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Report from the Constitution, Bylaws, and Ethics Committee
What's a Dentist to Do?
Jack L. Churchill, D.D.S.*
An adult patient we will call Joan presented to her dentist, Dr. A, with rampant decay in all of her molars, some of which were to the pulp chamber. The decay resulted in pain throughout her mouth, right and left sides. The upper left cuspid was abscessed. She also had Type III periodontitis. Joan is mentally compromised and unable to make decisions for herself.
Six months later, Joan left Dr. A because her insurance changed, whereupon she ended up at Dr. BÍs office. Joan was still in pain on her right side due to remaining deep decay in her upper and lower right molars. She had had a bridge placed from her upper left cuspid to her upper left second premolar, replacing the missing upper left first premolar. The abscess of the upper left cuspid was untreated. Her periodontal disease was also untreated.
This case is a good one with which to begin our journey into dental ethics. There are so many ethical considerations here that to dissect them all in one column would be a disservice. Therefore, we will discuss the relevant issues over the next few columns. Sound good? LetÍs get started.
First of all, letÍs differentiate between two terms: bad outcome and bad work. A bad outcome is a result that fails to achieve the intended benefit of treatment for a patient or possibly even causes harm. Bad work refers to a standard of care within our profession. Bad work is a diagnosis, treatment or communication with a patient that falls below that standard.
In our society, the distinction between these two terms is often overlooked. We as dentists may permit this oversight by not talking to our patients about bad outcomes because we donÍt want our patients to think we do bad work.
Our society holds that dentistryÍs techniques and technologies are infallible. This is a myth because those same techniques and technologies are developed and performed by fallible human beings. This myth enhances our status, but also increases the expectations of our patients. They then believe that all bad outcomes must be the product of human error, that is, bad work.
Dentists all know that the best dentist doing textbook dentistry for an ideal patient can still have a bad outcome. A bad outcome is not necessarily the result of bad work. We must always remember this when viewing otherÍs work, or our own, for that matter.
To judge whether a bad outcome is the result of bad work, Dr. B needs information. In some cases, the evidence is physically apparent: poor margins, poor color, non-retentive preparations. But often the evidence is less clear and more judgmental in nature, such as a patientÍs inattentiveness to a dentistÍs words or a patientÍs lack of cooperation.
To conclude that a bad outcome is the result of bad work, we must consider the clinical facts, the patientÍs comments about the situation and evidence that the patient understood the dentist clearly.
The situations in which a dentist observes another dentistÍs bad outcome fall into two groups: (1) those in which the patient is another dentistÍs patient, and (2) those in which the patient is yours and returning from a specialist, emergency care or simply
visiting for the first time and presenting you with work from other dentists.
The former situation is complicated. The bad outcome must be handled within the framework of preserving the primary doctor/patient relationship. We will discuss these situations in a later column.
The case is of the latter situation because Joan changed dentists. Dr. B. is obligated to inform Joan of the condition of her mouth, including the bad outcome, and is obligated to answer truthfully the patientÍs questions about the role of Dr. A in relation to the bad outcome, always giving Dr. A the benefit of the doubt when doing so. A collaborative effort by both dentists in trying to resolve JoanÍs needs would be best.
Of course, if Dr. B has irrefutable evidence of Dr. A doing bad work, Dr. B can report such to his local dental peer review group. However, such an action should be done with great thought and only as a last resort. Beforehand, Dr. B should contact Dr. A to discuss the case. Such communication can be one of the most effective actions in which the doctors involved can engage, but only if done for the correct reasons.
We all know that many bad outcomes can occur without anyoneÍs bad work. We all know occasional bad work without long-term harm to anyone is inevitable in any practice. Then such a conversation would not be an insult but an effort by Drs. A and B to put the patient first and leave egos behind. Patient care being the top priority, it would be the most effective way to resolve a difficult situation, each dentist learning something in the process. It would be an act of positive colleagueship based upon mutual understanding of the challenges of dental practice.
So whatÍs Dr. B to do? Communicate with Joan regarding the situation, answering her questions truthfully, being careful not to be overly judgmental. Dialogue with Dr. A with the patientÍs interest in mind. Go to a third party only if he must.
What do you think about this case? Bad outcome or bad work? If you called Dr. A, what would you say? Does Dr. A belong at peer review?
E-mail us at kdegrote@mndental.org or fax us at (651) 646-8246. We look forward to hearing from you not only regarding this case, but also if you have any ethical dilemmas you would like to present to the membership. Perhaps we can help you decide what to do.
*Dr. Churchill is Chair of the Minnesota Dental AssociationÍs Committee on Constitution, Bylaws and Ethics. He is a general dentist in private practice in Minneapolis, Minnesota.
Copyright 2003. Minnesota Dental Association
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