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Defensive practice – does it really lower our risk?

02 November 2021

Dr Simrit Ryatt, Dentolegal Consultant at Dental Protection, looks at why certain approaches to avoiding risk can become self-fulfilling prophecies

The fear of complaints, litigation and a regulatory challenge can sometimes be so overwhelming that it can impact on a clinician’s clinical judgement and decision-making to the extent that it causes them to practise what is described as ‘defensive dentistry’. 

Clinicians will often steer away from procedures that carry a greater risk of failure or avoid patients who have high expectations, in the hope they will have a reduced possibility of facing the risk of a claim or complaint. By practising in this way, clinicians need to be careful what they wish for, as the very risk they are trying to avoid by practising defensively creates a new risk or exposure to a different risk.

In terms of an evidence base supporting the concept of defensive practice, there is a fair amount of literature related to defensive medicine but very little specific to dentistry. When you search for a definition of ‘defensive medicine’ you will find several results. Oxford languages defines defensive medicine as:

“Medicine practised in such a way as to reduce the risk of malpractice litigation, typically by the use of excess diagnostic testing.”

When you search for the definition of defensive dentistry your results will be fruitless as the definition does not exist. Immediately lots of questions spring to mind such as, does defensive dentistry simply not exist? Is it only a medical phenomenon? The reality is that defensive dentistry does exist, and we often find evidence of defensive practices lurking in the background of complaints we are assisting members with here at Dental Protection. 

Does defensive dentistry really exist?

So what would be the definition of defensive dentistry? Could we apply the same definition of defensive medicine to defensive dentistry? The main bread and butter of our diagnostic testing in general practice is the taking of radiographs, vitality tests, tooth percussion and detailed pocket charting, and I am sure you will agree these tests tend not be over-used; therefore the commonly applied medical reference would appear to be inappropriate for dentistry. 

In a well-known defensive medicine study in 2013, Ortashi et al defined defensive medicine as: “A doctors’ deviation from standard practice to reduce or prevent complaints or criticism.”

This definition certainly resonates with defensive dentistry and, in addition, having reviewed many cases related to defensive practice we have also determined other common themes. I have found many practitioners influence their patients to choose treatments that they are more comfortable with and many dentists avoid certain treatments and certain patients. 

The final theme I have noted, and I feel slightly uncomfortable raising this point, is that some dentists lose the primary focus of ‘the best interests of their patients’ being integral to everything they do and let the focus shift to themselves. This last point is clearly in conflict with the standards of conduct, performance and ethics that govern us as professionals. We should always be providing the best possible treatment for our patients, so how do so many of us find ourselves subconsciously and inadvertently putting ourselves first and not our patients?

Examples of defensive practice

We will often assist dentists with the resolution of complaints arising from patients who are in pain and unhappy following an incomplete extraction and then have had to suffer for a substantial length of time to have their tooth eventually extracted elsewhere. A common scenario is a young dentist attempts to extract the tooth, gets into difficulty and nobody in the practice is willing to help their colleague and supports the referral protocol. 

It’s not because of  the unexpected clinical challenge; it’s more a decision taken to avoid being dragged into a potential complaint about poor treatment or service. Similarly, we review complaints from patients left in discomfort where the dentist was worried about adjusting a denture provided by their colleague for fear of getting blamed for worsening the situation. We also see dentists avoiding molar endodontic treatment as the treatment is perceived as being a potentially litigious procedure. The information presented to the patient includes the available options but is framed in a way that the extraction appears to be a more attractive solution for someone in pain. 

Why do some dentists allow their subconscious self-serving nature to influence clinical decision making to the detriment of a patient?

We accept that the significant driver for defensive dentistry is the possibility of facing a complaint, a claim for compensation or a regulatory challenge. This fear is the catalyst for the defensive action, which could almost be attributed to an unconscious form of self-preservation. This action could be described as ethical fading, which occurs when the ethical parts of a decision disappear from view. 

It often occurs when people focus heavily on other aspects of the decision such as a certain goal like stress avoidance, profitability or winning. In essence, ethical fading is a form of self-deception that occurs when we subconsciously avoid or disguise the moral implications of a decision. It allows us to behave immorally while maintaining the belief we are ethical and have integrity. For example, most dentists would say to their colleagues that they would never sacrifice healthy enamel for purely cosmetic reasons, yet our claims experience suggests that some of these dentists do actually destroy healthy enamel when they are the only judge of their own ethical conduct at the time the treatment is discussed and agreed.

A question of ethics

Ethical fading in dentistry is the subconscious bias that drives the self-serving nature so that we stop seeing the ethics in the situation. An example is a dentist coercing the patient or steering the treatment, so they provide the treatment that they are more comfortable with. The more it is repeated and successfully completed, it eventually becomes normalised and people will not even realise the decision is unethical. It is often described as self-deception and is rooted in psychology where ethical aberrations are distorted and disguised as actions with honourable intent. As we can see it is far removed from the famous ‘daughter test’, which uses the analogy that all patients should be treated as though they were a favourite daughter.

It is accepted that dentistry is a physically and emotionally demanding job where you need exemplary interpersonal skills and business sense. It can be quite isolating and mentally draining at times, so it comes as no surprise that sometimes people feel compelled to take the easy route, such as avoiding certain stressful treatment choices.

With over 125 years of experience we have a unique insight into why things go wrong and the best ways for our members to avoid them. As we have recognised that defensive dentistry exists, prevention is better than a cure, and having the knowledge to combat potential issues is the best way to stay protected. If the main driver of defensive practice is the fear of complaints or litigation, let’s look to see how they can be mitigated with better communication skills and effective complaints identification and management. It can be a team effort so everyone is on the lookout and when it happens they all know how best to handle the situation. 

We need to be honest with ourselves, particularly where we face ethical dilemmas, and be prepared to reflect on our decision making and setbacks and positively use them and not fear them; after all, we can only improve when we fail – and how can self-improvement ever be perceived as a negative?