Summer 2000 Practice Management Diary:

Keep cool: It will be all one a hundred years hence.— Emerson

I guess this is Emerson's version of "Don't worry, be happy!" When it comes to liability in orthodontic practice, our motto leans toward "Don't be happy - Worry!"

Certainly the essence of risk management is forethought and attention to good communication. We tend to focus on treatment liability. Diagnosis is an equally important topic. Nothing like a solid diagnosis to direct a sound treatment plan, and a low-risk relationship with the patient family.

These are some key areas in diagnosis and treatment:

* Gathering information at the examination. Will your exam and diagnostic records record a lateral shift in the occlusion? Do you listen to the chief complaint and address it in your recommendations to the patient? Are you aware of that 6mm mesial molar pocket in the 18-year-old patient?

* Dental and Medical history. We have had four patients in the last 20 years with spontaneous degeneration of one or both condyles. Starting treatment during this self-limiting condition can only be a disaster. That is only one example of an unusual condition that requires close attention to the patient history. Value the information collected in a good history form, and question the patient family carefully about information provided.

* Be sure dental and medical histories are updated at least once each year. Combine this activity with updating address and phone, sending progress reports, and requesting patient feedback.

* Consultation and written reports. The consultation is a most important time to discuss the nature of the patient's problem, and the risks and limitations of treatment. Far more important than a lot of time spent on discussing headfilm measurements with the patient family. Because everyone's memory is short and selective, oral consultation is inadequate. The key points must be summarized in writing.

* Realistic expectations. Patients tend to be overly optimistic about the glory of the final result of their treatment. Portray treatment results based on evidence you can rely on. For example, don't claim that your orthognathic treatments will solve that TMD. The literature is not on your side.

* Informed consent. The boilerplate form is not enough. Informed consent comes from a wide range of activities, and is played out in the exam, in the consultation, and in all written reports to the patient family. The signed form is simply a tool to confront the patient with the reality that they must agree to some terms. By the way, I favor the AAO document because it could be considered the gold standard, not because it is so perfect, but because it is provided by our national organization.

* Patient records. We have a gold standard for patient records, as well. It is defined by the AAO's Clinical Practice Guidelines, a little known but excellent document (order at 1 800 424 2841). It is also defined by the American Board of Orthodontics. Adhering to these standards for diagnostic records not only facilitates a sound diagnosis, but contributes to a good night's sleep.

* A change in treatment plan. When circumstances urge a change in the treatment plan, do not procrastinate. It is a time for progress records to document the need for change. One should treat this turning point similar to the beginning patient, with careful records, careful consultation, and complete written reports. If you like, an updated consent form is in order.

* Calling after stressful appointments. Could be the best way to increase positive rapport with the patient family. Such calls are just not expected these days, and patients are very grateful for the contact at a time when they are often quite anxious.

* Keep accounts current. When the responsible party becomes delinquent in payments to the office, he or she will start looking for ways to blame you. After all, who wants to criticize themselves? If they can think of some way you are not performing at least 110%, it justifies not paying the bill.

* Inform at each visit. The afternoon is busy, and Mary's retainers look fine. You skip touching bases with mom. Turns out she has some questions about a tender molar, that Mary failed to mention. The inflamed pocket goes untended, and when discovered, the furcation is involved. Parent contact is critical in the case of a child patient. This service can be delegated.

* Progress reports. A good way to make yourself communicate regularly to the folks in charge It is a chore. It can be done orally, or in writing. The written report has the advantage of clarity, and that a copy can go to the dentist.

* Decalcification and root-end resorption. These are the two most common risks of treatment; consequently they need careful management. Children's consumption of soda is much higher than in the past, and since it is both sugary and acidic, facilitates decalcification. We impose a ban on soda during orthodontic treatment. Not all comply, but the ban reduces the habit in most.

* Only x-rays can detect root-end resorption. Not obtaining progress x-rays during treatment is simply below the standard of care.

* Transfer patients and second opinions. Most of us are careful not to criticize other practitioners, for good reason. We simply cannot know what is in the other orthodontist's mind. We can identify concerns and offer strategies for successful continuation of treatment. In the case of a second opinion, it is usually best to help the patient and orthodontist continue with each other. Always communicate with the previous orthodontist to gain the benefit of his or her experience with the patient. If the patient refuses permission for this, we do not accept the case.

* Approaching deband. This is a good time to send a letter home explaining that deband approaches and you would appreciate feedback if there are any concerns. Describe the process of appliance removal, the retention protocol, and the need for final records. This will head off strained feelings if your expectations and the patient's are at odds.

* Patient not coming in, not responding to recalls or attempts to appoint. You need closure with these patients, and the dentist needs information. If the dentist thinks you are attending to the malocclusion, the retainers, or the wisdom teeth, he or she may tend to ignore problems associated with them. If a patient does not respond to our third recall notice or phone call, we send a letter of termination. We send a copy to the dentist. If wisdom teeth are still un-evaluated, or a cemented retainer is in place, we ask the dentist to follow up or encourage the patient to return.

* Documentation. Methods of good treatment charting have become common knowledge. Some fine points: If you use abbreviations, you should have glossary, which defines them. Narratives are powerful, since they provide specific information about that particular patient. Don't forget to chart all phone calls to patients, parents, and the patient's dentist. Also chart all discussions with the parent or patient at each appointment visit. Use your notes to follow up with patients about key information and agreements at subsequent visits. Chart all lapses in patient behavior in red: missed appointments, late for appointments, or failure to follow instructions.

After this list, I'm afraid you can't yet relax. You must consider your liability for compliance with State and Federal regulations (OSHA, child abuse, work rules, sexual harassment, patient disabilities, and discrimination. You need to conduct employee management in a way that accords with the law. You have a public facility, and when patients are injured in it, we hope you have followed all the basic public safety regulations. Patient records and employee records are confidential, and the public depends on you to train your staff to respect this private information. Finally, be careful how you advertise. Your State/Provincial Dental Board has some definite opinions about the proper way to proceed.

Isn't running a small business fun?

Some resources:

• AAO Clinical practice guidelines — 800 424 2841
  
  
• AAO Code of ethics — In the front pages of the AAO Member Directory
  
  
• AAO Risk management program — 800 424 2841
  
  
• AJO/DO — Section in the journal: "Litigation, Legislation, Ethics"edited by Dr. Lawrence Jerrold
  
  
• ADA Litigation stress support group - 800 621 8099

 
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