fbpx

I am joined by Dr. Stephen Hudson of Dental Law and Ethics Blog

Need to Read it? Check out the Full Episode Transcript below!

Protrusive Dental Pearl:

Download my EXACT examination Custom Screen for free! (I had to move the link to the Facebook group where you fill find all the custom screens – wait for group approval)

Once you are in the group, this is the post with the download:

In this episode we cover:

  • Who can call themselves an ‘Expert’ and why it’s stupid
  • Who was Montgomery and why did they have such an impact on our profession?
  • Where do you draw the line in terms of ‘explain every single option’
  • If you feel uncomfortable treating this patient – how can you tell your patient?
  • Consent forms – are they really necessary?
  • What happens when a child attends with the father, not with the mother?
  • Under age Teeth Whitening – would you do it?
  • Do you always need a PA for extractions?
  • The GDC says you should make a recommendation – what happens when the patient says ‘No’ to the recommended treatment?

The over arching theme of this episode is the importance of building rapport with your patient!

If you like what you hear, please Subscribe, leave a review on Apple Podcasts and share with a friend who may find it useful!

Click below for full episode transcript:

Opening Snippet: So there's been a lot of hoo ha about Montgomery because initially we were afraid about it. But what's happened?...

Jaz’s Introduction: Hello everyone and welcome to the Protrusive Dental podcast, it’s Jaz Gulati here. Today, I’ve got Stephen Hudson on the show, we’ve been talking all things about like consent forms, notetaking, how not to get sued, the relevance of Montgomery, Who the hell is Montgomery? You’ll find out today, like I did, I thought Montgomery was a guy, right? It’s actually a woman. So there we are. I’ve noticed that actually, a lot of my listeners are starting to message me with recommendations for who they think that should come on the show next, and I’m actually loving it. So please, if you’ve got any suggestions for topics, I’d love to hear it, I’ve got a good list of speakers coming up and guests on the show lined up for you. But if you think something would be beneficial to the audience, then please come with the suggestions. Before we dive into the episode I will give you the Protrusive Dental pearl for today. And that is going to be a gift to you guys. It is my custom screen for taking comprehensive examination notes. So for my new patient examination, I try and make it fairly comprehensive. It’s not ott it’s pretty detailed. And you know, you can fit in what you want. But basically the the benefit of a custom screen, if you never heard of a custom screen is on Exact, Software of Excellence , Exact. You can actually have a way of collecting notes where instead of having to have like a template where you’re adding and deleting stuff, I’ve converted it into like tick boxes and drop downs. So it actually makes it really easy for your nurse to follow what you’re doing. And like for example, molar classification, you can just drop down click class two whatever, you can select your sort of incisor classification, you can have the BP code within the custom screen, you can take where the radiograph is grade one, two, or three on page two of the custom screen. So basically, custom screen is a fantastic way of collecting notes efficiently. And also notes of very good quality. So I’m going to share with you my custom screen, the story of how I got to make my custom screen was basically I was a bit poorly last Christmas. Basically I hate doing nothing right? So I was in bed, I was super sick. So what the hell can I do anything I can move. So I got my laptop, open our log into exact. And I was able to bust out for hours and make this custom screen. So I know I worked really hard on this custom screen. But it’s not perfect. I realized that for example, if I could go back in time when I get some time. The next thing I’m gonna add on this custom screen is patient’s goals. Patient’s goals are so important in treatment planning, and I’m always having to add it on somewhere, I’d like to have a dedicated place. So it’s not perfect, but I’m hoping it’s going to really improve the note taking. So if you’re using software of excellence or exact, then you can download my custom screen, and you will probably find a way. I mean, I can’t tell you the top my head how to do it. I’ll probably include this in my instructions on the website and how to actually install a custom screen and use it and maybe like a video, that’s a good idea. Actually, I’m gonna put a video on how to install and use this custom screen. So I hope you like it. That is the pearl for you today. So let’s join Steve Hudson for today’s episode.

Main Interview:

[Jaz]
So Steve Hudson, welcome to Protrusive Dental podcast. Thanks so much coming on, I wanted to have you on because amongst all the episodes I do, for example, you know, the dahl technique or Tif Qureshi thinking comprehensive, and we’re talking about all these techniques and stuff. But none of this is valid, or it’s borderline dangerous if our consent process isn’t there. So that’s why I’m having you on. I’m gonna do a little bit of introduction for you. But I’d like you to do a bit yourself. So Steve, I know that you are a sort of author in apocalyptic books. And that’s what you’d like to do. You are I believe, a retired dentist who does a lot of medical legal work, you have a blog called GDP resources, which I find very useful. And I’ll link that for my listeners. Can you add to your crappy introduction I’ve just given you

[Stephen]
Well, the website has changed its dental law and ethics now.

[Jaz]
Okay, brilliant.

[Stephen]
Yeah, the apocalypse is mainly zombie fiction.

[Jaz]
Okay. Zombie fiction. That’s, of course, and when did you retire it clinically?

[Stephen]
This year.

[Jaz]
Congratulations.

[Stephen]
Literally this year. Yes. It’s true health though.

[Jaz]
Okay, fine. And so now, am I right that you do a fair bit of medical legal work?

[Stephen]
work through probably for another year, because there’s only a certain amount of time you can carry on doing it if you’re not practicing.

[Jaz]
Okay, fair enough.

[Stephen]
The courts like to think well, you’re not really practice, you’re not really going to keep current.

[Jaz]
Okay, fair enough. So it’s a shame because I think I obviously I know for a fact that you’re full of a lot of knowledge when it comes to this field. But you know, if that’s how it is. So that’s exactly what I want to talk to you about. You know, I was gonna call you a medical legal expert, but I you know, I’m scared this current state of affairs, Steve, I’m scared to call you an expert. And the reason I’m afraid to call you an expert is about a year ago, there was a leaflet produced with my photo on it. And it said, I’m some sort of expert in discipline I was using at the time, right? And then one of my good friends, my dear friends, I won’t name and shame him, but you know, he was one out for me, he messaged me saying, look, you know, I think just be careful with that term expert. And you know, then I reported back to the guy who made the leaflet and you know, he’s not a dentist and he’s like, well, what the hell if you’re not an expert who is an expert? So Steve, Who the hell is an expert? I

[Stephen]
I have no idea. But if you’re actually on the specialist register, it might be alright. I’m not actually convinced that GDC or that word with that?

[Jaz]
Okay, I’m glad you said that. Because an expert for me, someone who you know, I love reading self development books and that sort of stuff. And what I’ve gathered is you’re an expert, if you know if you’re in the top 5% of a population who knows about something that’s, you know, that’s why think so, for example, compared to a layperson, I’m an expert in dentistry. I’m an expert in composite resin. I’m an expert in a lot of dental things because the lay person wouldn’t be but if asked to call myself an expert in orthodontics, then you know there’s a gray line that yes, I have a diploma in orthodontics, or maybe I do have a right but you know, maybe you know, you have lots of experience in orthodontics. So you know that, you know, I don’t know if it’s worth exploring this topic or not. But so you think it’s not something worth worrying about too much?

[Stephen]
I think you have to be careful. If it’s like, if there’s an official specialist field like restorative,.

[Jaz]
Then I’m going to be very controversial and say, who can call themselves an implant expert?

[Stephen]
I don’t think there is a implantology specialties.

[Jaz]
There isn’t. So if I’m on someone’s website, and dentist, I said, I am an expert in placing dental implants. Is that cool? Is that kosher? Is that Halal?

[Stephen]
I think what the CDC doesn’t like to do to make yourself sound better than anybody else. I think that’s why they don’t like to use it. You know, if you get your BDS with honors, that’s why they don’t like using with honor. But

[Jaz]
That’s BS, because you know, can I worked really hard to achieve my honors? Right? I didn’t i think [inaudible] if everyone gets honors, correct me if I’m wrong, but no, I think generally the degree you get is with honors, but I might be wrong. I don’t know. But Look, I know a lot of dentists work hard to get the honors, and you know, you stick it on because you’ve been awarded it. But anyway, that’s a different topic. Look, Steve, let’s dive right in. Okay, I want you to tell me who this one Montgomery person is. And what are they done cause such a massive stir in our profession. And if you can, please clarify in terms of in relation to bolam. And if you can make it tangible for the listeners.

[Stephen]
Okay. Well, Montgomery was a legal case brought in Scotland, it was a woman who was pregnant. Because she was diabetic, she had a certain risk of giving a natural birth. And she wasn’t given that the warnings about that risk. So what happens you have the birth and that risk materialized in the child, the child’s got some shoulders, or some sort of shoulder scares. Yeah. And so she went to the court to sue, because she said, if you if I’d been given the risk, [inaudible]. And the Scottish court said, No, no, no, no, no. And they kept throwing the case out. And it wasn’t until they went to the Supreme Court that the judges agreed with and awarded a quite a large amount of money. So there’s been a lot of hoo ha about Montgomery, because initially, we were afraid about it. But what’s happened is the court take this kind of case law, and then they interpret it themselves. And I don’t think they’ve gone down the road, we were afraid that was, to be honest, all Montgomery has done is brought the legal side of negligence to the same standard as the regulatory side, because we look at the standards. Standards are saying this since 2013?

[Jaz]
You mean the GDC standards, right?

[Stephen]
Yeah. They’ve got a whole Principle number three, obtain valid consent. And it’s all about you must obtain valid consent before starting treatment.

[Jaz]
So it’s what’s changed, make a tangible to dentistry you know Monday morning, or you know, whenever I go practice because of Montgomery, what do I have to do now to make sure I’m doing things by the book? Is there anything any specific scenarios? Make it tangible.

[Stephen]
The Montgomery requires patients to be given the choice. So it’s not enough to advise of the risks and benefits of a recommended treatment, you must also have the risk of any other alternative. So generally, if you’re doing a composite and you give them the risk of the composite, you kind of got it to let them know about the option of amalgam as well, as long as we can still do amalgam [inaudible] [Jaz]
So option and the risks of the amalgam as well

[Stephen]
Yeah, cuz it’s a viable treatments, because the composite has risks and benefit, and amalgam has risks and benefits and so on. So patients will, believe it or not,

[Jaz]
It’s true, but you know, I’m really airing the frustrations of our profession because where do you draw the line? Because there’s about as Lincoln Harris one taught me there’s about seven different ways to treat a cavity. For example, do I now need to also discuss Okay, I can also put a sandwich I put a GIC at the base, then put the composite okay? And that’s another way how I could do an inlay. Okay, so do I need now discuss inlay? That’s a viable choice, clinically, that’s a viable choice. Okay. So where do you draw the line? This is ridiculous.

[Stephen]
Well, that’s where the the next bits come in draw the line? This is ridiculous. requires a doctor or dentist take reasonable care to ensure that patient is aware of any material risks involved in any recommended treatment and of any reasonable alternative or varying treatment. So it’s reasonable word is what comes out, though, it wouldn’t be reasonable for you to have to go through that because I actually figured out was 48 ways to fill an occlusal cavity. So it would not be reasonable for you to sit down because the patient wouldn’t understand it. If there was absolutely so the problem is the only body that can determine what reasonable is a court. So you should be reasonably aware that the particular patient would like to take significance in it and that comes through the conversation. You have the patient before treatment.

[Stephen]
Okay, so what should that conversation involve to make sure We get the right fee to the patient.

[Stephen]
Yeah. So you basically got to make sure the patient is on board with you that you’ve got rapport. If you don’t have rapport, we probably shouldn’t be treated. But yeah, if you can tell is that that sort of hesitancy the probably don’t like your conversations not flowing, you know, when the patient’s not on your side?

[Jaz]
Absolutely.

[Stephen]
You just shouldn’t be treating those.

[Jaz]
So I’m gonna jump straight to question seven because I made a list of questions to ask you. So we’ve gone from Montgomery, which question one, I’m gonna go straight to question seven, which is exactly about the situation. So let’s say we’ve encountered this patient now. Okay. And for those who listen to the basic implant occlusion episode with Ivan from the US, he talks about red flag patients. Yeah, so he’s got a system of, you know, you know, two yellow cards and red card and this is, he’s trained his staff to do this, right? So I have a red flag patient in front of me, just from the history that they’re giving me and I’m feeling uncomfortable in doing any treatment for this patient, how can you let them down in a way that is respectful and courteous, and within the law.

[Stephen]
Basically, with experienced, you’ll find a way to get rid of patients

[Jaz]
Commonly, there’s some tactics employed, I’m not endorsing these tactics as quadrupling your fees, which I don’t think is really a great strategy. But, you know, it’s very tricky.

[Stephen]
Yeah, I mean, things like that quadrupling your fees, if you’re doing this, just because the patient is annoying, or might sue, what if they take your product? What if they still go ahead with the treatment? Because they can still complain afterwards. And they can still cause problems with payment, and they can still complain to the GDC. It’s much better, in my opinion, and my opinion, may well be flawed in to get that patient to go to another dentist who may have a better relationship with the treatment,

[Jaz]
But it’s having that difficult conversation, you know, with the patient be like, look at you know, I don’t feel I’m the right dentist for you. I guess that’s the only way to do it. But you know, I don’t know, based on what he said, I’d love to help you. But I don’t feel I am the right sort of a match as a dentist for you. If you’ve got to do it, case by case, but it’s a tricky conversation to have.

[Stephen]
The ways I’ve done it in the past are exactly that, just to be honest. So I’m not the dentist for you. And half the time they were ‘Yeah, you’re right’, which can be a bit bruising to your ego. The other half of the time, the last one, and you’ll just look at me. I said, ‘Well, you know why? Because we’re not on board. We’re not on the same page, you’re gonna be better served most likely by finding a dentist who’s more tuned to you psychologically.’

[Jaz]
“Mr. Smith, I want the best for you, I think I’m not the best dentist.” I think that Yeah, fair enough. Honesty is the best policy. And I think that’s as best answer as we can possibly get into this sort of question.

[Stephen]
What I’ve just said is obviously for entertainment purposes only because I’m not a lawyer. I can’t give legal advice.

[Jaz]
Absolutely. Anything I ever say on any of my episodes is for entertainment purposes only. I’m just putting it out there.

[Stephen]
If you look at the principle, one of the GDC standards, it says put patient’s interests first. So if you’re going to treat this patient, you’ll be able to give them the result they want. You’re not doing it.

[Jaz]
Perfect. Love it.

[Stephen]
Though [inaudible] Parliament’s been buttoned up for years. Yep, they’ll treat patients who don’t like because they invariably don’t like you.

[Jaz]
Yep. And don’t treat patients you can’t have a laugh with. And it’s something I’ve said before, and it’s a good way to practice, actually. So next question, my friend, Steve, is consent forms, they aren’t worth the paper, they’re signed on. What is your advice in being involved in the medical legal field, being the expert. Consent forms? You know, is there a minimum threshold or procedure? For example, look, I’m being very honest. And I’m exposing myself, okay. I’ll be careful what I say, consent forms are not my favorite thing to do in life. All the things there are to do in life, consent forms aren’t highest priority for me, but I know that’s certainly my wisdom teeth, always. Oh, my gosh, wisdom teeth always. Now, can you give me some advice? Can you mentor me in this way, that should I be doing consent form for everything? Is there a limit? Photography? What was the medical legal take on consent forms?

[Stephen]
Well, as you said, they’re not really worth anything. The GDC only get insist you do them in very few circumstances, like general aesthetic sedation, that kind of thing. So I mean, you can do them, but they’re not going to prove anything, because you can give them a 27 page treatment plan, which they sign, and they can turn around and say, I won’t understand what it was, I just felt pressured to sign it. So again, it comes back to the patient, you must have the patient on board before you do any treatment. Now, that variable, you then have still have to do the treatment plan, because that’s the GDC requirement. But I wouldn’t get too concerned about the consent forms, to be honest.

[Jaz]
Amazing. This is music to my ears, but then you know, the type of some dentists are very fond of it. And you know, that doesn’t mean you change your practice overnight, stop doing it, whatever you find a comfortable way to build rapport and get your patients on board, do it that way. For me, I just look them in the eye and I tell them all the risks and I take my time I show them radiograph and as long as I feel we have an understanding and sometimes that what I love doing is I love quizzing my patients, you know, I say Okay, so what did I say the risks were from last time? What did I say on this? And half the time they remember but I remind them and I write in my notes patient, quizzed and reminded and it’s and patients you know, like that they’d like that interaction I found so that’s great. So consent forms to your discretion everyone there you know they’re not really the worth of paper though. You know the wrote on so I’m glad you said that. Anything else want to add to that before a move to next question? No, I think that’s it amazing right. So next thing is a children’s act. So when the child attends with their because a common scenario child attends with their father. There’s a whole Act about the father, if they’re not married must be on the birth certificate, blah, blah. Can you just clarify that scenario?

[Stephen]
That is quite a very complicated piece of law, the shoulders occurs. It’s all about parental responsibility. And if we get a second, am I able to pull something up from my computer?

[Jaz]
Yeah, go for it, please. Because I think this is a daily scenario for GDPs. And every time a child patient attends with their father, I feel like I know this stuff. I feel like I know, but every time I have a doubt, in my mind, I just feel so basically, I feel uncomfortable when a child is there with their father and not with their mother, because I’m not like 100%, you know, medically lead the best way, which is a shame. You know, as someone who’s became a father recently, myself, it’s a shame but you know, when a mother is there, I’m relaxed. With anyone other than the mothers there with a child. I’m on edge a little bit.

[Stephen]
It’s also good to worry about grandparent bringing,

[Jaz]
Oh, absolutely. Which is a common scenario. If you can shed some light on this for our listeners, that’d be amazing.

[Stephen]
I think if the husband, the father is on the birth certificate, then they’ve got parental responsibility. I think that’s what it is. But then how do you ask?

[Jaz]
Yeah, I’ve had to ask before and it’s just a terrible thing to ask. Very insensitive.

[Stephen]
There’s also things about children’s consent because the child has Gillick competence, then they can consent treatments, but they can’t refuse treatment. So generally, I would have the parents on board with until the kids 16 because then the 16 becomes an adult, it gets even more complicated then just have to find this thing I’m looking for

[Jaz]
No worries, but I’m gonna jump in as the now a 15 year old Gillick competent patient comes Okay? and they need some teeth whitening and I don’t mean they want teeth whitening, I genuinely means they need teeth whitening they’ve got yellow brown teeth and they’re being bullied at school. Okay? And I see this on the dental forums all the time. “Oh, I’ve got a 17 year old”, “Oh, I’ve got a 15 year old”, “Oh I’ve got a 12 year old patient” and by the letter of the law you can hack these teeth down for a minute you can slap on some composite which is going to need replacement events for the rest of your life and I don’t care what anyone says composite veneers they will need maintenance and replacement. So that’s all kosher and fine but then the teeth whitening bit so what is medical legal stuff because I you know, I hear it banded around that actually, if there is a psychosocial element to it, ie the child being bullied then whitening is allowed? Is that written anywhere?

[Stephen]
That the problem with that if they’re below the age of 18. There’s European law. So he can’t be, he can’t do the whitenening.

[Jaz]
Hashtag Brexit.

[Stephen]
Yeah, well, it’s probably gonna be still in British law for a good while. Yeah, even if we do leave, which I don’t think we will. I’m still don’t see that happening. Because if the states just pushing everything to try and stop Brexit from happening, despite what you hear from the Tory MPs. Yeah, so that’s gonna be interesting.

[Jaz]
But in the young person scenario needing whitening, I mean, my stance is this. And again, please guys, it’s for entertainment purposes only if I have like a 15 year old, 16 year old and I had the parents on board, and I have the child on board. And they genuinely are like, I haven’t had an encounter this scenario. But if they’re generally are really discolored, and the child’s being bullied, I would probably do it.

[Stephen]
Because you’ve also got the GDC principle, you got to do what’s in its best interest.

[Jaz]
Yeah, absolutely. So it’s a whole minefield, but that’s my true thought. And I would do that.

[Stephen]
So it’s not in the child’s best interest to pack their enamel off and rectify their porcelain deficiency. But it’s also is it in their best interest to do something that’s technically illegal is only a decision the practitioner can make based on their own judgment. And that’s going to be based on the relationship you have with the patient, the parents, because again, if they like you, and the wind goesw well, you’re not likely to have any problems.

[Jaz]
It’s true. So again, there’s a whole rapport thing again, with the parents and the child so it stick always goes back full circle, but I actually know a good friend of mine, restorative dentist, a fantastic clinician, I won’t name them just because I didn’t really agree to this. But in the one or two times they’ve had to do this exact scenario because it’s a referral practice. And they get referred the sort of cases he or she has actually written to the child and under parents to an explicitly written in the letter I will be carrying out illegal tooth whitening on you. This is illegal, in the letter, and it’s everything’s like really transparent.

[Stephen]
I can tell you what the ddu say,

[Jaz]
Yes, please.

[Stephen]
So this is under the law patients must be aged 18 or over. Although the GDC makes an exception for whitening the teeth of under 18 when used wholly for the purpose of treating or preventing disease. The DDU cannot envisage any circumstances where this might be the case, our legal advice is that there are no exceptions to the rule, and all patients must be aged 18 or over.

[Jaz]
Wow, that is very strongly worded. Today goes DDU says no, we’re not in any circumstance because they can’t envisage that scenario. But what is the definition of disease? You know, once again, you know, is it completely ignoring the mental side of it, which I think I’m sorry DDU, but I don’t like that.

[Stephen]
Yes, as well. I can’t go with DDU. I’d like to.

[Jaz]
Yeah, I think we’d all like to, but that’s not good. Okay. So we’ve talked a bit about the whitening to your discretion. I know some people who would some people who wouldn’t, but you know, that’s your discretion and it is what it is until the law changes. So next question is there’s an extraction that’s booked in, the tooth is grade two mobile, it’s a new patient to you, the diagnosis, whatever the diagnosis is, the tooth needs to be extracted. New you and the patient have come to terms with this, I would take a PA because make a medical legal world we live in even though in Sheffield, the way I was trained, it was actually a common, you know, it has two roots, you know, as you know, you don’t really need a PA. But nowadays, I don’t know a single clinician nowadays where we’re at, you know, and practicing, who wouldn’t take a PA in that scenario. So any comment on taking PAs prior to XLAs?

[Stephen]
I think you take a PA. I think that’s the way to do it now. Personally, I would also do a PA.

[Jaz]
Fine. So it is what it is, you know, take a PA, everyone.

[Stephen]
You can get, very rarely going to get some bizarre, apical pathology that makes you get [inaudible] that you know, some it’s like one in a million kind of thing. Some bizarre squamous cell carcinoma or whatever, they’ll ask me about all pathology

[Jaz]
but I think you’re right.

[Stephen]
I know one or two times I’ve heard dentist talk about what they discovered on a [radio]. So yeah.

[Jaz]
Yeah, I think in this current affairs, yeah,

[Stephen]
it’s like on peri I mean, you have to do your periapicals. I’m not convinced but I really need to, but that’s what the British regulation states

[Jaz]
Everyone, please take some PAs prior to XLA. Sorry. But that’s how it is.

[overlapping conversation] [Stephen]
This is literally wafting in the breeze when that when they breathe in and out. You probably be alright with that to not do a PA but don’t quote me on

[Jaz]
Of course not. But you know what I do in that scenario, I’d get my intraoral camera out and take three photos of that tooth in extreme buccal position, in the middle position and extreme lingual position, just so it’s like crystal clear. The degree of mobility.

[Stephen]
I think what you’ve highlighted actually, is there’s no proper guidance. There’s no, this is how you should do it written down on a piece of paper somewhere. Everything’s a bit vague. It’s a bit wishy washy. And there’s a reason for that, because dentistry isn’t the kind of thing you can have set rules for. But the drawback is everything’s open to interpretation. When it’s open to interpretation, then you get some fancy lawyer on the stand, who’s got his interpretation that it might sound completely wacky, but if the judge goes for it, then yeah,

[Jaz]
It’s a both a blessing and a curse in dentistry, that everything is obviously open to interpretation. But there are upsides to that as well, obviously, cuz you can, you know, justify and argue and that sort of stuff. So so that’s cool. Next question is, I used to work with a male nurse, right. And I’m terribly sorry, to my listeners if I have said this story before, but it’s a funny one. So I work with this male nurse, right. And he was taller than me broader than me. And he was a Sikh guy. And he had a bigger turban than me, right? So this is really is in private practice that and I know he’s listening to this probably right now. And I’m just gonna say, hey, champ, I hope you doing well. And anyway, so he’s actually a dentist in India, and now he’s just done his ORE and stuff. So patient comes in, female patient, okay? And obviously, he’s my nurse, and I’m the dentist. And quite a lot of times a patient would assume that he’s the dentist because he’s got, you know, a bigger turban and stuff and more authority and stuff, which was always a funny scenario. And the other funny thing was, when I’d been sort of leaning in the mirror and the handpiece and he’d be leaning in with the suction or turbans would clash, which is like a completely like, unprecedented scenario in clinical dentistry in the UK, I imagine. So that that was that’s my funny story done. But okay, in this scenario, I feel in this current climate two male nurses, female patient, that’s a no go.

[Stephen]
I think you might be right. I can’t quote you the law on it. And people will say there’s no problem. But the [climate] is so very driven. Now that I think you have to have a if there’s a female patient, you have to have a female in the room.

[Jaz]
Chaperone.

[Stephen]
But yet, but then that brings in all the other issues about transgender and all the different other genders that are now coming out. It’s a minefield.

[Jaz]
It really is, you know, women want equality. And we know I’m a big fan of equality and stuff. But what about this scenario, when you have a female dentist, a female nurse and a male patient? I know it sounds stupid, but you know, how is that different? Really, if you want equality?

[Stephen]
I don’t know the answer to that.

[Jaz]
It was just a stupid rhetorical question. Anyway. So Fine. So next question, thank you for that. So you’re allowed to make a recommendation, I mean, under GDC, you are allowed to, you should make recommendation to your patient, which I think is a very sometimes a forgotten point. And it’s a useful thing to have, when you’re explaining to patient that you know you’re allowed to recommend a treatment option. And then when the patient says no, and they’re completely within their right to refuse treatment for any reason, what would you recommend us, gdps do when a patient you know they need an extraction and you’ve had or they need a splint even and this, you know, you’ve come to the conclusion that, that’s what’s gonna be the most appropriate thing for their health for the prevention or whatever. So and the patient declines, it all you have to do is write at the notes for a patient declined and risks won is that as much as we need to do and or do we get in writing, that’s the sort of direction I want to explore with you.

[Stephen]
Well basically explain to the patient why you recommend the treatment, the benefits of the treatment and the risks of not having and the risks of the treatment and also the benefit not having the treatment and the risk of not having the treatment and then you record that in a clinical note, because the patient has the right to make what we think is foolish decisions because it’s their body. And obviously they’ll then turn up at [inaudible] on a Friday before Christmas. But yeah, just let them decide for that. And then when it then eventually happens that the face blows up on the middle of the transatlantic flight or whatever, then you’ve been seen to be the wise dentist warning them this might happen. As long as you’ve got the report and the relationship with the patient where they trust you that shouldn’t happen by and even if it does, you’ve got, you’ve told them and recorded it and then even warned them. And it was their decision not to go ahead.

[Jaz]
Yeah, this is always a tough thing. It’s a tough thing for all dentists. But I used to almost get like a flight or fight response inside me when like, for example, you know, oh, you just need two bitewing x rays, or you need two x rays in your routine x rays. And if the patient refused, and then I’m like, Oh, my God, I mean, this is, it becomes confrontation sometimes. So what I’ve adopted now is just don’t make the patient’s problem, your problem firstly, okay? Relax, and I just smile. And now I’m really, you know, I try and be real with them and say, “Look, I totally respect that, I respect your decision just to agree with them respect, I respect that, the main reason why we do it is because you know, you might have holes between your teeth, and I can’t see them in my eyes. And this is why we take those x rays, if you’re cool with it, I’m cool with it, as long as you know, there might be some holes. Is that right with you, Mr. Smith?” Are you saying that tone, and that really lightens the mood. Because, you know, there’s no point once they’ve made up their mind, okay, they’re not having it. And they’ve got their preconceptions or whatever. And sometimes it will, Oh, I didn’t realize that I’ll have the X rays. And but you’ve done your bit, and you’ve done it in a non confrontational, non judgmental manner. And I think that’s the most important way to do it. Would you agree with that? /-Yeah./ – And one thing that David Winkler taught me, you know, guys who work with him, he patients who need extractions, and, you know, they because the tooth gonna blow up, okay, he just smiles them and says, “Just don’t call me on Christmas Eve, just don’t call me on Christmas Eve”, you know, patients get the point. I love that. It’s so straight and real. So that’s a great communication tip to just smile, Yeah, that’s fine, Mr. Smith, but just don’t call me on Christmas Eve. And they sort of get it. So that’s mine. And I’ll get there. Shared. Steve, those are the questions I had for you. Tell me is there anything else that you’d like to mention that the microphone is yours to GDPs. Mostly, you know, I’d say 80% of my listeners, young dentists between the age of 25 and 45. So any anything you want to send out to them.

[Stephen]
Don’t be afraid of Montgomery. What we’re seeing is since it’s been brought in, isn’t that the court are kind of feeling their way with it. And they’re generally going down a more sensible road than we considered they would. I think, if I remember that in two legal cases, recently, I think it was A) versus East Kent hospitals university NHS Foundation Trust and Tasman vs. Bar. And both those cases, the case was thrown out because the risk patient was complained about that they weren’t warned about was considered immaterial, it was to support some really rare thing. And it was the risks of it happening were less than one in 1000. So generally, the resists or it’s not set in stone, and the courts might turn away and go down a different route sport, I think if the risk is less than one in 1000, it’s not classed as material, which means you probably don’t have to worry about it.

[Jaz]
That’s interesting.

[Stephen]
There’s three kinds of risks. There’s the general risks, so you know, do an injection, you’re going to be numb, that’s a general risk. Treatment specific risk, you can take out a six and the root [inaudible], but it’s also patient specific risks. And that’s where the gray area is, it’s a rare risk that might be relevant to a specific person based on their their lifestyle. So a trumpet player might consider the risks of paraesthesia, for lower lip more relevant than, say, someone who works in a factory,

[Jaz]
Even though the risk might be again 1000, wherever it becomes more patent,

[Stephen]
Because if they have paraesthesia [inaudible] and that’s their life, that’s their livelihood.

[Jaz]
So the message there is have that rapport because you would have no idea about the trumpet playing if you didn’t already have rapport built in and a social history.

[Stephen]
So that’s where the conversation in the chat comes in that will then come out.

[Jaz]
Because when you mentioned that about the 1000, I was thinking well hang on a minute, oral bisphosphonates the risk of you having you know, [bronch] from a tooth extraction on someone who’s, you know, on oral, you know, an uronic acid or whatever, without any steroids, nonsmoker, that sort of stuff is like one in 10,000 to 100,000. But you’re right, that’s a very patient specific risk. And you know, you should discuss that with the patient.

[Stephen]
or we shouldn’t even be the ones that were warning them about that should be the medic.

[Jaz]
Yes, true. And so many times a patient have no idea or maybe the, you know, maybe the medics have told them, they just forgot, who knows

[Stephen]
The medics generally don’t tell them. I mean, I’ve had a bit of interaction with medical question the last few years and their consent process is woefully inadequate.

[Jaz]
Oh, absolutely. I mean, I’ve had some medical procedures and the way they’ve gone through stuff with me and I’m there saying Whoa, this is consent?

[Stephen]
But the thing is litigation side because the patients don’t pay, there is this for medicine, there is this because you lack of need for all this. But if you look at the NHS, it’s putting some money aside for future litigation. I think something like 60 billion it’s a crazy amount of money. It’s just sat there to fight off future litigation because the lawyers are really getting clued up on this and so the patients. Patients are realizing now that negligence can be a good way of earning a little affair trust

[Jaz]
So very sorry state of affairs.

[Stephen]
But patients won’t sue you for like, you know, there’s been study after study that shows that if the patient likes you, they won’t sue you. When I’m sure you read the book, blink.

[Jaz]
Yeah, read blink. Yep.

[Stephen]
Yeah, the As a gold chaplain in that book,

[Jaz]
I’ve also read your book, the dentist Survival Guide. There was that chapter. Oh, gosh, is it by [Amin Armenian] Is that right? Fantastic. Really, And it was that book wasn’t a dental Survival Guide. Or was it masters? Message for masters? Which one was it?

[Stephen]
Dental Survival Guide

[Jaz]
Okay, so what I loved about his bit, and it’s worth mentioning here is that if you do too, and correct me if I probably recall this wrong, Steve, if you do two of the following three things, right, your patient probably won’t sue, okay? So A) if you’re nice to the patient, and have rapport B) if you do the correct treatment plan, and see if you do the treatment plan well, so for example, you could be nicer to the patient, and you can do some really good treatment, but maybe it wasn’t the most appropriate treatment, then you probably should be fine. Or you could you know, do some, the correct treatment plan. It’s not, look amazing, whatever. But the patient likes you, you sort of like also be fine. So I really like that way of thinking about it.

[Stephen]
Yeah, the problem is, no matter what you do, there’s always going to be that risk, there’s always gonna be the patient that can slip through the whatever systems you put in place. So you just have to keep good note. And again, there’s the other thing, when, where’s the guidance on how to write notes?

[Jaz]
I’m hoping you write a book on that, mate.

[Stephen]
Well, does this mean you remember? I got some guys from dentinal tubules. And we did the examination. what’s right for examinations? What five restorative procedures? Which is given away free on my website, just like I mentioned that,

[Jaz]
no, absolutely. I’ll link everyone as well. Because this is, you know, people always like, you know, “templates” or whatnot, because it really helps you as a signpost to make sure that you’re consistently recording notes at a high standard.

[Stephen]
Because there’s guidance from the faculty of general practitioners on what to write for examinations. There’s guidance from the various society on what’s the right tone of treatments, and there is a little bit of guidance. I’m not sure how it can be called guidance, but it’s everything we’ve got. It’s a position paper from the European endodontic society or something, which I think that’s now classes what you should record when you’re doing endodontic treatment. But apart from that, I can’t really find anything for MLS manual surgery, like take your teeth out, what should record obviously, there’s going to the implant societies will have guidance for what to record with an implant. I know. You know

[Jaz]
[Kara?] [Stephen]
Yeah, he’s got a website, I believe

[Jaz]
my implant plan,

[Stephen]
Yes. Which has everything he needs to record and everything to tell the patients which is very good. And that’s free as well, I think,

[Jaz]
Wow, I didn’t know it’s free. I will contact Parven with I’m sure would be fine with me sharing that with our listeners, because anything to help everyone would be good. So thanks for raising that.

[Stephen]
Just record everything.

[Jaz]
Good luck.

[Stephen]
When are you having a conversation with the patient, your nurse could be typing away?

[Jaz]
So I’m so glad you mentioned that. Yeah. So my nurses, I try and train them as much as possible that when I’m done with my patient, there should literally be like, you know, like a transcript like Jaz said this, patient said this. So yeah, fair enough. Some nurses are better than others. But hey, this is an in service I’ve seen an advert for it’s like [Hiroku] or something it’s called, it’s where apparently, it’s like an Amazon Echo that’s listening to your conversation and converting into notes and stuff. So if anyone’s got any experience with that, and once it gets feedback, how that’s going, please let us know. Because that’s, you know, anything that can help everyone record notes better, faster, quicker, that sort of stuff. So that’s interesting as well.

[Stephen]
There we have databases and patient conversations teacher is a whole server forms full of these. Now, I don’t think we need to go to that level. I think just because if it’s in the note, the courts will generally say that’s what’s happened. Promise, you can’t rely on templates, because I’ve actually seen this in legal cases where you’ve got the notes, and it’s the notes of Mr. Smith. And halfway through the record of that day patient warned about pregnancy. So it’s been cut and pasted and they’ve not actually read through your notes can have a certain degree of templates applied to them, but they still have to be bespoke.

[Jaz]
This is why I like custom screens. Are you familiar with custom screens?

[Stephen]
I try to avoid computers as much as

[Jaz]
You are so old school. No, Steve, custom screens are amazing. And this is actually give me a really good idea, I use a really good custom screen, which I made myself on SOE and I’ll try and sort of share that with everyone. It’s like, so on a custom screen you’re actually taking things and your drop down menu, select things so you never sort of writing or using like a template, you have to actually manually choose something which means that you would have had to go through it. So I love that. I think that is more, you know, medical, legal proof if you like.

[Stephen]
Yeah, I think that’s really good. The only thing that makes me pause is how that looks when it’s printed out on paper.

[Jaz]
True. I’ve never tried it. That’s a great point. Actually. Worst case scenario just open up exact. You know, it’s all there. I just buddies text screen shot

[Stephen]
Simon factory did his LLM, his law masters and his dissertation was on bias and expert witnesses. And he found that expert witnesses are very biased if I remember and one of the thing that occurs to me if you’ve got notes that are hard to read, let’s say let’s make it easy, you’ve got handwritten notes and you’ve done spider scroll. If you give that to an expert witness, he or she’s going to be like, you’ve got legs? So the expert is already against you. Because you’ve made it difficult for them, if you’ve got a good notes with everything, then it’s going to be easy for them. And that bias might slip in your favor. It’s just a thought it just occurred to me.

[Jaz]
No, no, it’s true. So make sure your notes are clear and legible. Because if shit hits the fan, Excuse My French, then they won’t be able to read your notes.

[Stephen]
I mean, I teach dental students, and they do like to write their magnum opus, every time they see a patient, slightly less patient that the site don’t need to go to that level. But if you do want to go to that level, then at the end of it, just do bullet points of what the actual treatment was. So you can skip all that anything. Okay, that’s what’s actually been

[Jaz]
So the notes have to fulfill the benefit to use so that when you actually go back next time, and you look, you know, you’d have to read through all that stuff. So that’s a good point, you know, have you made notes and have a little summary to help you. So, Steve I think that’s all we’ve got time for today. Thank you so much for coming on. I will share your law and ethics website. So because I know it’s got a lot of helpful resources, the templates that you mentioned, I’ll reach out to Pam I’m sure be happy for me to put my implant plan out there, I try and get a exportable version or importable version if you’d like of my SOE exact template, which I think is a pretty good and thank you for covering really pertinent key points, which actually confused dentist and finally, I realized that Montgomery is a woman and it wasn’t a man. So thank you.

Jaz’s Outro: Thank you very much, guys, for listening all the way to the end. I really appreciate it. I hope you like my custom screens. I’ll make it available to download on my website will be on www.jaz.dental/customscreen. That’s all one word custom screen. So now you’ll be able to download the custom screen. It’ll also be on my normal under the of the blog post for this episode. I hope you find it useful. Give me some feedback. See what you think. And if you guys have got like, if you guys in the Protrusive community have got good custom screens and you want to share them with everyone, please send them to me I’ll happily like make it make a page on websites we can all share our customer screens because look if we can all help each other, record better notes more efficiently, then that’d be amazing. Apologies if you’re an All for though, I realized that I haven’t really given you guys anything. Sorry. Once again, thanks for staying at the end. And next episode will be with Jason Smithson. And we’re talking Emaxs onlays and vertical preps, vertical crowns, which is really really good episode obviously pre recorded. We’ll be launching that soon. Tickets for occlusion 2020 are pretty much almost sold out. So hence why I’m not really promoting it that much anymore. You can be seen a massive drop in the ads. I’m running on Facebook. So thanks so much for those who’ve booked and I’m looking. We’re so stoked for May. It’s gonna be the best occlusion event ever. So we’ll see you then.

Hosted by
Jaz Gulati

More from this show

Episode 20