A bridge too far

‘A Bridge Too Far’ is the title of Cornelius Ryan’s epic reconstruction of the British Army’s parachute and armoured thrust across Holland to the Rhine and Germany in late 1944. If it had succeeded it would have shortened the war and incidentally but not coincidentally, made it a British rather than an American victory. In making this thrust, Montgomery ignored his lifetime’s instinct and training and launched this campaign with minimal planning, minimal consideration of the risks, minimal consideration of other options and put the plan into action in less than two weeks. To succeed, the plan required faultless military intelligence, every phase to work perfectly with no breakdowns and the weather to remain fine. Early in the piece one of the parachute generals opined that “it was a bridge too far” but was ordered to get on with it. The general was aware that they had ignored the advice of the Free Dutch Forces, and most of the troops were keen and eager but lacked combat experience. It’s a matter of history that the essential elements all broke down despite the heroism of the frontline troops. There was much pain, sacrifice and loss, the war was lengthened and the Americans re-exerted their dominance.

So, how do the lessons of this military experience relate to Dentistry? Recently, there have been discussions of how on the one hand you should listen to the advice from Guild Insurance warning about the risks of practitioners exceeding their scope and capacity, but on the other hand, if you can’t develop your skills in general practice then you remain professionally underdeveloped. It is accepted that although you can be taught the relevant principles in Dental School, you must be able to enhance your actual skills after registration and indeed, for the rest of your practising life.

Aspects of this were illustrated in a recent interstate medico-legal case in which I was involved as an expert. (The key facts are accurate but it has been modified to protect those involved). A 40ish successful business woman asked a young dentist as to whether anything could or should be done about a single edentulous first molar space in the mandible. The tooth had been extracted long ago but it was only recently that she had the time and finance to do anything about it. The dentist replied that indeed, things could be done, a bridge was the answer and why not start today, so they did. During the bridge construction the lady asked if ever anything went wrong with bridges and was told that “nothing could go wrong”. Indeed it did and was followed by three years of pain and loss, multiple visits to the dentist, various medical and dental specialists and many treatments without result.

Eventually, an interstate expert, an Oral and Maxillofacial Surgeon (guess who) said to her that if the pain had started with putting the bridge in let’s take it out. “At last”, said the lady, so the bridge was removed. Soon after the patient’s pain went but the dentist’s pain commenced as lawyers were consulted. The legal pain went on then for a further three years but wisely just before it came to trial, the matter was settled out of Court.

What are the lessons from this? Although it was quite a nice bridge that the dentist had made he had erred in a number of places. He certainly failed to give the lady the full range of options; namely do nothing as she had been like it for a long time and there would be no problems with doing nothing. This was not an aesthetic issue, minimal (less than 5%) reduction in chewing ability and healthy adult teeth do not drift. A removal or partial denture could be made but is a poor option for a unilateral single tooth loss. A bridge is an option but with some risks and a significant failure rate over time. Alternatively, a single tooth implant could be made but is associated with increased risks. Essentially, the dentist gave her only one choice which is not a choice. Thus legally she could not give informed consent.

He knew that the lady was a bruxist before he started the bridge and learned much more about her intense personality and bruxing habits when she was in pain and in legal pursuit. He also knew that she had a skeletal class three malocclusion with a cross bite but failed to take this into account and in particular, to understand the extreme lateral loads which could be generated by her bruxing on the bridge and its abutments.

He failed to give the lady time to consider the options. Indeed, as a savvy business operator she would have had no difficulty in travelling a few hundred kilometres to a metropolitan specialist for an implant. With careful research, she could have found one with the necessary skills and training not to screw the implant into the mandibular nerve and to graft sufficient bone to replace the marked alveolar atrophy. A specialist in prosthodontics should have been involved to ensure that the crown was not overloaded by her malocclusion and bruxing. Alternatively, as a smart lady, she may well have decided that doing nothing really was the way to go.

Lastly, although the dentist could demonstrate that he had made a number of bridges, he could not demonstrate that he had attended any courses in bridgework, occlusal problems or TMD since he had graduated. He had become comfortably isolated as ‘the expert’ in his solo practice. Interestingly, once the bridge was made and the pain started he, and indeed, all of the dental specialists she variously consulted were keen to keep the bridge in situ. Most looked at it as a bridge with the patient’s mouth wide open, rather than infunctional (dysfunctional) occlusion. It took a non-restorative specialist from interstate to indicate that “if in doubt, out”.

So what does a military strategy to end World War II and this dental case have in common? Both failed to adequately consider the options, effectively plan and train and to change the plan when things went wrong. Both did go horribly wrong with much pain and suffering to those involved, one on a macro scale and the other on a micro scale.

So, what should a general dental practitioner do to help their patients with complex problems and to develop their scope? On the one hand, one does need to read and think about the advice given by the dental liability organisations regarding risk. If however a practitioner wants to broaden their scope and knowledge then they should carefully think, plan and improve their skills by attending hands on courses and working with specialist mentors. Indeed, most commonly, the practitioner who gets into trouble doesn’t do any of those things and plunges in with supreme over confidence. If you have reached this spot in the article, congratulations, you probably are already a careful and prudent practitioner. So, you are less likely to attempt a “bridge too far”.

 
 
 

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    Importance of Informed Consent

    All health practitioners would be well aware of their requirements to obtain informed consent from their patients before assessment or treatment takes place.  However, Guild Insurance’s vast experience in managing claims made against health practitioners has highlighted that many practitioners don’t meet all their informed consent requirements.

    What is informed consent?

    There is an explanation about informed consent in the Code of Conduct for each of the professions regulated by AHPRA.  In this document, informed consent is defined as ‘a person’s voluntary decision about healthcare that is made with knowledge and understanding of the benefits and risks involved’.  This statement highlights the difference between consent and informed consent.  If a patient hasn’t been made aware of the benefits and risks, their consent isn’t informed.

    Informed consent isn’t just required for treatment. Depending on the nature of the healthcare being provided, informed consent should also be obtained for assessment. 

    Informed consent and insurance claims

    Informed consent can feature in insurance claims against practitioners in a couple of ways.

    It’s not uncommon when a patient is unhappy following treatment for them to allege they weren’t made aware of the risks when they consented to treatment.  Quite often they will allege the treatment was negligent and has resulted in harm or suffering.  They then add that had they been informed of the possible risks, they wouldn’t have consented.

    In other cases, patients may not make any allegation about consent, their complaint might solely focus on the clinical outcome, yet when their claim is being managed it’s found that they didn’t give their informed consent prior to treatment being provided.  When this occurs, it makes it challenging for Guild to prove that the practitioner has treated appropriately and met their requirements.

    The informed consent conversation

    Informed consent requires a conversation between the treating practitioner and the patient.  This conversation needs to occur prior to assessment and treatment. 

    The conversation must:

    • detail the recommended assessment and treatment as well as alternate treatment options
    • include the expected benefits of that treatment
    • provide information about the risks of the treatment
    • allow time for the patient to ask questions
    • be held in language which can be understood by the patient which means practitioners should avoid technical clinical language.
    • take place in a private area where the patient will feel comfortable being open and honest about their health situation.
    • be tailored to that individual patient and their unique clinical needs

    Recording informed consent

    It’s imperative that practitioners make a note in the clinical record regarding the patient providing their informed consent.  This needs to be more than ‘IC given’.  The record needs to show what treatment options and risks were discussed as well as any questions asked by the patient.  The record should also show what the patient consented to as well as what they didn’t consent to where relevant.

    The informed consent form

    One area which leads to some confusion about informed consent is how to use an informed consent form.  Having a patient sign a form is seen as a quick and simplified way of having a patient provide their informed consent and keeping a record of that.  However, they are unfortunately too often used inappropriately. 

    Signed forms aren’t a requirement.  While recording consent is required, this doesn’t need to be done using a form.  Notes in the clinical record are sufficient.  However, signed forms do provide additional evidence if there is an allegation that informed consent wasn’t given.

    Forms can’t be used to replace the informed consent conversation.  A patient can not read a form and gain the same level of understanding as they would from a conversation with the practitioner.  Nor can they ask questions of the form. 

    A form should only be signed after the conversation with the practitioner has been had and the patient understands what it is they’re consenting to.  Patients are occasionally asked to sign consent forms at reception before they’ve seen the practitioner.  As there has been no assessment or discussion about treatment at this stage, this can’t be considered informed consent as the patient hasn’t been informed.

    Some practices combine new patient forms with the consent form.  This isn’t ideal as the two forms serve different purposes.  Also, having them on the one form encourages patients to sign the consent form at reception before they’ve seen the practitioner.  Therefore, they should be divided into two separate forms.

    Informed consent is not a one-off event

    Practitioners regularly ask how often their patients need to give informed consent.  There is no set time frame for when informed consent conversations or signed forms need to be repeated.  The requirement is that when a patient is receiving any assessment or treatment, they need to have given their informed consent to this.  Therefore, informed consent should be an ongoing process; it’s a continual conversation with patients during consultations.  And when there is any change in the treatment being provided, or if the patient has returned following a period of absence, informed consent needs to be revisited.  A general ‘consent to all treatment’ for the life of the therapeutic relationship is not appropriate.

    Informed financial consent

    As well as consenting to assessment and treatment, patients should also give their informed financial consent.  This means they need to be provided with information about the expected cost of treatment before this treatment commences.

    In summary…

    There is no one right way to undertake an informed consent conversation and process.  Practitioners must adapt what’s discussed for the patient they’re treating and that patient’s unique circumstances.  However, what must occur in all cases is that the patient is informed of and understands the proposed treatment, alternate treatment options and the risks involved.  Only with this information can they give their informed consent.  The practitioner must also be sure to make a record of this informed consent discussion in the clinical record.

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    Managing patient expectations in dentistry

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    It’s well recognised that patients don’t necessarily complain simply based on their clinical outcome. Most dentists will have heard of or seen situations where a patient has experienced an outcome which wasn’t ideal yet wasn’t particularly poor, however the patient has been quite annoyed with the outcome and has lodged a complaint.  On the other hand, there are many cases of patients who have experienced quite poor outcomes yet have chosen to not complain.

    There are many reasons why the above may occur, some which are easier to identify than others. All patients are different and human behaviour isn’t always predictable.  Good communication and the relationship between the patient and dentist will greatly influence the likelihood of a complaint.  One other very important factor is the expectations of patients.

    Patient expectations

    Many patients will go into dental appointments with some level of expectation regarding their likely outcome. They may have a very clear and detailed outcome in mind or it may be more broad and open.  Most importantly, some of these expectations will be realistic, however others won’t be.

    Unrealistic patient expectations pose very real challenges for dentists. If a patient undergoes treatment which they have unrealistic expectations about, it’s unlikely those expectations are going to be met simply due to them being unrealistic.  If a patient’s expectations haven’t been met, it’s likely the patient is going to be unhappy or dissatisfied with the treatment.  Those unhappy and dissatisfied patients are the ones more likely to complain about the treatment and expect further corrective treatment or compensation.  It’s therefore vital that dentists do all they can to help the patient fully understand treatment and the likely and possible treatment outcomes before treatment begins.

    Creating realistic expectations

    A key step in making sure a patient has realistic outcomes regarding treatment is to have an open and honest conversation with them. This will not only provide the patient with further information about their treatment, but will also give the dentist a clearer understanding of the patient’s expectations.  A dentist’s clinical skills are vital to what they do, however effective communication goes a long way in providing positive outcomes.

    To assist a patient to have realistic expectations, dentists must ensure they explain the treatment and outcomes using simple, clear terms. Technical clinical language should be avoided as many patients won’t understand this.  Dentists should also consider how they tailor their language and the information for each individual patient.  For example, a person with language or literacy challenges may need information presented in a more detailed manner than other patients.  Dentists should also consider using diagrams, pictures or models to assist with understanding where appropriate.

    When discussing treatment with a patient, it’s important that dentists don’t make assumptions about what the patient will or won’t understand. It’s easy for dentists to become so familiar with what they do and know that they sometimes forget how foreign that knowledge can be to other people.  Patients will have varying degrees of knowledge and experience regarding dental treatment.  Therefore, what they understand about their treatment will also vary.

    When a patient attends a dental clinic and requests a particular form of treatment, this is an occasion when a dentist should be especially mindful of the patient’s expected outcome. When a patient has requested a form of treatment, the patient has clearly formed a decision around what treatment they need to get the outcome they desire.  What they’re requesting and expecting may be reasonable and realistic, however in some cases it may not be.  When presented with this situation, dentists need to be sure they don’t rush into providing the patient with the requested treatment.  As with all patients, there needs to be a thorough assessment and diagnosis process.  Then the patient is to be provided with their treatment options, as well as the risks and benefits of those options.  There may be treatment options which are more suitable for that patient which the patient isn’t aware of.  The patient also needs to be made aware of the likely treatment outcomes for each of those treatment options.

    The dentist needs to be sure the patient has all required information before consenting to treatment and this includes understanding the likely outcomes. A patient requesting particular treatment doesn’t alter this required process.  And dentists need to remember that they’re always responsible for the treatment they’ve provided, regardless of whether it was requested by a patient.

    In summary…

    Dentists should be doing all they realistically can to improve the outcomes for their patients and reduce the likelihood of poor outcomes and complaints. An important step in this process is making sure patients have realistic expectations regarding treatment outcomes.  Dentists have a very important role in using their clinical knowledge in conjunction with practical terminology to assist patients to develop realistic expectations.  Dentists need to remember this is of great benefit to both themselves and their patients.

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    Guild Insurance Limited ABN 55 004 538 863, AFS Licence No. 233 791. Guild Insurance supports your Association through the payment of referral fees for certain products or services you take out with them. This article contains information of a general nature only, and is not intended to constitute the provision of advice.
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    Are you prepared for a power outage?

    Are you prepared for a power outage?

    Power outages are unfortunately becoming a somewhat common occurrence in parts of Australia. The threat of heatwaves, and therefore higher than usual demands on power, means that power outages are a real threat to many businesses over summer.

    Insurance protection during a power outage

    It’s important that all businesses understand their insurance cover in case of events which impact the running of the business, such as a power outage. Guild Insurance will provide cover when the power outage is unplanned, and this is defined as when there is less than 48 hours’ notice that the outage will occur. Cover will be provided for the cost of hiring a generator. And the really beneficial part about this cover is that there’s no waiting period with Guild Insurance. So if the power is out for only 2 hours, the policy will still respond and provide cover for that short period.

    Planning for an outage

    Sometimes there is no notice that a power outage is to occur. And even when notice is given, there may not be enough time to allow a business to adequately prepare for the outage. Therefore it’s vital that all businesses have a plan in place, sometimes referred to as a business continuity plan, for what they’ll do if a power outage was to affect their business.

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    • What are the implications for both the business and clients if the business doesn’t operate for a period of time?

    Remember, planning during an outage is too late. Don’t think this won’t happen to you, have a plan just in case.

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