By Dr Simrit Ryatt, Dentolegal Consultant
It is not unusual to find yourself taking over the care of patients from a colleague within the practice you work, as dentists move on to different practices, retire, take annual leave or face sudden illnesses. It can sometimes be a daunting experience if you have to cover for a colleague, especially if it is someone who is very popular with patients or has a personality and persona that is very different to your own.
Successful dentist-patient relationships are rooted in reciprocity – mutual trust and respect. The departure or absence of a dentist from the practice has to be managed with a number of perspectives in mind. It is always a good idea to be as transparent as possible about any changes to your patients’ care and to advise them of a clinician’s departure, whether this is face-to-face or remotely.
Ideally, a personal introduction offers many benefits – the so called “warm handover”. This is not always possible, especially if a colleague’s departure is sudden and unplanned. Other times there may be commercial sensitivities and contractual arrangements may even forbid certain conversations. Communications relating to a colleague’s departure may be limited depending on the circumstances. While it may be ethically desirable to be open and transparent about the circumstances, the truth may infringe personal rights of the individual such as confidentiality. Where possible, the incoming and outgoing parties should agree the message and also ensure that the dental team is aware.
This can be a positive if the patient now has a dentist they prefer, but more commonly it introduces an extra challenge for the new dentist of building trust and respect midway through a course of treatment.
The continuity of clinical care is facilitated by well-organised, clear and comprehensive treatment notes. If there is an opportunity, discuss the handover with the colleague in question. Taking over the care from a predecessor need not be a daunting process and it can be an opportunity to hone your communication skills and build rapport with new patients. Relationship building and effective communication are key to risk mitigation when it comes to the transfer of care from one clinician to another.
Case study 1
When a former colleague has left and there are detailed clear notes
Dr C contacted Dental Protection as she was worried about a situation she was facing at the practice where she worked as a locum associate.
Dr C was aware one of her colleagues had left the practice on bad terms and many of his private patients were only part-way through the treatment plan. The practice owner offered Dr C the opportunity to become a permanent self-employed associate and suggest that she took over the departing associate’s patient list, and confirmed that she would receive the relevant fees from now on.
The clinical records of the departing associate were very comprehensive, clear and unambiguous. The clinical justification and rationale for the clinical treatment had been recorded and there was evidence that the patient has consented to what was done and what had been planned.
The previous associate had forged strong professional relationships with his patients largely through his likeable character and personality. He was by any standards a ‘hard act to follow’.
The practice principal had assumed and hoped that Dr C would be able to continue where her predecessor had left off. Both dentists were specialists in restorative dentistry but with a different career profile and Dr C had only recently returned after a one-year career break.
Dr C contacted Dental Protection to seek clarity and guidance about the dentolegal aspects of taking over a treatment plan that had been formulated by a different dentist. The second part of her inquiry related to her lack of recent experience in carrying out certain procedures. She also mentioned that she was apprehensive about taking over from a very charismatic colleague. She was aware that her own demeanour was a stark contrast to that of her predecessor.
Her adviser at Dental Protection suggested Dr C adopt a proactive approach and review each treatment plan to identify what procedures she felt comfortable undertaking and which procedures she wished to avoid. She would then need to consider whether any patients should be referred to other clinicians within or outside the practice.
It was noted that this is a complex scenario for a number of reasons. Competence and confidence impact on a clinician’s ability to undertake complex procedures and there are also patient expectations to manage. There may be situations when a dentist may wish to reformulate a treatment plan or change the order of the treatment. It is important to spend time discussing the options with the patient and giving them time to digest new information. This is particularly the case with extensive or expensive interventions. It is also important to go through the consent process again to avoid any misunderstandings later. The risks and benefits that have been presented to the patient may be identical but the manner in how they are presented and framed can differ from dentist to dentist and this can affect the patient’s understanding. The discussions should be recorded in the clinical records.
Most patients will accept seeing a new dentist if they perceive the dentist as caring, conscientious and authentic.
With Dental Protection’s assistance Dr C had a clear plan of action in place and the reassurance had an immediate impact on her confidence.
Case study 2
Continuing treatment for a colleague who is shielding/clinically extremely vulnerable (CEV)
Dr L was handed the responsibility of looking after a list of patients following the latest lockdown, as the principal of the practice was CEV and his medical specialists had advised he should no longer attend patients. The principal of the practice was in his late 60s and his record keeping was not of the standard that Dr L had expected.
On the first day back in practice after the news had broken, Dr L decided to contact those patients would be affected by the principal’s absence and introduce himself to them.
His first patient attended midway through his treatment for the “try-in” stage for a new set of complete dentures. Dr L completed the try-in stage of the denture and noted the severely atrophic mandibular and maxillary ridges. From the clinical records, he discovered that the patient had been edentulous for almost 40 years and had previously experienced difficulties with the stability and retention of complete dentures.
The patient commented on the stability of the denture and said he hoped the final dentures would be “a better fit”. It was at this stage that Dr L realised that the patient had high expectations. He reviewed the available radiographs and felt that the patient would benefit from an implant retained denture, but this option was not recorded in the clinical records and after a conversation with the patient, it was clear that no discussions about the options had been discussed with the patient previously.
Dr L’s immediate reaction was one of disappointment and some frustration. He now faced the challenge of how to offer an alternative treatment plan without any overt or implied criticism of the previous practitioner. There were also other cases that day where Dr L felt that patients had not been given the full range of options and in some cases the risks and benefits of interventions had either not been fully explained to patients, or the patients had not understood them. The clinical records were sparse, and this caused him further concern.
After speaking to an adviser at Dental Protection, it was agreed that each case should be assessed separately and that the situation be discussed with the practice principal, with a view to him contacting his patients – not only to introduce Dr L but also to advise them that given the unavoidable delays due to lockdown, the treatment plans would need to be reviewed and reassessed where necessary.
It was also suggested to Dr L that he and the principal could also have a handover discussion about those cases where there was likely to be a difference in clinical opinion. As all dentists are responsible for the care they provide, Dr L would need to feel comfortable with the care and treatment being provided and that the onus would be on him if any aspect of future care was challenged or questioned.
It is not uncommon for dentists to examine a patient and come up with different treatment plans. Some of these may be explained by different perspectives – when, for example, should a discoloured composite restoration be changed? On other occasions a failing restoration may be perceived as a failed restoration and vice versa. After speaking to his adviser at Dental Protection, Dr L was reassured that clinical decision-making is not always as rational as we might believe and that bias can unwittingly affect the decisions clinicians make. Genuine differences of opinion can occur, and just because they do doesn’t mean one approach is right and the other wrong.