Dentists have, among other things, obligations to maintain the standards of practice, not practise negligently (at the risk of being sued for dental malpractice) and render treatment which the dentist is skilled and competent to perform. For instance, in Ontario, it is professional misconduct to contravene a standard of practice or fail to maintain the standards of practice of the profession and also to treat or attempt to treat a disease, disorder or dysfunction of the oral-facial complex that the dentist knows or ought to know [italics mine] is beyond the dentist’s expertise or competence (O.Reg. 853/93 under the Dentistry Act, 1991,as amended, s.2, paragraphs 1, 5).
Dentists also have obligations to charge reasonable fees and not misrepresent information on dental claim forms submitted to third party payors like dental insurance companies. Again, using Ontario as an example, it is professional misconduct for a dentist to recommend or provide an unnecessary dental service; submit a charge for dental services or sign a certificate or report or document that the dentist knows or ought to know [italics mine] is false or misleading or contains false or misleading or an improper statement; and charge a fee that is excessive or unreasonable in relation to the service performed (O.Reg. 853/93 under the Dentistry Act, 1991,as amended, s.2, paragraphs 6, 28, 31,33).
For the new dentist, problems related to these issues can arise early in your practice years. Patient disputes arise when the patient is unhappy with the treatment rendered and have to have the unsatisfactory work repaired or redone by another more experienced dentist or specialist or when they discover that certain procedures performed are not being covered by their dental benefit plans when the retreatment is performed. The reasons for these types of problems arising can vary and are also beyond the scope of this article.
In order to try and avoid these stressful situations from occurring in your practice, I have listed some important risk management tips which may be helpful:
As a new dentist in an associateship relationship, if the principal dentist suggests that certain types of dentistry be performed by you and you do not feel you are knowledgeable, skilled or experienced enough to perform the treatment, be sure to discuss this with the principal dentist before rendering the treatment to the patient. One of the best benefits of being in an associateship relationship is the opportunity to learn and develop new skills and obtain clinical guidance to enhance your practice of dentistry. If you are in an environment where this does not occur, try to resolve this before it is too late.
Be wary of relying on the argument that the reason you are practising dentistry as you are is “because the principal dentist or office staff made me do it”. Most associate agreements set out that the associate dentist is an independent contractor responsible for his or her own dentistry. As such, trying to blame the principal dentist or office policy for your actions may be inconsistent with the terms of your associate agreement.
The new dentist associate should satisfy himself or herself about what can and cannot be done in the practice of dentistry and then clarify any outstanding concerns with the principal dentist as necessary.
As a new dentist, if you are in your own dental practice as a sole proprietor or in practice with a fellow new dentist, you should make a bonafide and objective self-analysis of your clinical skills, knowledge and experience before you recommend or offer certain dental treatment to your patients. Know your limits. In this scenario, you are indeed on your own as there is no principal dentist to consult. Therefore, if you are in doubt, consult with a trusted colleague (while maintaining patient confidentiality) before recommending and performing any specific dental procedure.
Keep in mind that if a patient alleges unsatisfactory dentistry after the fact, not only can you be sued for alleged negligence but a complaint can be filed against you with the regulator (eg. RCDSO in Ontario) alleging substandard treatment and inappropriate conduct on your part (see list above). How you defend yourself against such allegations may depend on your ability to “prove” what your credentials were and the requisite skills, knowledge and experience you possessed at the time justifying your recommending / rendering of the dental treatment in question to the patient (also see discussion below regarding relationships with specialists).
If you are unclear about how to address the situation you are confronted with, seek legal advice before doing anything you might regret later.
When dentists are facing complaints or investigations by an insurance company or the regulatory College regarding alleged billing irregularities, ignorance of the terms and guidelines of the applicable fee guide is often mentioned by the dentist to explain / justify the alleged behaviour. Dentists can misunderstand how the procedure codes listed in the dental fee guide are to be used and consequently submit claim forms improperly. Whether you are an associate or sole proprietor new dentist, it is highly recommended that you spend the necessary time to read and become fully familiar with the respective fee guide used in your jurisdiction of dental practice.
For Ontario dentists, the applicable fee guide is the Ontario Dental Association (“ODA”) Suggested Fee Guide for General Practitioners. Some dental specialties also have suggested fee guides as well. It is highly recommended that dentists practising in Ontario become members of the ODA so that they can avail themselves of the resources and support from the ODA regarding the proper use of the Fee Guide. From a risk management perspective, the ODA can be very helpful in educating and guiding dentists on the key issues which arise from time to time relative to the Fee Guide and how to use the Guide appropriately.
Also keep in mind that well-meaning colleagues can, in fact, provide you with inaccurate and incorrect advice regarding procedure code utilization. Just because you are told to do something because “every dentist does it” does not make it right; if in doubt, investing in some legal advice prior to submitting improper claim forms is a prudent and wise decision which will save you worry, anxiety, liability and expense later on.
What constitutes a “reasonable fee” to be charged to your patients is a topic in itself. Applying the aforementioned principle of “knowing your limits”, the ethical and conscientious new dentist should be wary of charging fees which an objective third person may consider to be excessive in relation to the services performed.
For the new dentist, having strong and trusting professional relationships with specialists in all the clinical disciplines of dentistry can be the best risk management tip to follow. By cultivating good rapport with such specialists, even a solo practitioner new dentist can create a support network to help achieve the necessary risk management goals to “stay out of trouble” including
1) learning necessary diagnostic, treatment planning and treatment skills for that area of dentistry to render proper care as a general dentist to your patients,
2) knowing when it is appropriate to render the care yourself and when to refer to the specialist,
3) having someone specific you trust and know to refer your patient to in a timely manner should complications or emergencies arise during treatment,
4) having a specialist in the specific area of dentistry who knows you and your skills and can act as a refer
ence to support your credentials should an allegation be made against you regarding your competence or compliance with the standards of practice of the profession and (5) having a qualified supportive person whom you can trust to help you deal with the difficult situations every dentist can run into in daily practice.
Keep in mind that although there are numerous continuing education opportunities in virtually every clinical area of dentistry being offered to dentists, the prudent dentist must consider whether or not the information to be obtained at the course will be objective and sufficiently educational so that the dentist is able to obtain bonafide information useful about the subject matter at hand. For instance, the dentist should know what other options are available to the clinician in this area of dentistry, the risks and benefits of same and what and why certain techniques and modalities should be used in which situations in the best interests of his or her patients.
If the area of dentistry being practised by the new dentist (eg. Implantology) is being taught by a multitude of providers and educators with varying philosophies, techniques and products from different sources, it will be incumbent on the new dentist to know the relevant information applicable to the field of dentistry in question so that the new dentist is able to comply with the standards of practice of the profession and adequately discuss the subject matter with his or her patient so that informed consent to treatment can be obtained prior to rendering treatment.
Although dental information now available to dentists can be from truly global sources, from a risk management perspective, it is critical that the new dentist determine whether or not the information being taught at the course is in fact within the practice of dentistry in the Canadian jurisdiction in which the dentist practises dentistry. This is a perfect example of how you can rely on your specialist “network” (see discussion above) for help in determining what clinical standards apply.
It can be very stressful to be the subject of a patient complaint and /or regulatory (College) investigation at any time; let alone early in your practising career. Adhering to sound ethical, professional and legal guidelines and seeking legal advice proactively can go a long way in helping the new dentist have a successful dental practice. DPM
Rollin M. Matsui provides dental-legal lectures to third and fourth year dental students at the Faculty of Dentistry, University of Toronto as well as to dentists in numerous continuing education courses. He maintains a full-time law practice in Richmond Hill, ON and a part-time dental practice in Toronto. In his law practice, he primarily acts for dentists in patient disputes, dental insurance claim inquiries / audits, College complaints, College investigations and professional misconduct related matters and provides legal advice regarding business agreements involving dentists in various working relationships. E-mail: lawyer@drrollinmatsui.com Website: www.drrollinmatsui.com
