An interesting contrast between legal cases which involve dental practitioners, and those which involve medical practitioners, is that medical practitioners are often accused of 'failing to treat' or of 'delaying treatment' but rarely 'over treatment'.
The dental practitioner by contrast can find all three allegations are made against them. Over treatment is difficult to define accurately and is often nothing more than a difference of clinical opinion. One practitioner may feel a crown is required on a tooth whilst another is confident that a large restoration will suffice. It all depends on the clinician's perspective.
Not providing treatment is quite another matter and the clinician can often find themselves facing allegations of 'failure to treat' or 'delayed treatment'. Collectively these allegations are variously described as 'under-treatment', 'underprescribing' or even 'supervised neglect'. The background to these cases is often more complex than it might seem at first sight. The emotive phrase 'supervised neglect' is often used to describe a situation where a patient's oral health has been allowed to deteriorate over a period of time, despite regular attendances to the dentist who is responsible for the patient's care and treatment.
It is sometimes confused, with a situation where the patient's oral health has been deteriorating despite the dentist's best efforts, rather than because of any lack of effort or attention on the part of the dentist concerned.
The key to this pivotal difference is often to be found in the clinical records, from which it will be clear:
- Whether or not the dentist had identified the relevant problems that existed in the patient's mouth (for example, defective or fractured restorations, periodontal disease, uncontrolled caries, tooth tissue loss through erosion, abrasion, attrition or fracture, hard or soft tissue pathology, etc).
- Whether or not the dentist has been monitoring the patient's condition, and/or carrying out the appropriate investigations (sometimes over a period of time) that would provide the information necessary to reach a proper diagnosis and treatment plan.
- Whether or not the dentist had identified any relevant risk factors that might be contributing to the patient's deteriorating oral health (for example, oral hygiene, diet, smoking, bruxism or parafunction).
- Whether or not the dentist had informed the patient about their oral condition, and communicated effectively with the patient about what was being done and why, or what the patient could do to help, control or improve the situation.
- Whether or not the dentist had explained the available treatment options to the patient which in some circumstances might include the possibility of a referral for specialist advice or treatment. In many cases most or all of these circumstances may have occurred but are simply not recorded within the records. This casts doubt on the clinician's validity particularly as that clinician has a duty both from the ethical and regulatory point of view, to record such events.
The patient's response
On the one hand, there will be cases where the patient has successively declined the dentist's recommendations for certain treatment, or perhaps a referral. This may be on grounds of cost, inconvenience, disinterest/apathy, or for a variety of other reasons. Whatever the circumstances, it is important to record the recommendations that were made (and the patient's response) very clearly in the notes at the time.
Similarly, it is important to record each and every appointment which the patient fails to attend, or cancels at the last minute. Reception and administrative staff should be encouraged to amplify clinical notes to reflect what has been agreed with the patient. For example, 'Patient rang to cancel appointment. Offered to rebook, but patient prefers to contact us when more convenient'.
With most (although not all) computerised records and appointment systems, it is relatively easy to record the fact that a patient cancels an appointment scheduled for them several days or weeks later. This helps to establish a more complete record of the patient's attendance pattern, and this can become very important if allegations of supervised neglect or excessive treatment delays are made at a later date. All too often in these situations, patient's maintain that the practice could never fit them in for an appointment.
Where manual (paper) records are being used, however, it would be much more unusual for a receptionist to retrieve the patient's notes, specifically in order to record the fact that the next appointment a week or two later had been cancelled by the patient. The busier the reception area the less likely this is to occur, In the absence of this record, the appointment book itself can sometimes become a valuable additional record.
Unfortunately, many receptionists prefer to complete the appointment book in pencil simply to have the ability to erase cancelled appointments completely, in order to indicate availability and to legibly insert a new name.
Most practitioners will have had patients, at some stage in their career, who seem to stagger from one crisis to another, and whose treatment never really feels to be under the practitioner's control.
These patients often present with so many unexpected emergency problems in between their scheduled review appointments, that one course of treatment seems to merge seamlessly into the next. There is then a very real danger that the patient's treatment might be dealt with on these occasions in a reactive 'patch and mend' fashion, rather than with a more proactive 'what's happening here, and why?' approach. In such circumstances the practitioner can easily lose sight of the bigger picture and the overall direction of treatment.
Assessing the situation
To avoid finding yourself in such a situation, it is important to stand back from time to time, and to make the effort to take a more detailed overview of the patient's oral health, approaching this in the same logical fashion as one might approach a patient who you were treating for the first time. If the records can demonstrate that this was done, then it becomes much easier to defend subsequent allegations of under-treatment or 'supervised neglect'.
The records sometimes tell the story of a patient who was at one stage being treated very diligently and attentively by a practitioner, but gradually this picture changes to one in which medical histories are not being updated, periodontal health is not being monitored, x-rays are not being taken, and so on,. A periodontal problem or a sinus over a root apex is 'treated' with a prescription for antibiotics, but with no other details recorded in the notes, and no arrangements made for follow-up. Worse still, the records simply mention that a prescription was given, with no explanation of why this was being done.
Many factors can contribute to a greater or lesser extent in the 'supervised neglect' of a patient;
- A dentist who is under stress for reasons unrelated to dentistry (perhaps financial worries, or domestic/ personal problems) may be distracted by these outside pressures and become less attentive in the treatment of patients.
- Other dentists are unwell physically or mentally, and may not always realise this at the time. In one instance the explanation was no more complex than that the practitioner in question had not realised the extent to which his eyesight had deteriorated.
- Sometimes dentists are simply too busy, perhaps having been unable to replace a departed colleague, and 'supervised neglect' becomes a response to having to see too many patients in too little time.
- As a dentist 'matures' in a practice alongside their patients many of which will have being seeing the dentist for a considerable number of years, a degree of compliancy can set in on both sides with the dentist adopting a patch up mentality rather than the provision of more definitive restorations.
A significant number of the 'multiple' cases of 'supervised neglect', tend to involve practitioners who are nearing retirement. This is of particular concern, since a large number of the practitioner's patients will shortly be seen by a second dentist who of course looks at the patient with fresh eyes and without the 'benefit' of any past history. This is often the means by which 'supervised neglectâ' comes to light. Alarmingly where supervised neglect has been occurring on a wide scale basis and over an extended period of time, there have been many instances where this has created a nightmare situation (financially and logistically) for any dentist(s) who takes over the care of the patients within the same practice.
The worst scenario arises when such a dentist has taken over a 'rolling' list of capitation patients, and finds a significant number of them needing extensive treatment in return for minimal capitation payments. When a dentist is treating the patient within a capitation payment system, 'supervised neglect can arise for slightly different reasons.
Very occasionally, a dentist appears to be practicing planned inactivity on capitation patients, while carrying out a normal range of treatment for patients who are paying fees on an 'item of service' basis. Clearly, it is difficult to justify and defend the ethics of such an approach; or even be sure of why it has occurred. Capitation schemes are based on a 'swings and roundabouts' principle where the cost of treatment is spread over a period of time. In some situations then the supervised neglect is a result of poor financial planning and capitation fee setting, whilst in other cases the dentist develops the perception that the treatment they are providing is not being remunerated. Either way it is a deliberate abuse of the capitation remuneration system and it is important to appreciate that it is the individual dentist, not the payment system, who is responsible for abuse of this kind.
When a patient actively declines treatment that has been recommended for them, the situation becomes quite clear-cut. A feature of 'supervised neglect' cases, however, is sometimes an assumption on the part of the treating clinician that the patient 'wasn't interested' in a certain treatment option, or that some old and discoloured restorations 'didn't worry them'. When there is no confirmation of this in the records, it is easy for a patient to respond along the lines of how did you know ' you never asked me?'.
To avoid this situation it is sensible either to make, or not make, a specific treatment recommendation, to discuss the options with the patient, and most importantly to record the outcome of these conversations clearly in the clinical notes. This becomes particularly important when treating patients with whom you have a less formal relationship - perhaps professional colleagues, staff members, friends, or family members. These are precisely the situations where conversations that should take place, might not take place or when the discussion does occurs it is not recorded within the records as the dentist perceives there is no need.
Various studies have shown that dentists are likely to look more critically at restorations placed by others, than they are in situations where they placed the restorations in question themselves - particularly in a regularly-attending patient that they have been treating over many years.
One will often observe an old restoration with lessthan- optimal margins, or surface defects, or discolouration. A clinician, who has observed these same restorations over several years with little or no deterioration, and no other signs or symptoms, is well placed to appreciate that the situation is stable. A clinician seeing this patient for the first time might take the decision to replace the restorations immediately. Whether or not this is seen by the patient as indicative of any fault on the part of either dentist, will often depend heavily upon the way in which the second dentist describes the situation. The patient will often perceive the situation as being a failure to treat on the part of the previous dentist or perversely an indication of over treatment by the new dentist.
One will often observe an old restoration with lessthan- optimal margins, or surface defects, or discolouration. A clinician, who has observed these same restorations over several years with little or no deterioration, and no other signs or symptoms, is well placed to appreciate that the situation is stable. A clinician seeing this patient for the first time might take the decision to replace the restorations immediately.
Whether or not this is seen by the patient as indicative of any fault on the part of either dentist, will often depend heavily upon the way in which the second dentist describes the situation. The patient will often perceive the situation as being a failure to treat on the part of the previous dentist or perversely an indication of over treatment by the new dentist.
Every dentist has a duty of care to exercise a reasonable level of skill and competence, when treating each patient under their care. Failing to provide necessary treatment is one way in which this duty of care can be breached; recommending or providing unnecessary treatment falls at the other extreme, but is still a breach of a clinician's duty of care.
Regular and effective communication with the patient about their oral condition, what treatment is (and isn't) being proposed and why, is a valuable protection against an allegation of under-treatment. Full, accurate and meticulous records, based upon appropriate investigations, are equally invaluable.
These two strategies, coupled with an up-todate awareness of current thinking in diagnosis and treatment planning, will avoid the majority of problems in this area.