There is a moment in every case where a disgruntled patient becomes a complainant. The Tipping Point is a series of cases and commentary that highlight that very moment.
Dr Mike Rutherford, Senior Dentolegal Consultant, Dental Protection, reflects on how a career building trusting relationships with your patients can really help when something does go wrong.
I am a child of the 60s with a sweet tooth to boot and so, long before my dental enlightenment at university, I managed to accumulate a significant restorative burden, or lots of fillings as they say on the streets. As you would all be aware, this is a legacy you carry through life despite improved oral hygiene and dietary changes. Nevertheless, my teeth ticked along quite nicely throughout a 40-year clinical career with a steady but infrequent stream of complex restorative replacements, and the loss of one third molar.
That is until I sold my practice.
I sold it to Andrea, who had been an associate of ours for many years and was a highly capable and empathic dentist who I continue to see now as a patient. Soon after the sale went through, my molars, seemingly by contractual arrangement, decided to sequentially ‘die’, requiring endodontic referrals and cast coverage. Why didn’t they do this when I owned the place and could absorb the cost of treatment in the business? Life is strange in many ways.
Andrea has placed several crowns to date and had recommended a further crown for a previously endodontically treated 37, rather than the existing cusp coverage large composite. She took a PA and all looked fine. We then became distracted with work and my 16, which decided it was its turn to become symptomatic and take precedence. Finally, a week before my 37 crown prep appointment, I started to get food packing 36-37 and minor interproximal and buccal gingival swelling. That’s okay – a bit of composite marginal ridge loss my tongue told me, that can wait.
On appointment day I mentioned it to Andrea, but she took way too long when examining this and she had that concerned look on her face that we all try to conceal. “I’ll just take a PA to check this” – why? Well as it turned out the PA revealed significant mesial bone loss on the 37, which matched the 7mm probing depth that Andrea had detected, nether of which were present when Andrea had taken the pre-op PA three months previously. The crown prep appointment became further confirmation that my tooth did indeed have a mesial vertical root fracture, and one that had presumably been present for some time. At a later date I had the 37 surgically removed.
The Tipping Point
“So what,” you might say, “these things happen.” Yes they do – but I had the unique (for me anyway) experience of seeing this from the patient’s point of view for once. What if my gum hadn’t swollen and Andrea had prepped this tooth for a crown in all clear conscience, not knowing that it had a vertical fracture just waiting to announce itself? What if I didn’t have dental knowledge and understand that vertical fractures do not always present neatly and clearly on pre-op PAs?
Say the tooth had become symptomatic between preparation and crown insertion – or even say two months post-insertion? It is a big leap of faith to go from having to sit through (and pay) for endodontic treatment and then a crown procedure to being told that the tooth is unrestorable and requires removal. Surely someone (the dentist!) has done something wrong or missed something? This can’t be reasonable and just bad luck?
Andrea had of course gone through all the risks and warnings with me (despite my clinical knowledge) prior to treatment, but even so I could not help but feel that for the average patient the scenario I have described stretched credibility. Sure they have been warned, but you took an x-ray! Everyone knows that fractures show up on x-rays, that’s why doctors take them!
Learning points
So how do you defend yourself against your patient’s likely disbelief if this happens, as it no doubt will if you practise long enough? By doing what Andrea did: taking a pre-op PA, by being thorough with the consent process – even with a dentally knowledgeable colleague – by stopping and analysing the cause of food impaction before commencing the preparation, by being genuinely empathic and upset at my unfortunate circumstances and saying how sorry she was, and by walking me through her clinical findings (pocketing) and the PA. Is that enough?
Certainly in my case, but for your average patient: sometimes yes and sometimes no. An offer of an endodontic referral for an independent opinion of both the diagnosis of fracture and, importantly, the cause of these fractures may help if there is doubt in your patient’s mind. A good quality pre-op PA and clinical notes referencing the findings, as well as a documented consent process, are protective should a complaint arise, and like many things in life – you only know that you needed this documentation and consent process afterwards, when an adverse outcome has already occurred.
Finally, this is where Dental Protection’s oft cited concept of the “bucket of goodwill” comes into play – the concept that all the times you treat your patient respectfully and as a fellow human being and not just a set of teeth, incrementally builds up a relationship based on mutual trust and respect. This accumulates all the times when nothing goes wrong, but it is there to be drawn on, when something does go wrong. This concept is important for all patients, and not dentists masquerading as patients, but in a funny way it worked for me too. My years of knowing Andrea and admiration of her dental skills meant that I did not question her judgement or pre-op assessment of my 37 – she had already banked the goodwill in our relationship.