Mario Catalano, DDS, MAGD

Background
A challenge in any healthcare setting is maintaining a healthy patient load for a profitable practice, but not becoming too busy that it could possibly compromise quality patient care. This case shows how — even with the best of intentions — a dentist can fail to meet the standard of care when the schedule does not allow adequate time to assess and treat the patient. 

Case Discussion
After completing dental school, Dr. J was pleased to join Dr. M’s dental practice as an associate. Dr. M, who had practiced for 30 years, was not only a great mentor but also had a busy, prosperous practice and was interested in selling it to Dr. J in the next few years.

Unfortunately, shortly after Dr. J started, Dr. M experienced a major medical event requiring extensive treatment and recovery. While Dr. M was recovering, he and Dr. J agreed that everything possible should be done to take care of established patients. They also agreed to grow the practice as much as possible to support the second dentist. So Dr. J increased his hours considerably during Dr. M’s absence and made every effort to maintain a full schedule.

Mr. G came to Dr. M’s office as an emergency patient because he had developed oral pain while his regular dentist was on vacation. After determining that Dr. J participated in his insurance plan, Mr. G contacted the office and was seen promptly.

Because it was an extremely busy day, a dental assistant greeted and triaged Mr. G. He pointed to tooth number 28 as the site of his pain. The dental assistant took an X-ray that indicated approximately 50 percent bone loss. Direct examination also indicated periodontal issues and some tooth mobility. The dental assistant reported these findings to Dr. J.

Dr. J reviewed Mr. G’s health history and the X-ray, and conducted a brief physical examination. Mr. G insisted that he wanted the tooth extracted because the pain had prevented him from sleeping for the past 2 nights. Dr. J extracted the tooth without any difficulty.

A few days later, Mr. G’s regular dentist returned from vacation. Mr. G’s pain persisted, so he saw his regular dentist on an emergency basis. Direct examination showed that the extraction site was healing well. However, when Mr. G’s dentist ordered X-rays of the remaining posterior teeth, tooth number 31 revealed a periapical abscess. His dentist opened and medicated that tooth, and Mr. G’s pain quickly subsided with the administration of antibiotics.

Mr. G filed a complaint with the state board of dentistry because he was very unhappy about unnecessarily losing tooth number 28. Although Dr. J’s professional liability insurance carrier appropriately represented him, the board of dentistry found that Dr. J had deviated from the standard of care, resulting in injury to Mr. G. The board imposed a fine on Dr. J and required him to complete 10 hours of continuing education focused on diagnosis and pain management.

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Risk Management Considerations

Theodore Passineau, JD, HRM, RPLU, CPHRM, FASHRM

Every student learns in dental school that the source of pain is not always consistent with the site of pain. All dentists must keep this in mind whenever a patient presents with pain. Diagnosing the cause of pain can be tricky, and it also can lead to professional liability exposure. Dentists must be comprehensive and thorough when examining patients to pinpoint the source of pain.

In this case, because of Dr. J’s busy schedule, he delegated a portion of the initial consultation with the patient to his dental assistant. Although the assistant’s actions may have been appropriate, it is also possible that, if Dr. J had conducted the interview, he may have expanded the diagnostic field to include tooth number 31. If that had occurred, his subsequent treatment would have been achieved without the unnecessary loss of tooth number 28.

Delegating certain aspects of patient care to dental staff is not inappropriate; however, the dentist is always responsible for all treatment rendered in his or her practice. A staff member’s mistake does not excuse improper treatment. 

This case also raises the issue of informed consent for treatment. When a thorough diagnosis indicates that extraction is necessary, a complete informed consent process should occur. The process should include advising the patient that referred pain is a possibility and that extraction may not relieve the pain. Nothing in this case indicates that any informed consent process occurred.

However, informed consent has its limits. If the information conveyed to a consenting patient is incorrect because of an inadequate diagnostic process, then the patient may still have a valid cause of action against the dentist. Informed consent for treatment does not excuse a deviation from the standard of care. 

Conclusion
In an ever-shrinking reimbursement environment, it can be difficult to maintain a sufficient cash flow to support a dental practice. As a result, dentists may take on a larger number of patients in an attempt to increase revenue. However, it is imperative that sufficient time and attention is devoted to each patient, including a sufficient amount of the treating dentist’s time. The risk of error increases when dentists do not have enough time to thoroughly evaluate and treat patients. Thus, planning adequate appointment timeframes should be a major part of dental practices’ scheduling processes and commitment to quality care.

Question
How should an associate dentist handle a situation in which he or she feels that insufficient time is allotted to appropriately care for patients?