Advice


05 •


ON THE DEFENSIVE W


Dentist Laura McCormick discusses how practising defensively can lead to deskilling and unhappy patients


E have probably all had that sinking feeling at some point in our careers when we realise something has not


gone to plan or a patient returns unhappy with a treatment outcome. These experiences can be tricky to deal with and may negatively impact our self-confidence, making us doubt our skills as a dentist. For some, this may even affect our clinical decision making and ultimately the care we deliver to our patients. Let’s consider that one particularly challenging patient for whom if something can go wrong you can be sure it will happen to them. Your appointment book shows they are due in with you for the extraction of an upper 7. You recall explaining to them that root treatment was not possible on this tooth and extraction seemed the most appropriate option. Before they come in you check the medical history: all fine. You look at a previous radiograph: roots not close to maxillary sinus, no abnormal root morphology, so all looks good. You are about to bring the patient in when


you feel a nagging doubt creep in. You start to worry about the adjacent teeth. That upper 8 looked really spindly – what if I take that out inadvertently? Should you have given more thought to root treatment? You convince yourself it is too difficult, too risky and the patient can be demanding so out comes the referral form. You explain how complicated the procedure is and that it really should be done by a specialist. The patient is unhappy at having to take more time off work and is impatient for the procedure to be carried out. You reinforce the complexity of the procedure and feel relieved as they leave your surgery. But was that referral really necessary? You


have carried out numerous extractions before; why is this one different? The term defensive dentistry is one we are hearing more frequently and describes a type of clinical practice where clinicians avoid what they perceive to be “high risk” or “difficult” procedures. These are usually procedures that could reasonably be provided but, due to the fear of a complaint, are not offered. While this might seem like a smart way to stay out of trouble and avoid complaints or General Dental Council referrals, the opposite is true. Dentists who practise defensively are effectively placing protection of their own position ahead of the patient’s best interests. In doing so, they are actually more likely to be subject to a complaint from a dissatisfied patient like the one in our scenario above. The GDC’s Standards guidance states: “You should only deliver treatment and care if you are confident that you have had the necessary


“We cannot offer treatment options based on us being afraid”


training and you are competent to do so. If you are not confident to provide treatment, you must refer the patient to an appropriately trained colleague”. This is sound advice but it is being used by some “defensive” dentists to justify referring any and all complex or unpredictable cases so as to minimise the risk of a poor outcome. We cannot offer treatment options based on us being afraid. If you are appropriately trained, have risk-assessed the procedure and obtained consent from the patient, then you should proceed. If you lack confidence in your own ability then attend courses to increase your experience. It is vital that as clinicians we do not allow ourselves to become deskilled. To restrict your practice to a narrow range of “easy”, “low-risk” procedures is the beginning of a downward spiral which can result in a loss of motivation and a lack of pride in your work which will adversely affect the quality and range of your patient care. The most ironic part of this treatment


avoidance approach is that it brings additional risks. How can we obtain valid patient consent if we did not initially offer all available treatment options? As dental professionals we


are obliged to listen to patients’ concerns and wishes and fully explain all appropriate treatment options and their relevant risks, being sure to make contemporaneous and accurate notes. How can we expect patients to trust us if


they find out too late through Dr Google there were other treatment options they could have chosen? Trust between dentist and patient can only occur if the patient feels that you are acting in their best interests by arming them with all the facts to make an informed decision about their care. A lack of trust can lead to dissatisfied patients which can lead to complaints. No dentist wants to feel like they are


looking over their shoulder, scared of a patient complaint or GDC letter. But these things happen and MDDUS is here to advise and support our members through any adverse events that may occur due to your dental practice. It is likely that if all protocols have been correctly followed then MDDUS will be able to resolve the matter swiftly for you.


Laura McCormick is a dentist and early practitioner adviser at MDDUS


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