July 1, 2005
by H.I.Holmes DDS, DIP OMFS, FICD
After four or more arduous years of intensive study at Dental school, usually preceded by a variable number of years of University education we finally receive our Dental Degrees and a license to practice is conferred upon us by the Royal College of Dental Surgeons. It is this latter confirmation that extends to us the “privilege” to now put into practice, that which has taken us so long to acquire. Unlike our dental degrees which are irrevocable our ” license” is however not, and it’s maintenance is dependent not just on remitting our annual fees and ensuring the continuance of our education but more importantly on our ability to continue to practice in accordance with the Dental Act, guidelines of the standard of practice set forth by the College and it’s code of “Ethics”.
Regretfully, in spite of best intentions, some of us will inevitably be subjected to a patient complaint to the RCDS, commencement of a legal action or both. The RCDS, once it receives a complaint from a patient, even if seemingly frivolous in nature, is required by law to investigate it. On the receipt of a complaint the RCDS, which is the self-governing regulatory agency of the dental health profession and whose prime responsibility is to ensure the standards of our professions and protection of the public, will issue you a letter explaining the nature of the patients complaint, a request that you respond to the allegations and as well forward your complete dental record for this patient. Complaints that seem largely related to communication issues can often, with the mutual consent of the member and complainant be resolved equitably with the Colleges’ help. If this is not the case or the complaint is more significant, such as a standard of practice related issue, then it will go through the full process of the Complaints Committee. Even when the Complaints Committee finds that the member acted in an appropriate fashion, a Complainant, if dissatisfied with the decision, may appeal the decision of the Committee to the Health Professions Appeal and Review Board. In spite of how a complaint is initiated or for what, you can imagine one’s feelings at the time. Your stomach pains, your heart starts to pound, your mouth gets dry, beads of sweat appear and you imagine your world coming to an end.
Those of us who perform oral & maxillofacial surgery, be we generalists or specialists, put ourselves at slightly greater jeopardy of patient complaints simply in that, the nature of what we do can carry with it an expected level of unpreventable and undesirable outcomes. Therefore those who perform the surgery need to ensure that their standard of care relative to it is un-impeachable.
In a general sense the problems encountered with surgery that can lead to a complaint stem from the failure to perform “ideal surgery”, which in a broad sense means:
* It is painless;
* There is minimal or no trauma to:
– the investing structures
– the contiguous structures
– the patient as a whole
* There is uneventful healing.
In a more specific sense problems are encountered as a result of:
* Poor pre-operative assessment and preparation;
* Failure to recognize one’s own limitations, or being pressured by a patient to undertake something surgically for them which truly we do not feel lies within our competency;
* Failure to adhere to sound surgical principles;
* Failure to give proper post operative instructions or follow-up care.
Once the complaint is initiated, the College may request an “expert” opinion. This “expert” will usually be a certified specialist in the discipline of oral and maxillofacial surgery. At this point the information relative to the complaint, the response of the dentist and dental record will be forwarded to the “expert” for review and with the request that an opinion be given as to whether the member “maintained the standard of care of the profession” expected of a prudent practitioner. At this point everything in our patient record is open for scrutiny and at this time we recognize our record is the most important and only tool, if complete, that will substantiate that we are practicing at an appropriate standard. If our charts have the proper information the RCDS or courts will support us, if not, it cannot, as a contention whether a certain action occurred, which cannot be supported by our record, will be deemed not to have occurred..
As one sometimes requested by the College to give an opinion as an “expert” on surgically related issues, it is always my hope that the record provided me, will substantiate that the member involved carried out their care for the patient in a manner that reflected a standard of care that would normally be provided. The underlying problem is that in many circumstances, even though the clinician may have, it is not adequately reflected in the patients record. Indeed, the failure to keep proper records of sufficient detail is by far the most significant downfall of our profession with respect to dealing with a complaint.
Our record must reflect that we have:
* Performed a proper medical history or update;
* An exam;
* Ancillary test such as radiographs of adequate quality;
* Established a diagnosis which substantiates the reason for the surgical intervention;
* Explained to the patient the options of treatment available;
* Offered an appropriate referral for further investigation or treatment if appropriate.
If we elect to treat ourselves there must be evidence in our record that;
* An informed consent has been obtained;
* We have given pre-operative instructions specific to the case;
* Discussed the financial responsibilities.
Likewise, once the procedure is completed it would be expected that there is a notation of:
* What was done, how and with what;
* Complications encountered if any;
* The condition of the patient on discharge;
* That post operative instructions were given both verbally and written;
* Medications prescribed or advised to be taken (no. of pills, dose, frequency of use);
* One’s follow-up arrangements.
It is also assumed that we would deal with any problems that arose from the undertaking or if unable, to ensure an expedient referral to someone who could.
Far to often there is a failure to record an adequate diagnosis substantiating the treatment, or appropriate treatment options, no obtained or recorded evidence of an informed consent, no evidence of appropriate post-operative instructions (written and verbal), an inadequate record of the procedure, no evidence of the provision for follow-up care of an adequate nature either by ourselves or by referring in a timely fashion, those things outside the scope of our expertise.
An informed consent, although a medical-legal enigma is very critical with respect to surgery. It may represent a specific form that you have the patient sign and have witnessed or a statement in your record. In reality its physical documented form, although essential to have, is less important than the process of obtaining it as it is a process founded on communication with a patient, which ultimately establishes a bond of trust. Regardless of its form, it should embody certain essential elements, which are:
* The nature of the procedure;
* That the normal sequela were explained;
* That the risks and complications specific to the procedure were explained;
* Compromise related to social or employment issues were explained;
* The financial responsibilities of the patient were explained;
* That any pre-operative instructions were given;
* That questions were entertained and answered to the patients’ satisfaction;
* That the patient understood that which was explained to them.
What are the normal sequelae and risks or complication that we should inform our patients of? The National Institute of Health (NIH) 1977 consensus advocates divulging any transitory condition which may occur with an incide
nce of five percent or more and any permanent condition that has an incidence of occurrence greater than 0.5 percent. In relationship to the surgical removal of a of a lower third molar therefore it would be expected that the patient be informed of pain, swelling, trismus, bleeding and bruising, dysphagia, a feeling of illness and pyrexia, nerve damage either temporary or permanent to the inferior alveolar and lingual nerves, post operative infections (dry socket, sub periosteal abscess or soft tissues), fracture of a root, sensitivity of adjacent teeth, damage of adjacent teeth (looseness, displaced fillings or crowns) and loss of work. Obviously with any particular tooth or proceedure, any additional mishap that may occur related to the anatomical relationships should be addressed. It would be expected therefore that the dentist would be cognizant of the frequencies of such problems, so as to put them into perspective for the patient. This serves as a guide only as some complications related to surgical procedures are rare and poorly documented as to their incidence. The fracture of the mandible or a displacement of the tempromandibular joint disc would be such examples, as would the perforation into the sinus with the subsequent development of a sinusitis or oral antral fistula or the displacement of a tooth or root tip into the sinus or other contiguous space. Such things owing to their morbidity and the requirement of additional treatment are best disclosed if the circumstances dictate.
I would suggest three basic considerations we might want to consider so as to avoid complications and complaints in light of that previously discussed.
Firstly, treat all patients, as they are one of our most beloved family members, always asking ourselves can I do the procedure in the least traumatic, most comfortable, safest and expedient manner. If there is any doubt or the answer is no, then it would be best to refer them to someone who can. A wise mentor of mine, during my training, always reminded me that we will never be able to treat every patient who comes through our doors. That is why there are specialists. Would your mother deserve any less?
Secondly, the saying “an ounce of prevention is worth a pound of cure” is true. Even the most skillful and experienced clinician needs to ensure that potential risks or complication of what they may do are provided to the patient prior to the undertaking. Doing so, the patient will often applaud the doctor’s insight rather than construe a mishap as an indication of ineptness of skill. Explanations after the fact are never accepted well by patients.
Thirdly and finally, keep detailed records. They represent the best evidence we have in establishing that we are practicing to the expected standard, and are the tool with which the College and an “expert can support you.”
It is also essential to remember that although the College has a mandate in its responsibility to the public, it does so in a milieu of an organization that is also involved with the profession in risk management advice, helping us in our daily practice by sharing information in a positive context, either through the ‘dispatch’, individual interaction or its continuing education programs. The College is our ally in ensuring the goal of providing the best and highest level of care to our patients. We need only to practice responsibly.
Dr. Holmes is Assistant Head, Div. of Oral & Maxillofacial Surgery; Director Undergrad OMFS Education; Surgical Director Surgical Orthodontics Teaching Program, Faculty of Dentistry and Mount Sinai Hospital, University of Toronto.