, this was their decision to take this medication and someone else’s to prescribe it; why am I carrying it?”
A Final Act: The Forgotten Efforts of Care
The idea that we carry the fallouts of our patients’ decisions was no different with this patient. In my response to being accused of treating her like an animal, I repeated that she was anxious and she knew she was anxious. In fact, she knew she would be anxious long before she made the appointment. I told her that we really need to revisit her taking Xanax before any procedure. She responded that it was inconvenient for her to take during the day, as it would require a ride to the office. And because she didn’t, she didn’t take care of herself like she knew she needed to, and we were bearing the magnitude of that decision. She came to the office scared, irritable, and left angry. But was that not preventable? And by holding her accountable for her misdemeanor in my response, I was refusing to carry the weight of her actions. I likely also lost a patient.
So here is the rub: I am not advocating being a jerk towards patients. I am happy to be the compassionate doctor I so often want to be and was born to represent when I care for my patients. And yes, all humans deserve compassion. You don’t have to earn it; you simply deserve it.
And as I make that statement, please do not discount the fact that I, too, am human. Please do not discount every other thing that I have done and will continue to do to provide care of the highest level. Do not discount the fact that working with anxious patients is unforgivingly difficult and, in many cases, does not hold any additional reward for those extra miles traveled. When she accused me of treating her like an animal, she forgot about the multiple appointments when I did hold her hand. She forgot about the time I made for her after hours and alleviated her anxiety on the weekend when she fractured the tooth. The patient forgot about the accommodations made for her the following Monday, as well as the streamlined scheduling with an oral surgeon and the seamless communication between us, the two practitioners. She forgot about the care and attention she received during her bridge preparation. She was angry and irritated, and that’s all she saw. That was her reality. The more I thought about it, the more I realized I wasn’t uncompassionate. Not even a little. I simply redirected the compassion. It moved toward my dental assistant and me.
Being Perfect Meets Being Human
What could I have done better? I could have acknowledged her feelings. After all, all any human wants is to be seen and heard. But I left that out of my response. And sincerely, it wasn’t out of anger or some sort of desire to punish her. I left that out because I wanted to get to the good part. I, like her, wanted to get to the part about me being unseen and unheard. I explained to her that, as a provider who sees an anxious patient, we try to work extra fast to minimize the amount of time we spend in their mouth. As a dentist, it is extremely important that no saliva, not even a breath of saliva, gets on our prep or bridge. And as someone who is a perfectionist, we do not sacrifice any quality of care along the way; in fact, we continue to uphold the highest standard of care. Initially, I really thought that she might come to see how challenging that appointment was not just for her but for the two of us. Very quickly, I was aware that it had the opposite effect. She walked out.
Would I have done things any differently if I could do it again? Sure. My biggest regret or lesson from this is allowing the patient the ability to speak without interruption. In this case, it would have been to allow Doreen to speak and make sure she felt heard. I will have an opportunity to learn from this and put it into practice tomorrow and the next day. Because that’s all life is—a series of lessons from which, some days, we learn more than others. The one thing I will not allow to discount me or my actions tonight is the fact that, as practitioners, we cannot carry the weight of the decisions that patients are making. We are human, too. As I face my own lessons and regrets in this, I sure hope that I could display a sign in my lobby on some days: “We are human, too.”
Proceed With Caution: We, Too, Can Be Broken
This experience reminded me of a truth I often preach but momentarily forgot: compassion is not just a tool for patient care—it’s a practice that must extend to ourselves and our teams. For new dentists especially, the drive for perfection can feel overwhelming, as if every interaction and every procedure must be flawless. But perfection is an impossible standard, and holding ourselves to it leaves little room for grace. While I regret not allowing my patient to feel fully heard, I also recognize that I am human, and my response was shaped by the energy she brought into the room. As providers, we cannot carry the full weight of our patients’ decisions, nor can we always meet their expectations perfectly. What we can do is learn, grow, and strive to do better with each encounter. At the end of the day, I hope my patients—and the world—remember they are as capable of breaking us as we are of breaking them.
ABOUT THE AUTHOR
Dr. Maggie Augustyn, FAGD, FICOI, FAAIP, is a Dawson-trained practicing general dentist, owner of Happy Tooth, author, and inspirational keynote speaker. Featured on 4 dental magazine covers and recognized by Dentistry Today as one of the top 250 leaders, she inspires others through her writing, helping them find healing and connection. Dr. Augustyn serves as the national spokesperson for the Academy of General Dentistry and as a faculty member for the Productive Dentist Academy. She contributes monthly to her “Mindful Moments” column for Dentistry Today and AGD Impact and writes for other publications as well. With unwavering compassion and a dedication to excellence, Dr. Augustyn addresses audiences ranging from a few dozen to thousands, guiding them toward fulfillment and meaningful impact. To contact her, email [email protected].
FEATURED IMAGE CREDIT: PeopleImages/Shutterstock.com.
