Trust yourself

2020 was a very difficult year for dentists and patients alike and the recent holiday season has given all of us plenty of time to reflect on how things could be better in the New Year. This applies just as much to individual treatment failures as it does to the broader issues involved in adapting to the pandemic. A confident professional response from a dentist, when things don't go to plan, can do as much as an indemnity policy in achieving an amicable result for the patient.

The human brain is a wonderful thing. It is far more difficult to recall unpleasant experiences than pleasurable ones. It is not that bad memories disappear, they are stored and retrieved differently to some others. The selective recall of pleasurable events can lend enchantment to almost any aspect of life and generates some comfort in the process because too much pain can be hard to bear. In turn, our worries are replaced with hopeful expectation and trust. Well, at least until the next time those expectations are shattered.

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Dentists normally provide treatments that have a predictable outcome and meet the expectations of their patients. These treatments need to be safe and although nothing can be guaranteed to last for ever, there is an expectation that the treatment will endure. We know from the recent survey undertaken by the GDC that patients are generally confident in the dental profession to achieve such standards.¹

Occasionally, the result is not what was planned at all. In such circumstances it's helpful for the dentist to have a plan in place for such eventualities. It works on three levels:

• 1. Access to experienced colleagues whose support can be relied on. You will need good advice to manage the situation - preferably from an empathetic dentist who understands the clinical and legal aspects of the problem

• 2. An indemnity insurance policy to provide protection against costs that may be involved in resolving the matter

• 3. Confidence in your own skill to manage the situation from the moment you become aware of the problem. Confidence requires a combination of knowledge, empathy and honesty.

The first two strategies are provided by choosing the right sort of indemnity arrangements, but confidence in your own ability has to come from within. Any dental professional who cares for their patients will find that their confidence has been quietly developing ever since leaving dental school.

This case study demonstrates how all three elements of such a plan might work. Although it describes an episode of dental treatment, the strategies involved in managing the situation also apply to the potential for complaints arising from the business interruption created by COVID-19.

Case Study

A new patient attended a local dental practice with a dull pain in the lower jaw. He was seen by an associate who, after reviewing the heavily restored teeth, recommended endodontic treatment. To ensure the best result, the patient was referred within the practice to the principal who had an MSc and a special interest in Endodontics.

Arriving for the treatment, the patient explained he was anxious about treatment and because of this had avoided seeing dentists for a number of years.

Fortunately, the treatment proceeded uneventfully, and arrangements were made for the patient to return for the second stage of treatment. The patient was very appreciative of the gentle treatment and congratulated the dentist on helping him to get through it.

Whilst writing up the notes, the dentist realised he had treated the wrong tooth. The inevitable sinking feeling in the pit of the stomach left the dentist feeling anxious - how had that happened?

The error was caused by the principal mis-reading the handwritten note from the associate; a '6' was read as '5' and the principal could have kicked himself for the mistake and for not evaluating the clinical situation personally.

He called his indemnity provider to explain what had happened and to seek approval for his proposed remedy for this error. He intended to explain the mistake, offer to treat the '6' and complete the '5' at no cost to the patient in recognition of the error. Alternatively, if the patient had lost confidence in his care, he would refer them to another endodontist, again at no cost to the patient.

As an aside, the principal observed that the '5' also required treatment due to the condition of the pulp when opening the chamber but this view was only mentioned in passing and was not intended to justify the error retrospectively.

The dento-legal adviser agreed with the proposed approach, the dentist called the patient, gave a brief explanation and apology over the phone that same evening and invited the patient in to see him the following day, allowing him enough time to mull over the options.

The patient returned as planned; he reported no further pain following the treatment and said initially he had been alarmed to hear the wrong tooth had been treated. However, he decided to let the dentist continue with the proposed treatment and accepted the goodwill gesture of no charge. The patient was also provided with a copy of the practice complaints procedure, just in case he changed his mind.

This proved unnecessary, as the patient appreciated the dentist's candour in the honest admission of a mistake. The patient found it refreshing as well as generating trust in the professional relationship.

The end of the story?

The principal dentist completed treatment of both teeth and was delighted to receive a letter of thanks from the patient which expressed his wish to remain a long-term patient at the practice.

What strategies had been deployed by the dentist to respond do confidently when he noticed his error in treating the wrong tooth?

Empathy

The patient was new to the practice and said he was anxious. The experienced principal will have tuned into the feelings of the patient both expressed and unexpressed. Knowing that endodontic treatment can be disturbing from the moment the rubber dam is applied, the dentist will have picked up the patient's stress but supressed his own emotional response to it in order to carry out the procedure skilfully and with care; fear is communicable in any human interaction and dentists regularly need to manage this.

The human brain is a wonderful thing. It is far more difficult to recall unpleasant experiences than pleasurable ones. It is not that bad memories disappear, they are stored and retrieved differently to some others.

Competence

The dentist had mastery of the required endodontic skills and was well qualified and up-to-date with the necessary techniques to painlessly deliver care of a good standard.

Honesty

On recognising his error, the dentist accepted the mistake and did not try to justify what he had done. He was honest with himself and admitted that it would have been better if he had taken a history and revisited the examination and diagnosis rather than just relying on the associate's plan. He was unhesitatingly honest, when speaking to the indemnity provider and then to the patient.

Self-care

We all make mistakes; how we deal with this internally is crucial. Self-recrimination can lead to a negative spiral and undue stress, which can ultimately be disabling. By seeing the error for what it is and reflecting on how it occurred and what could be done differently; more constructive self-talk is possible. So, negative and destructive thoughts like 'This proves I am useless and should give up now' can be reframed , and replaced with, 'get this into perspective, I have made an honest and unintended mistake which I will do my best to put right and learn from the error; the dentistry itself was good and I managed an anxious patient'.

Communication and courage

The dentist called the patient to ensure he was aware of the error as soon as possible, (the same day). This brief explanation gave the patient time to think and the offer to meet face to face the following day was well judged. It demonstrated emotional courage on the part of the dentist when instinctively others may have gone into hiding to avoid the difficult conversation. Patients 'sense' cover up and this can be a motivation to start litigation. Honesty is the best policy and a sincere apology and offer to put things right generally goes a long way toward resolution and demonstrates professionalism.

Professional advice

Rather than reacting to the error and inadvertently compounding problems, the dentist sought advice from his indemnity provider who confirmed the approach was appropriate and that if the patient decided to complain or pursue a claim, he would be supported.

Money

Money talks and indeed exchanges hands in dentistry; so, the offer to put things right with a goodwill gesture of free treatment achieved a swift resolution. No effort was made to put a case that the premolar required treatment in any event. The fact was, the patient had given consent for the 6, not the 5 to be treated and on that basis there were grounds for a claim.

Complaints policy

Whilst resolution may seem to have been achieved, patients can change their mind (or others can persuade them to do so). The practice complaints policy explains the mechanism for making a complaint and directs then 'in-house' in the first instance. This is, of course, preferable to the patient heading to lawyers or the GDC.