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Risk Management

The Case of Divergent Treatment Philosophies

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Graduation will soon be right around the corner. Before you become immersed in a dental practice, you might want to familiarize yourself with a possible scenario that frequently challenges new dental graduates. This scenario involves liabilities that may arise out of differences in treatment philosophies.  In this case, the differences were  between the practice owner and an associate.


The owner -- let’s call him “Dr. Sherman” -- ran a busy pediatric practice in Texas. To help with the patient load, he also employed a number of associate dentists. Carlotta, the patient in this case, was a 15-year-old female who presented for a prophylactic appointment to “Dr. Potter.” one of Dr. Sherman's young female associates. Following a complete set of radiographs, Dr. Potter performed a comprehensive exam and reported her findings to the girl's parents. Carlotta's parents concurred with the proposed treatment plan, and she was scheduled for four appointments during which 11 composite restorations were performed.


At the time of the initial examination, Dr. Potter noted decalcified areas on several of Carlotta's teeth. Because these decalcifications were still confined to enamel or were not cavitated, she did not treat them. It was Dr. Potter’s intention to conservatively manage the lesions for several months to determine if improvements in Carlotta's diet and home care regimen, including use of prescription fluoride toothpaste, would improve the carious process. However, Dr. Potter did not inform Carlotta's parents of her findings or of her intention to use a conservative treatment plan. She also did not document her intentions in Carlotta's record. Within eight weeks, Carlotta’s treatment was completed and she was scheduled for a six-month recall appointment.


When the recall appointment date arrived, Dr. Potter was on vacation and out of the country. Rather than reschedule, Dr. Sherman took the appointment and in preparation for the appointment reviewed the patient’s radiographs. Because Dr. Potter's notes did not include any reference to monitoring Carlotta's recommended home care regimen, Dr. Sherman saw only that the patient had eight carious lesions. His treatment philosophy, being more aggressive than Dr. Potter's, suggested that the teeth should be treated. He, therefore, informed Carlotta's parents of the proposed treatment.


At this point, the parents became furious and took their daughter to another dentist for a second opinion. The consulting dentist confirmed that Carlotta did indeed need at least eight additional restorations. Carlotta's parents, unaware of Dr. Potter's original intent, held her accountable for this perceived diagnostic and treatment failure. They consulted with an attorney and filed a lawsuit.


After a period of discovery and depositions, Dr. Potter, whose malpractice insurance policy fortunately required her consent to any settlement, requested that the case go to trial. After four days of testimony, the jury returned a defense verdict, and the doctor’s reputation remained intact.


 Risk Management Review 

Kathleen M. Roman, MS* 


Communication is an often-ignored element of human society. We presume that it occurs naturally and doesn't take much effort. Yet, few of us, either as children, or as adults, have received much formal training in communication skills. As a result, minor communication gaps can cause – as clearly seen in this case – complicated business and legal challenges. Relatively simple communication processes could have prevented this lawsuit. 


First, every healthcare professional should define for himself or herself a personal professional practice philosophy. For example, as seen in this case, some dentists quickly address any sign of abnormality while others use a more conservative approach, monitoring a less-invasive treatment plan before recommending aggressive treatment. In many instances, both approaches could be acceptable practice.  


Dr. Sherman's practice had evidently not found it necessary to discuss practice philosophy and to identify some common team practices that they could all agree upon. This important discussion, "Let's understand each other's diagnostic and treatment philosophies," might help, but could still be insufficient if the group can't reach consensus. Ideally, they should seek to establish a common ground, although a rigid treatment policy isn’t necessary. 


Even if they had worked through this "agreement" phase, their consensus might have been insufficient to have prevented this particular lawsuit as there were also other communication errors. Dr. Potter made two important communication errors: a) she didn't explain her observations and proposed maintenance plan to the parents in any detail and, b) she didn't document her conservative approach. 


Had she discussed her less rigorous approach with Carlotta's parents, Dr. Potter might have been able to formalize their buy-in to this short-term – and likely less expensive – approach. Knowing the temporary nature of this proposal, they might actually have been grateful to Dr. Potter for her conservative suggestions. Consequently, she set herself up for their wrath by not including them in discussions of both short- and long-term treatment planning and obtaining their buy-in. 


It should be noted that, in some instances, the parents actually might have wanted the more aggressive treatment plan to be initiated. The lack of discussion deprived them of this option as well. 


Dr. Potter's failure to document her conservative approach was a disservice to her patient and, as became apparent, to herself as well. Had this case gone to a dental board for review, she might have been criticized for her poor interactive and written communication processes. Depending on the state, the dental board might also have criticized Dr. Sherman for lax oversight of his staff's treatment planning and documentation. 


A good rule of thumb is that communication with the patient ensures that everyone is on the same page -- but the discussion should be documented. It confirms the attempt to obtain informed consent and it confirms the patient's commitment to compliance with the treatment plan. A final element of this rule is that documentation should also accommodate continuity of care -- ensuring that another practitioner can pick up where a dentist has left off and, with confidence, proceed with treatment if the first clinician is unavailable. The patient's record isn't only a memory jogger for the treating practitioner; it also facilitates continuity of care and patient safety when short-term -- as in this case -- or long-term/permanent transitions become necessary.  


As a dental student, you are advised to start considering now what your practice philosophy will be, and always maintain complete written records as well as open communication with your patients and any practitioner(s) in your practice. In this way, you may be able to save yourself a lot of heartache. 


* Kathleen M.  Roman is Risk Management Education Leader, Medical Protective, Indianapolis, IN.