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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. 

The Importance of Consultation with the Patient's Physician

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As you work toward your dental degree, give credence to the importance of physician consultation.  If you don’t, you may find yourself in court.  One experienced dentist--we will refer to him as “Dr. William”--learned this lesson when he deemed it unnecessary to consult with a patient’s physician during extended dental treatment.  Dr. William was an accomplished implantologist and surgeon who had treated the patient--we’ll call her “Cecilia”--on several occasions over a 12-year period.


During this timeframe, Dr. William had performed periodontal surgery on Cecilia, as well as an extraction, with no postoperative complications.  Sometime in 2007, Cecilia made an appointment to consult with Dr. William about the possibility of restoring her mouth with a fixed implant prosthesis.  During this visit, she stated that she could no longer wear her mandibular removable partial denture due to decreased salivary flow and dry mouth.


An update to her medical history, completed during this consult, revealed that some of her oral complaints were likely associated with her medical status, which included a diagnosis of scleroderma and lupus.  Cecilia also had been treated for breast cancer, had received systemic bisphosphonate therapy, and was currently receiving oral maintenance therapy of this drug.


Having successfully operated on Cecilia twice before, Dr. William decided that she would be well served with an implant and made this recommendation to her. The surgery was scheduled to include placement of an implant in the position of tooth #28, which would be used to create a fixed appliance incorporating teeth #25 and #26 as abutments, and replacing tooth #27 with a pontic.


Surgery was scheduled and performed. Following surgery, the patient was placed on antibiotics and released from the hospital.  Healing appeared to go well.


At six months, the implant was uncovered but it had not integrated, thus necessitating its removal.  More important, however, as a result of the patient's reduced salivary flow, she now had significant carious lesions on teeth #23, #25, and #26.  In an attempt to address the situation, Dr. William recommended an even more aggressive treatment plan, consisting of removal of the remaining mandibular anterior teeth and a lower right molar, and replacing the entire quadrant with a fixed prosthesis.


Because he had treated this patient on several occasions over a 13-year period, Dr. William did not think that consultation with her physician was necessary. On the basis of his knowledge of the patient and his experience performing these types of procedures, he believed that none of these conditions contraindicated implant placement.  Dr. William decided, therefore, that the surgery would be in Cecilia’s best interest.


Early in 2008, Dr. William removed four teeth and placed five root-form implants.  Even though Cecilia had been given prophylactic amoxicillin, the site became infected almost immediately after placement.  Within 30 days, all five implants were lost.  Compounding the problem, the wounds did not heal and it was determined that Cecilia either had osteomyelitis or osteonecrosis secondary to the bisphosphonate therapy.


Cecilia was referred by Dr. William to the oral surgery department at a major teaching hospital where she underwent a series of surgical procedures--all unsuccessful. Eventually it became necessary to remove the right half of her mandible.  Reconstruction was deemed too risky, and so she was taught to function with only the left side of her mandible.


Cecilia filed suit, naming Dr. William as the sole defendant.  Interestingly, she made no allegations relative to his surgical skills; rather, her complaint focused on his failure to consult with her physician prior to treatment.


Cecilia's physician testified at trial that he would have recommended against surgery, not because of any one of her ailments, but based on the overall picture of her medical health, including the multiple disease entities.


Unfortunately for Dr. William, the jury agreed with Cecilia and her doctor, and awarded her $1.3 million.  The case was not appealed.


This case provides several important lessons. Most obvious is the value of consultation with other healthcare providers based on the patient's medical status.  Certain diseases or conditions should trigger automatic discussion with the patient's physician.  Second, an updated medical history is a key component of any treatment plan; for patients with co-morbidities, its importance cannot be overstated.  Third, all patients have the right to sufficient information and consultation so that they can give a truly informed consent.  For the high-risk patient, additional discussion and deliberation may help him or her understand the potential risks, especially when the conversation takes into account input from the patient's physician(s) or other providers.


Management of the High-Risk Patient 

Kathleen M. Roman, MS 


When you become a practitioner, you may complain--as some dentists do--that patients don't recognize the relationship between oral health and systemic wellness.  This concern poses an excellent opportunity for patient education.  At the same time, it challenges dentists to practice what they preach as they assess the medical status of patients who need dental care.


In this case, Dr. William made a number of assumptions--most of which turned out to be incorrect.  Following are some practical tips that might have helped him prevent the serious injury to his patient and the unfortunate legal consequences.


  1. Implement a policy that ensures periodic review and update of the patient's medical history.  No one's health status remains the same forever and sometimes significant health changes can occur within a relatively brief period of time.  Example: Mr. Smith is mid-stream with a series of extractions, restorations, and implants.  You saw him last month and his next appointment is scheduled for tomorrow.  Last week his physician started him on a blood thinner.  Odds are that Mr. Smith won't remember to tell you that he's started taking this drug--unless you ask.
  2. Develop a personal checklist for patients whose health conditions put them at high risk for dental complications.  While most dentists would automatically add HIV, autoimmune diseases, and cancers to this list, other conditions such as morbid obesity, high blood pressure, diabetes, and mental disorders are sometimes ignored--with dangerous consequences.
  3. Stay current with advances in medicine as well as in dentistry.  If a patient reports that he or she has a condition you're not familiar with, do some research.  Many genetic disorders, for example, have oral health implications.  And, new procedures and drugs may significantly alter a patient's candidacy for dental treatment.
  4. Consider whether or not the patient is capable of complying with treatment-related instructions.  Find out what obstacles may stand in the way of the patient's full cooperation.  Ask.
  5. Do your best to include the patient in treatment planning by discussing the anticipated benefits and the potential risks associated with treatment options.  Take into account the patient's specific health conditions and personal health objectives.
  6. Encourage patients to obtain second or even third opinions in high-risk cases.  This advice should include dental specialists as well as consults with medical experts, if advisable.
  7. Document all of these interactions.  Documentation will help you remember important elements to be considered while planning treatment.  It will help identify differences in your expectations as compared with the patient's.  It will help keep you and the patient's other healthcare professionals on the same page.  And, it will likely be your very best witness if a less-than-satisfactory outcome turns into a dispute.


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

Holistic Treatment Gone Awry

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Several years ago, “Dr. A” moved to a west coast community known for its laid back “sixties” lifestyle. Having decided that the "back to nature" atmosphere of the community would support a holistic approach to dentistry, Dr. A opened his practice and differentiated it from other dental offices in the area by advertising that he specialized in "holistic dentistry." In order to differentiate his practice from other more established colleagues, Dr. A even had the local pharmacy compound a distinctive mouthwash, using all natural ingredients, which he dispensed to his patients as yet another distinctly holistic service.


As his forays into the holistic side of dentistry were successful, Dr. A slowly began to downplay the importance of sound research in making clinical decisions. In his treatment planning, he began to rely more and more on anecdotal reports from patients and various alternative healthcare providers. At some point, he was introduced to the “therapeutic” benefits of magnets and began to use them in the treatment of myofascial pain and bruxism. Over time, Dr. A became less committed to conventional treatment protocols and increasingly relied on unproven treatment options (eg, magnet therapy) for some of his more acute cases.


Then, Dr. A met patient Wayne who presented with a painful tooth. Doctor A diagnosed a periapical infection of tooth #4 but, since holistic dentistry calls for minimal use of radiographs, this diagnosis was made without the benefit of one. The appearance of swelling, percussion sensitivity of the tooth, and a large restoration essentially confirmed the diagnosis of an abscessed tooth. Wayne requested holistic treatment--meaning that he wanted neither antibiotics nor endodontic therapy.


Doctor A explained that those would be the best therapies under the circumstances, but Wayne appealed to Dr. A's reputation as a holistic dentist and pushed for a less invasive treatment. As a compromise, Dr. A offered magnetic therapy, which involves placement of a series of magnets of increasing strength on the outside of the cheek and alternating with poultices placed on the buccal mucosa over the apex of the tooth. Remarkably, the magnet-poultice treatment seemed to work. The swelling decreased and Wayne reported that the tooth felt more comfortable. In about four weeks, however, he began to experience symptoms of sinusitis, including a slight yellow-brown discharge from his right nostril. He sought advice at his local health food store, where the staff suggested a tea that, reputedly, soothes the maxillary sinuses. Wayne followed this regimen for about 10 days, but his condition worsened. Tissues around the tooth again began to swell and became increasingly sensitive to percussion.


Concluding that the two sets of symptoms might be related, Wayne decided to seek the services of Dr. B, his employer’s dentist, an experienced and respected local practitioner who had a reputation for conservative dental care. Doctor B completed a radiographic evaluation and found that tooth #4 had a large radiolucency over the apex, which was precariously close to the maxillary sinus.


He immediately prescribed amoxicillin and referred Wayne to an endodontist in a nearby community. Endodontic treatment was performed and the swelling declined; however, the drainage persisted. Wayne was next referred to an otolaryngologist, who diagnosed a severe sinus infection of dental origin.


The otolaryngologist initiated an aggressive antibiotic regimen, but the infection did not heal. Finally, the tooth was removed and the oral antral fistula was surgically repaired. Wayne's recovery from the surgery was unremarkable, but he continued to exhibit symptoms of a chronic sinusitis, which were treated and continue to be treated symptomatically by his ENT physician.


Wayne was extremely angry over this turn of events, insisting that he would have had conventional therapy had he known about the potential complications. He sued Dr. A.


Unfortunately, Dr. A's notes were problematic. They lacked any discussion of the risks associated with refusal of pre-operative radiographs or endodontic treatment. Very few entries documented clinical management of the case. Without adequate scientific evidence or documentation to support treatment planning discussions between doctor and patient, Dr. A's malpractice insurance carrier was concerned that the case might be difficult to defend. In light of this challenge, Dr. A elected to settle the case out of court.



Risk Management Assessment: 

When is Holistic Dentistry a Valid Choice? 


Kathleen M. Roman, MS 


 Complementary and Alternative Medicine (CAM) continues to make rapid headway in the U.S. Adults in the U.S. spend nearly $34 billion annually on out-of-pocket healthcare products and services, according to a 2007 National Institutes of Health survey.1 Holistic modalities--those that focus on treating the entire individual, rather than just one ailment--are an integral part of many types of CAM practice. 


 Holistic modalities are not unknown in dentistry, and some dental practices market holistic approaches to patients who claim that they want to take a more proactive role in their healthcare, including the prevention of oral disease. While there is scientific evidence to support the benefits of many CAM therapies, some modalities have not been adequately tested and some may be dangerous. 


 The problem in this case is not that Dr. A offered his patients a holistic approach to dentistry; rather, it appears he forgot to consider the core elements of diagnosis and treatment planning. Some elements of care cannot be ignored. Wayne had a significant infection, which could not be resolved without the use of antibiotics. 


 Further, it is unclear how assertive Dr. A may have been in suggesting that his patient needed a radiograph or needed to see an endodontist. The reason for this lack of clarity is because Dr. A's records didn't include documentation of any recommended diagnostic workup, the need for endodontic treatment, or the risks that might occur without these needed interventions. Further, the record didn't document Wayne's questions or concerns. 


 What the case later showed, however, was that Dr. B apparently had little difficulty convincing Wayne that he needed radiographs, a heavy antibiotic regimen, and finally, surgical intervention. If Dr. A had been able to identify the scope of the infection and convince his patient to seek specialty care, it is possible that the infection could have been promptly treated and appropriately monitored, thus potentially avoiding the need for surgery. 


 Dr. A had an obligation to explain to his patient why holistic methods are appropriate for some types of treatment but not for others. He should have explained the need for the radiograph and his rationale for recommending a non-holistic treatment plan. If Dr. A had done a better job of explaining these matters and documenting them, Wayne might have changed his mind and, regardless of the outcome, a lawsuit might have been prevented. When the record is blank or incomplete, it can be very difficult to defend the doctor's actions. 


 Settlement of this case was primarily influenced by two factors: a) Dr. A's apparent failure to adequately explain to his patient and to document his rationale for a non-holistic treatment plan, and b) Dr. A's overreliance on an unproven treatment without explaining the potential risks to Wayne and documenting Wayne's questions or concerns. 


 Both the American Dental Association2,3 and the American Medical Association4 are supportive of further research and education for healthcare professionals relative to the use of CAM therapies. Since this is an area in which no clear standard of care has been established, it is especially important that patients be informed when a CAM therapy under consideration falls into the category of experimental or untested. Without the doctor's clinical oversight and without the patient's acknowledgement that the proposed treatment may pose unnecessary risks, it could later be alleged that the doctor did not obtain an adequate informed consent. 


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



 1.   Costs of Complementary and Alternative Medicine (CAM) and Frequency of Visits to CAM Practitioners. United States, National Institutes of Health. National Health Interview. 2007. 


 2.   Little JW. Complementary and alternative medicine; impact on dentistry. Oral Surgery 2004;98(2):137-145. 


 3.   Wright EF, Schiffman EL. Treatment alternatives for patients with masticatory myofascial pain. J Am Dental Assoc 1995;126(7):1030-1039. 


 4.   American Medical Association Policy H-480.964. AMA House of Delegates Resolution 306; June 2006. 


Preventing Aspiration or Accidental Ingestion

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As a dental student, you may have considered the possibility of a future patient’s accidental ingestion of a dental instrument. One case of unintended ingestion involved a female patient – let’s call her Mrs. Jones – who accidentally swallowed an implant hex tool. The patient's care was further complicated by the fact that a hospital emergency room failed to consult with her dentist before deciding to undertake a complicated procedure.


Mrs. Jones presented to a doctor – we’ll call him Dr. Smith – for treatment of peri-implantitis secondary to four implants supporting a mandibular overdenture. She had been a patient of this dental practice for over 20 years, although Dr. Smith had only recently purchased this general dental practice and was meeting her for the first time. Mrs. Jones had a history of dysphagia and had undergone swallowing therapy and periodic esophageal dilation, but she did not tell Dr. Smith of this condition.


Upon examining Mrs. Jones, Dr. Smith decided to remove the abutments in an effort to evaluate the implants and treat the inflammation. As he had not placed the implants or fabricated the appliance, this would enable him to evaluate the problem more thoroughly.


In the course of removing one of the abutments, the wet instrument (approximately 4 cm in length) slipped out of Dr. Smith's grasp, fell to the rear of the patient's mouth, and disappeared down her throat. Immediately concerned that Mrs. Jones might have aspirated the instrument, Dr. Smith sent her to a nearby hospital.


At the hospital, radiographic exam revealed that the hex tool was located in Mrs. Jones' stomach. A gastroenterology consultation was requested and, based on the instrument's sharp-looking appearance, the consulting physician offered to remove the device. The patient's informed consent did explain perforation of the esophagus as a risk associated with the procedure. Subsequently, the instrument was removed.


Because Mrs. Jones had a narrow esophagus, the gastroenterologist was unable to use a sheath, which might have been able to protect the walls of her esophagus. At the conclusion of the procedure, the gastroenterologist noted that he may have lacerated the esophagus. He immediately ordered a swallowing test that confirmed the perforation, and a surgeon was consulted. Mrs. Jones was taken to the operating room and the surgeon repaired the laceration. A few days later, Mrs. Jones was discharged with instructions to follow a puréed diet.


During the next few months, she underwent several additional medical procedures in an attempt to help her with her swallowing and increase her ability to eat more substantive foods. She seemed to be doing very well in her convalescence; however, her condition suddenly worsened, requiring hospitalizations for a minor stroke, atrial fibrillation, renal insufficiency, and a second stroke. Because of her loss of some motor function, a gastrostomy tube was placed so she could be fed.


About two weeks post-op, while having breakfast with her husband, Mrs. Jones complained that she was still hungry even though she had been tube fed. He made her a scrambled egg, fed it to her, and she appeared to aspirate it. She was rushed to the hospital, but expired shortly after arrival. A lawsuit was commenced, naming the dentist, the hospital, and the gastroenterologist as defendants. Given the potential risk of a high-dollar verdict, the defendants elected to settle the case out of court.


Though such cases are frightening, they are also preventable. As a dentist, you will be able to use any number of clinical mechanisms to prevent this type of injury. Some examples include:


  1. Tie a piece of dental floss, too long for the patient to swallow, around or through the instrument before placing it in the mouth. This technique is also helpful in endodontic procedures that must be performed without the benefit of a rubber dam.


  1. Maintain the patient in as upright a position as the procedure will allow, so that a dropped instrument will fall to the floor of the mouth rather than to the back of the throat. This would also be the preferential position for the placement of crowns on the posterior teeth, with special consideration given to maxillary second and third molars.


  1. A throat pack of some sort can be employed. This alternative is not as beneficial, because it could also lead to gagging, and the management of the tongue might become an issue. It is, however, sometimes helpful in surgical situations.


This case study poses some interesting challenges, most of which could have been avoided if Dr. Smith had used a clinical mechanism to prevent his patient from swallowing the dental instrument.

Social networking: A good thing from a malpractice perspective?

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I am a relative newcomer to the Facebook universe and, as such, I am having one of those “lifetime learning” experiences as I negotiate my way around the world of social networking. It would be an understatement to say I am overwhelmed. But as a dentist who has practiced for 40 years without incident, I enter into all new practice-altering relationships with a healthy dose of attention to risk. For today’s discussion, let's consider the hypothetical case of Dr. Mario, a dentist completely conversant with social networks and who, in order to protect himself appropriately, must ask himself the following questions:   


Question: What are the risks of staff members and patients becoming Facebook friends?  

Let's start with a case that I often share as a cautionary tale. It begins with a young dentist who bought a practice that included a patient who was in the midst of an extensive implant treatment plan. During the treatment plan, a chance meeting between the dentist's receptionist and the patient occurred in a social setting. This chance meeting, and the inappropriate health-related conversation which ensued, resulted in issues that culminated in a lawsuit with allegations of negligence.


If we fast forward to today's social scene, the same type of accidental meeting could still occur within the context of electronic social networking. Not only could such a meeting occur, but in the course of posting on a respective wall, a patient and a staff member might even discuss care-related issues such as potential treatment problems, fees, shared clinical experiences, complaints, or other comments that could potentially harm the practice. 


As a preventive measure against this kind of risk, it might be helpful to develop a social networking policy and to have employees sign a confidentiality agreement that specifies the kinds of information that may and may not be exchanged with patients outside the formal interactions of the office. This type of agreement should be written by an attorney and it should address the actions of employees, as well as the behaviors of former employees, regardless of whether they have left the practice of their own volition or their employment has been terminated. 


Question: What if I receive ‘friend requests’ from my patients on Facebook? 

I have been solicited for friendship by a few patients and friends of patients. Do I want to enter into anything less than a doctor-patient relationship with these folks? Is anything posted on a social networking site admissible in a court of law? Given that this is an evolving area of legal debate, it would be wise for anyone using social networking sites to assume that they are never private and that anything posted on them has the potential to be accessed by individuals who may have a dangerous agenda.  Thus, I am extremely careful about what I say and to whom I say it in a public forum such as Facebook, Twitter, MySpace, etc.


Would I advise you to do the same? Absolutely! Quite frankly, I see nothing but landmines for professionals who are careless with their personal and professional postings. Even a very innocent activity or comment can be taken out of context. Do you want one of your friends to post a picture of you at a party? Perhaps with an alcoholic beverage in hand? How about in a gambling casino?


A suitable alternative may be to create a professional page for the practice. This way, you do not need to outright reject a “friend,” but rather suggest that the potential friend visit your business page instead. Note too that THE NEXT DDS, which enables access only to validated dental students, may provide an option for professional exchange that is out of the public domain. However, having chosen either option does not, in any way, diminish the need to be vigilant about what is posted on both your personal or professional page.   


Question: What if staff members use the Internet and social networking sites to post information and pictures that involve office activities, staff, and doctors?  

There should be concern about possible revelations on a social networking site--including trade secrets, questionable office practices, patient care, the social shortcomings of the doctors, vacation schedules indicating when the office is empty, and more. For example, doctors and staff might be enthusiastic about posting pictures and activities from a continuing education trip to Hawaii. The intention of the post may be to indicate that the staff and doctor are zealous about staying current with new science and clinical skills. The post may even go a step further to announce to readers that they are now able to offer their patients a new procedure. It sounds very exciting, but remember how I said earlier that postings can often be misconstrued. The post might instead suggest to patients and prospective patients that the doctor is inexperienced in that modality, and thereby question the doctor's competence. The post may also give readers the impression that a practitioner who can afford a Hawaiian trip probably charges higher rates than other dentists. 


As a preventative measure against this kind of risk, it might be helpful to have a clearly-defined policy for all employees that restricts posting information and pictures about office activities on social networking sites and specifies the consequences for posting such information. In addition, if the office has its own business site, all items posted should be approved by the doctor or another individual who understands the risks involved.  


Risk Management Summary 

It is important that users of social media remain aware of issues such as good manners, safe behavior, and security. Because new protocols are still emerging, healthcare professional must be vigilant against aberrant behaviors that may include:

  • Young people sending inappropriate photos or messages in social networks that may cause embarrassment and hamper their future careers.
  • Employees of healthcare organizations taking inappropriate photos of patients (whose privacy is protected by ethical constraints as well as by federal regulations). These actions open the employees for job loss, professional disciplinary actions, federal fines, and, depending on the actions and motives, criminal charges.
  • Professionals becoming tangled in a swirl of social "gossip" and then finding it difficult to extricate themselves when the actions of the group are unwelcome or inappropriate.
  • Doctors and staff members who are lax in the way they manage their personal communications while on the job--or while communicating away from the office--may unintentionally allow non-employees a glimpse of protected information relative to the doctors, other members of the healthcare team, other providers, patients or former patients and families, or other clinically focused transactions.
  • Employers, many university and graduate programs, law enforcement, and security monitors represent just a small sampling of observers of social network communication that may harm the senders, the individuals they "chat" about, and those who are part of the senders' networks. Sadly, those who have less-than-honorable intentions may also threaten the safety and security of networking individuals who are too casual in the amount of personal information they share about themselves, their colleagues, friends, or patients. 


Until the processes for social networking and instant electronic communication (e.g., Facebook, Twitter, SMS messages and photos) provide sound guidelines for good behavior, doctors and future caregivers must be vigilant about protecting the reputations of their practices and their employees, as well as the privacy and security of their patients' and employees' personal information.


Human Resources policies and procedures should address this subject from the perspective of 1) Employees' rights (not to be gossiped about, for example) as well as professional obligations (to protect patients); 2) Patients' rights to privacy and security, 3) The doctors' ethical and legal duties and boundaries, and 4) Compliance with federal, state, and professional guidelines. Clinicians can prevent inappropriate use of social networking and electronic media by setting an example of restraint in the use of these technologies and by requiring policy compliance by anyone associated with the practice, including part-time or temporary employees.