Pain after Crown Fit – an Upset Patient! How to Manage Tough Scenarios – PDP167

Jaz’s Introduction:
And everything goes smoothly, you did it under rubber dam, and it looks beautiful, and he followed all the adhesive principles, but unfortunately this asymptomatic tooth became very symptomatic and now you’re looking at a pulpitis and the patient needs a root canal.

Now sometimes the patient is upset. Does this sound familiar? Well if this doesn’t sound familiar then you probably haven’t done enough dentistry because this is something that we face. It’s a real world problem. It’s no one’s fault that this happened. It’s just biology. But attached to this scenario are emotions and feelings of the patient which can sometimes be quite bitter.

So today we tackle the clinical part of the scenario in terms of what do we do, how do we prevent this from happening, what kind of communication should be happening with the patient to preempt this kind of scenario, and medically, legally, how can we protect ourselves. I’m joined by a fantastic dentist called Dr. John Swarbrigg. And Dr. Neel Jaiswal, together they are two of the nicest guys in Dentistry. And yes, my voice does sound a little bit different. I’m sick again! Like, literally I was sick three weeks ago. I don’t know why, it’s like a chest infection this time. It’s all these bugs that the kids bring from the school.

But I’m powering through. I’m powered by coffee. I’m also powered by your love on social media and also on YouTube. It’s been amazing to have all these new listeners join. And all the veterans who’ve been listening to the podcast for so many years. To be part of the community on Telegram or the Facebook group or the app itself. Thank you so much to all of you for supporting Protrusive Dental Podcast.

Protrusive Dental Pearl
As you know, every PDP episode, I give you a Protrusive Dental Pearl, and today is a bit of a funny one. It’s an app I want to recommend, and I don’t know if it’s an international app or not. I know it’s in the UK, but I don’t know if it’s international, but I love the concept.

So maybe in your country you have something similar. It’s called Too Good To Go. So picture this, Costa or Starbucks, they have some really nice sandwiches and muffins that are delicious, but they expire on that day. So instead of throwing it away, how about you purchase it for a absolute bargain? So instead of playing like 12 pounds you’re paying like three pounds for example. And you’re also saving the environment because you’re preventing waste. So I’m totally addicted to this.

I’ve been using it for the past few weeks now. I’ve been telling all my practice where I work about it. All the receptionists, all the nurses are on board. So the Too Good To Go app has just been absolutely brilliant. As you know, I do love a good bargain. I like that feeling of getting a bargain. And so the occasional discount at Starbucks or Costa or Harvester, it makes me happy.

So I want to pass that happiness to you. If you’re like me, then download the Too Good To Go app and see what’s local near you. How can you help the environment? Also, get yourself a bargain from the places that you already like to eat at. Oh, and while you’re there, also download the Protrusive app. Now let’s go ahead and join the main episode with Dr. John Swarbrigg and Dr. Neel Jaiswal.

Main Episode:
Dr. John Swarbrigg and Dr. Neel Jaiswal, welcome back again. Welcome to the Protrusive Podcast. How are you guys? John, how are you doing?

[John]
I’m very well. All good. All happy. Up here in the-

[Jaz]
In the clinic. You’re squeezing this in between patients, right?

[John]
Yep. So I still work five days a week, much to my, probably I should be scaling back a bit at my age, but I’m still at the cold face Monday to Friday.

[Jaz]
That’s amazing. You love it so much.

[John]
Absolutely, yeah. They say if you love your job, you never work a day in your life, so I still enjoy it, so I’m still working.

[Jaz]
Great. And for those of our listeners and watchers who haven’t heard of you before, seen you before, just tell us about where you work and a bit about you as a dentist, as a person.

[John]
Yep. So I’m born and bred in the Midlands. Mum and dad are all Irish. So they moved over, grew up in the Midlands in Dunedin. And then I came to Leeds as a student in 1988. Qualified, graduated in 1992. And I’ve never left Leeds ever since. I don’t have had class myself as an honorary Yorkshireman nowadays.

I’ve spent more of my life in Leeds in Yorkshire. And I’m still working in the first practice that I came out. So back in those days, VT, it was called FD as it’s now known, was optional. So I came out and went into practice. I did a little bit of a part time hospital job. Hospital jobs, I worked as sort of like a staff grade in oral surgery, BRI, for a few years as well.

And then just worked basically in the practice, which I ended up buying then about four, five years, a little bit by default, really, not with any planning, just because the current principal decided he’d had enough and it was a case of either you buy it or I’m closing the place down. So I became a practice owner at a fairly youngish age, and then I’ve been here ever since, and then I set up a referral practice, which would be probably 10, 11 years ago in Harewood with Don Sloss, who was previous president of BACD, a local colleague.

I’d met them because I ended up going through the Royal College and doing MFGDP. I did a diploma. I did my MSC and then a completed fellowship. So I kept on coming across and bumping into those guys because they were part of that training pathway as well. So we ended up setting a practice up together, which and now coming out the other end of my career, cause Farsley, where I’m here today and working, we sold to Dentex, which is recently merged with Portman, and Harewood we sold to Bupa.

So I’m now, well I’m 54 now, so I’m hitting that back end of my career where I’m phasing out slowly, but without as much of the day to day hassle, shall we say, of running the surgery?

[Jaz]
Well, we need to extract everything out of your head because the beauty is with you and I’ve seen you lecture, I’ve seen your work, it is truly top end and what I admire about you is this ethos, which a lot of successful dentists I look up to have, which is staying in one place for a long time.

Seeing your failures come back, and no doubt you would have had that. And so it’s very much in going with the theme of what we’re discussing today, right? How many times it would have happened to you, because it happens to all of us, whereby you prep a tooth, and it becomes hot, hot pulp, and things change, and those conversations they need to have, probably they’ve changed as you’ve changed, as you’ve developed as a clinician, those conversations, your attitudes have changed as well.

So I’m looking forward to delving deep into that. But just before we do, I’m going to introduce Neel. Neel, you’re a veteran on the show. You were there on episode four when way back when it began and also recently as well in the sort of medical legal series. Just remind us about you, my friend. What is it that you do?

[Neel]
Thank you, Jaz. And thank you for having me back again. I’m a private practitioner. Got my own practice here in Hertfordshire and very much involved with that with my wife, Kamal. And we started PDI indemnity company, five, six years ago now. And it’s grown and grown. So that takes up a lot of my time as well, as well as, Jaz, we’re both little ones and that’s another full time job.

No, so really enjoying it and really blessed and just wish the weather was a bit nicer today. If I could take a little one out. But, I was just reflecting back on John, we met probably 14 years ago at Hayward House for a breed end all on four thing, I think. And he was a young whippersnapper then and actually caught my eye.

And interestingly, we’re on the same WhatsApp groups. And whenever we give advice to youngsters, because they go down a very narrow path, they don’t look wide. We both say the same thing, you know. What’s the occlusion? What’s the patient want? Where’s the smile line? So I think we’re very much in sympathic over there. So I’m looking forward to, well,-

[Jaz]
John, hearing what you I saw says John, I saw a lecture recently. We were their lecture together in Yorkshire. And like I said, it was fun. Fantastic. I’m sure you’re a really nice guy. I want to sit with you more than worry about. But I have to say that Neel is, for me, is the nicest guy in dentistry, right?

He’s the nicest guy in dentistry. And he’s so approachable. So, want just commend Neel on that? So let’s dive into the scenario. Long story short, right? You’re going to prep a tooth for a crown, but as you’ve done that, as soon as you’ve done that, the tooth now is suffering in pain, the patient’s in pain, you’ve basically set off a pulpitis basically, and it’s a difficult conversation that you need to have with the patient.

Now, the difficulty of that conversation will depend on the pre conversations that you had before, but that’s the sort of, in a nutshell, I’m going to now just for, make it into scenario, Neel’s very kindly prepared this, right. So tooth loses vitality after a crown. So here’s the official scenario that we can just that kind of like a role play thing, but let’s just set the scene.

Mr. Smith is a 65-year-old retired GP and he comes in with a large cracked amalgam. We see large, cracked amalgams all the time. It’s asymptomatic, really key point here, an asymptomatic molar. So patient’s perception is different here. You’ve discussed his options with him and agreed to do an onlay which he subsequently returns for, and then you fit the onlay and it becomes sensitive.

You look after the patient, you recommend some sensitive toothpaste, and he continues to suffer with his teeth and is now avoiding eating on it. A month later, he comes back with a throbbing pain. He’s very upset as a tooth was absolutely fine before you touched it. What do you do? So, how do you want to begin to unpack that, John?

[John]
I have this rule, and I’m going to give this away to you now. I call it the four R’s. So whenever we see something like that, and it’s asymptomatic, there’s always four things that I always talk about with people. And I say there’s four R’s that we can do this. We can Review it, we can Repair it, we can Restore it, or we can Remove it.

What would you like us to do, particularly if it’s asymptomatic, because at that time, I think, well, what experience has taught me is if teeth could talk, they’d ask us not to drill them. So sometimes the less intervention we do, particularly with this asymptomatic, is there isn’t a problem there, but there might be a problem coming down the line.

So it’s how that patient perceives that and how they would like to manage it. And again, I have two things I always say to people. Are you a proactive or a reactive person? How would you like us to manage this? Because at the minute, I can show you now, the great thing we have nowadays is scanners intra oral cameras.

So, he may perceive that he doesn’t have a problem, but we can see and probably know that coming down the line there’s a problem. So if we do nothing with that tooth, that crack is open, it’s probably absorbing bacteria and by our intervening, we’ve just accelerated what possibly would have happened already with this tooth.

But of course, it was fine until we touched it. So I was touching it means that we then own the problem. So my starting point always with that is, I mean, thankfully we have a scanner in the surgery so I can scan him. I can show him and blow him up, show him the cracked amalgam and then I can instantly say, how do you want to do this?

Are you a proactive reactive? Because the minute you’re getting no pain, but the chances are that this will either your bite and it will break. And are you happy managing that? In a reactive way, we might be sure it might be the weekend. You might be on holiday, might be Christmas Eve. You might not be able to get in, you might get discomfort.

And so I’m trying to give him his problem for me, so he can tell me how he wants to manage that risk. If we leave it in the-

[Jaz]
I like that, John, and something similar to what I do, because to really make the best decision for the patient, you need to understand the patient more. And so their, I guess, it’s risk aversion, their attitude towards risk in life in general, will reflect the decision they’re likely to make.

And we have loads of patients like, if it ain’t broke, don’t fix it, right? That’s my best Yorkshire accent, right? If it ain’t broke, don’t fix it. And we need to still, how do we consent that kind of individual that actually, when the proverbial hits the fan, don’t go blaming me for something I advise you? How do you say that in a nice way?

[John]
Yeah, yeah. Well, I think, I mean, we’ve had, like you said, this is a scenario we’ve had one, if not two in already this morning like this. And I work in Leeds, West Yorkshire, where we have wall to wall amalgams. Every tooth is a massive amalgam that has some sort of defect, ditch, crack, failure in it.

And if I treated all of them, I’d never leave the surgery. So, and a lot of those teeth are fine, you see those teeth and they do last and last and last. And some people’s approach is likely to say, just leave it. I just don’t want them touching. The downside is if you’re kicking the can down the road, which we’ll all look and say, I know it’s not bothering you now, but I know it’s more than likely.

And I like to use non definitive terms like more than likely. It might not be bothering you now, but more than likely. And that could be next week, next month, next year, this will cause you a problem. What we can do is talk about how we can manage it, so we can review it. If you’re happy leaving it, that’s fine, except that it might blow up.

But I don’t need to be disappointed if you’re then ringing trying to get in for a treatment, and it’s happening at a bad time because they’re always then becomes my fault if I’ve not then told them and informed them. If they’re happy to review it, roll it on. But I then tend to say what I’ll do is I’ll summarize the options that were spoken for you into a letter.

And over my 20 plus years, I have a library of consent letters. That means I can sit and I call it my little green book. It gets written down in there. And then on that page is all the clinical bits and pieces. So I make a point of writing it down. Some of that for me is dramatic demonstration. For the patient, it actively shows that I write their name down, what it is. And I’ll say, you’re in my green book and I will do for you a letter in the next day.

[Jaz]
I love that.

[John]
Which will then summarize out. So for me, that’s easy. I’ll type into my word database, upper left six, core or crown or fill. And it produces up a template letter that I can then personalize. And say you presented today.

This was the scenario. These are all your different options. And this is what all the different costs are. And then this is coming back from a Royal College days when we had to do for all the exams. There’s a little bit of prognosis. There’s a bit of presenting complaint, past dental history, risks and benefits, maintenance, etc, etc.

So there’s a little sort of standard paragraphs that apply that I can very quickly tweak to that. I email that over to my team and that goes out.

[Jaz]
Brilliant. Well, before I get to expand on that and zoom in on certain things, Neel, any comments so far from your perspective?

Hey guys, it’s Jaz interfering here with a message. So Dr. Neel Jaiswal, one of the guests on this episode right now, was also featured in Indemnity versus Insurance recently. So if you haven’t listened to that, please do check it out. He represents PDI, Professional Dental Indemnity, and they really are the nice guys in indemnity and insurance. Now, if you are due a renewal for your insurance or indemnity or more dental malpractice, then you need to get a quote from these guys.

You need to get a quote from PDI. The best way to do it is go to protrusive.co.uk/insurance. Remember that insurance is like the newer, sexier, better cousin of indemnity. And it offers you the highest level of protection and they offer claims made policies and claims occurred policies. So if you don’t know what I’m talking about, you need to listen to that Indemnity versus Insurance episode.

But if you do a quote, if you do a renewal with your indemnity, then do check out protrusive.co.uk/insurance. By visiting that link, you do get a hundred pounds off your quote. So whatever your quote is, you will get a hundred pound discount for being a Protruserati. And as this is a paid partnership, you also help to support the podcast.

So why not join me and hundreds of other dentists to switch your indemnity to PDI? That’s protrusive.co.uk/insurance. And let’s join the main episode again.

[Neel]
I think two things. One is what we might get out of this. And I know Jaz, you like tools for your listeners because they’re going to do a prep tomorrow. And I think I’m almost working with John’s help and with your help and a little algorithm of what are the key points that we should have, and we can perhaps put that together as a PDF or something. One of the things John probably does mention, but he didn’t mention just now, is also the risk of doing and the risk of not doing.

And they both have complications. So it’s really important that you might say, oh, we’ll kick it down the road, as you said, or if you want to review it, but actually we may lose the tooth because that crap could propagate. I’m sure, John, that’s something you’d tell them.

[John]
Oh, 100%, yeah. There’s pros and cons, actions and consequences, no matter how you are. And if we do nothing, one of the potential consequences is always tooth loss. And that comes then down into risk profile as well. For some people, the thought that they may bite and it causes a fracture that leads to tooth loss. They don’t want to be sat there thinking, I wish I’d done that. And that some of it comes down to as well.

I mean, I wrote down some notes before we did this and you picked up on it. And if you get to know your patients and you stay a long time, the less likely to sue you that’s probably just a fact. Basically, they build trust with you. So when you have lots of conversations with your patients all the time, you get to know personality type, how they are.

How they like to be fed information and how they like to receive information. And you get better at spotting the personality types that are more likely to give you a problem down the line. And there are some people who always want to shift blame. It’s never their fault. It’s not their problem. It’s our problem because we didn’t diagnose it.

We didn’t treat it soon enough. And as people living longer and keeping their teeth longer, we are seeing more tooth wear cracks and failure and some of those are incredibly difficult to diagnose and manage even with this simple scenario here at which point you intervene with an old filling. That’s perhaps been there 30 years that’s showing signs of breakdown-

[Jaz]
A lot of times I got these pins and by the time you move the amalgam you got nothing left anymore, right? And then you’re like, hang on a minute. It was doing just fine and now I’ve dismantled it and actually how am I going to place a crown on this?

So it becomes really tricky actually and and one of the challenges there is I mean, let’s take this a step further then let’s say with your communication. You’ve done the scan They’re in a green book. You sent the letter out and a few weeks later, they say, you know what my risk profile is that I’d rather not kick the can.

I would like this treated now to reduce my chance of tooth loss. Okay, the patient then goes on to have a crown. And then the patient has a sensitivity and it blows up into an into an endo basically needing an endo. Now, what can we do before it gets to that point in terms of the consent and the chat that you have? Because now the patient’s on board, but how do you then warn them that actually by me touching, I’m going to make it worse. But that’s the whole point of consent. They need to know that.

[John]
Yeah. Yeah. I mean, that comes in my standard letter. So when I’ve said to them, I’m explaining the four hours part within that letter is the risk. So pros and cons benefits and treatments. And within there, there is a certain number of teeth that as a result of this procedure, we’ll end up needing root canal treatment.

There was a separate fee for this. And that fee is XYZ so I’ve put that into the initial letter, which they sign initial to go and consent with treatment before they start.

[Jaz]
So you consent them for the fee for the additional root canal as well, right? That’s in the letter, right? So if you need root canal, it will be this much. And I think that’s important.

[John]
Yeah. Yeah. So that that’s in there and the pre consented. So I think it was a chap called Peter Thompson, who is a bit of a management guru. So it’s not what you say. It’s what you say before you say what you’re going to say that matters. So that all was stuck in my head in terms of I’m no different.

I’m a consumer the same as the rest of us are, probably by nature is dentists with detailed individuals. We like data, we absorb stuff. So I’m going to go and make a purchase. I want to know if there’s going to be a backend, and something might go wrong. I’m okay. Just tell me about it first. So it doesn’t come as a surprise.

I think sometimes if we haven’t communicated that, then we shouldn’t be surprised if patients pull us on it. We know it’s happened, but if you haven’t warned or told them and explained that there might be an expense to it, you shouldn’t be surprised if patients then push back a bit at you.

[Jaz]
Well, we’ll talk about that scenario in a moment, Neel.

[Neel]
I think just from a consent point of view, you’ve obviously written a consent letter and you’ve said these risks, and there it’s a general letter. And I think consent, as you know, is an ongoing process and an individual process. And I think what’s also useful would be your notes on the prep day.

Because then you can actually you’ve got your picture beforehand, so you’ve got your scan. I take a picture after taking the amalgam out. Here’s the cracks, here’s the leaking, here’s what it looks like. And I might write minimal caries, moderate caries, deep caries. What do I think the likelihood of risks with it likely, unlikely.

Do I repeat any warnings with more gravitas now? So you’ve gone from a general your green book to actually this is what we found on the day communicating that even before the patients come back for the fit, moisture control, whatever, so that you’re sort of fine tuning your risk as you go along and making it relevant and pertinent.

[Jaz]
It’s a continual thing. It’s not a one-time thing. I remember having surgery once, many years ago, and the surgeon came in, and he looked at me, and he’s like, why are you here? What are you doing? And I thought, am I in the right place? Is this the right surgeon? You know, why is he asking me these things, right?

But I said, I’m here for this procedure. He’s like, why? I’m like because X, Y, and Z, I loved it because it really, I knew what he’s, I got to the, oh yeah, that’s what he did. And so I do this to my patients. So if I had that kind of scenario, John and Neel, I’ve had that pre chat, I’ve done that green book, I’ve done that letter and they’ve agreed.

And now they’re coming back in. I’m going to say, why are you here today? Is it, oh, I’m going to get that film. Okay. Why are we doing this? Oh, so it’s not a big problem further down the line. And then my question is, what are the risks of doing it? And let them say, oh yeah, I might, you said, oh yeah, you, or they usually forget.

And I say, oh, let me remind you, there’s a chance you might need root canal. I’ve looked at your risk category. You are asymptomatic. So it’s on the lower side, but if I was to put a number to it, I might say one in five, one in four. I just make whatever’s appropriate for them, basically, right? With the crack and stuff. And I give them that, basically.

[Neel]
Another thing I do, Jaz, maybe not for an onlay case, but where there’s a bit more complicated, people get confused with different teeth. I’ll get the pen and paper with a chart, and they’ll write down in their own words, upper left six is fractured. If I don’t do anything this, why should I do it?

What’s the cost? And then they’ll have a page of their own treatment plan, which I then scan into my notes and they take it away with them. So it’s very hard to ignore that you’ve written something down in your own writing and it wasn’t told or you didn’t understand.

[Jaz]
Brilliant. So they are writing this as a summary. So they’re taking notes on your discussion.

[Neel]
Yeah. And I said, would you like I’ve never heard that one.

[Jaz]
That’s cool.

[Neel]
I think there’s a lot to take in here. And I need to make you a dentist. If you’re a dentist, somebody can be on a level playing field. So, I teach a little bit about charting.

I’m going to just go back to the scenario, John, and you probably will never have it, where this poor dentist has done what he thought best for this doctor, hasn’t written the notes up, hasn’t got a scanner, thought it’s an easy win. And now, sort of the medical legal aspect is actually, I don’t want to pay 1, 200, he never told me this could happen.

What would your communicator, and you’re now the principal, and maybe it’s one of your associates, how would you talk to that patient about what’s happened, why it’s happened, and what would you do about it?

[John]
Yeah, I think obviously, because we know it’s nobody’s fault, it just happens. And so, the central piece in that is always cost to the patient. Time out of the workplace, inconvenience, as well as financial, and you can make that go away and the biggest softener is making the financial go away. So with those cases, the easiest thing for me is to say, look, nobody wanted this to happen, but it’s recognized as nobody at fault here. But we appreciate that you’ve ended up now with a tooth that wasn’t causing a problem and now is causing a problem.

What we’d like to be able to do is fix that for you. And on this occasion, a gesture of goodwill. We’ll be able to finance that for you. If you want to stand your ground, you end up then having a fight, but that emotionally takes a lot of time, effort and energy, particularly if it’s escalated into complaints and handling it. So in my time-

[Jaz]
I’m just clarifying, John, I’m just clarifying. This is a scenario. You’ll be offering this kind of we’ll do the root canal for you only if you found that we as the clinician didn’t do our due diligence and we didn’t warn that’s the only time because if you did all the warnings everything by the book and it blows up you’re not going to give a free root canal, right?

[John]
The paperwork and the communication hasn’t been there and it happens, I’ve been there It’s happened to me in the past. For me, when we’re building the practice, I’m after lifetime patients. So I want that patient to go away. I want him to tell his friends and I want him to come back. And if he comes to me for the next 30 years of my career, The value to me and my practice in terms of what he’ll potentially invest and spend within the practice is massive.

I don’t have to go out and market for patients if I’ve got a base of really good people. And occasionally things go wrong and it’s the same again for us as consumers. If you’re anywhere and you’re having a meal at a restaurant and it isn’t quite on point, but they come over and say, do you know what?

We’ve not quite hit it today, but don’t worry about the drinks. We’ll take care of those for you. You end up telling people you turn a negative into a positive. I can’t believe we went there. Tell you what? The bloke is brilliant, though. If you have a chat and it’s not quite on point, it does this.

And I think that’s what builds your brand locally. Both our practices are very different. I’ve worked in and owned. Farsley is a very community based local practice. I walk up the road. I’ll bump into all my patients everywhere. My children go to school locally. So I will be meeting and greeting.

The wider public all the time, Harewood’s a little bit more niche, a little bit more referral, but the people who come there have, I would say, nice people have nice friends. So you want to leave them all the time, feeling warm and cozy about their experience with you. So as a consumer, for me, occasionally, I think we have to recognize if things haven’t gone well, just, hold up, admit it.

Sometimes you just take the finance out of it, it’ll always come back to you. That patient will spend that money with you further down the line, probably.

[Jaz]
And you divert to a potential complaint, which is the main thing.

[John]
And you meet each other, it de-escalates everything at that point.

[Neel]
Isn’t it nice to hear, Jaz, how to get new patients? Do the right thing. Be in one place. Admit your failures. Look after the patient. You don’t have to do TikTok dances to get patients. You just have to have integrity.

[Jaz]
Frank Spears says that his view on failure is that, listen, I just want to go in and fix it. I just want to help, right? And so when we drop the ball and we can see that and sometimes we can clinically drop the ball, like we’re going to talk about one of the scenarios about a perforation Neel in the future, right?

I’m going to have an endo guess and we’ll talk about perforation. What happens when we perforate, right? So we then again, goes back to the consent, but when things go wrong, sometimes you’ve got to say, okay, you know what the communication aspect, me or my colleague dropped the ball here. So let’s really look after this patient and make sure this doesn’t go any further. I think that’s exactly the point you’re making, John, isn’t it?

[John]
Yeah. Yeah. Sometimes it’s just nobody’s fault. Sometimes it just happens. And then for me, I think the best business is always relational business where you get on well with people and every now and then it doesn’t hurt to give a little bit away to receive back for 20 years.

Something coming back, you can’t underestimate what lifetime value and patients who learn to trust you. And you can turn that negative into a positive. And instead of spending 1200 quid on a marketing campaign, that’s your marketing campaign right there by just doing the right thing.

[Jaz]
Now, Neel, I’m going to ask a question here. Now, let’s say we had a scenario whereby this has happened. And really look back at notes and perhaps either you didn’t warned them as well as well as you should have or you didn’t write it in notes which is just as good as it didn’t happen, right and unfortunately, right because the patient’s got selective hearing. So in this scenario, then they now need a root canal, but it’s a complex root canal. This was a sclerosed pulpal kind of thing and endodontist needs to do it and let’s say it’s going to cost a patient a grand. Who’s footing the bill should the associate have to pay?

Reduce from the associates gross? Is the indemnity who needs to pay? Who pays for this kind of stuff? It’s an interesting question.

[Neel]
Let’s say for me, this patient came back, my notes went missing that day, so I can’t say that we’ve had the conversation, let’s say, and the poor doctor’s come back in with pulpitis or ulceritis, so I would have a conversation with him in the surgery, and that would kind of tell you where you’re going, so let me explain what’s happened here, let me show you what pulpitis is, I’ve got CIC medivision, which I quite like, and if he’s a doctor and he’s a bit scientific, he can understand inflammation and all that kind of stuff, and we’ll go, this is what’s happened to your tooth, most likely it was going to happen anyway.

And really, from our point of view, this is a complication that happens. There is a fee to that, and there’s a measure of goodwill. Then from John’s point of view, you either say we’re going to pay for it.

[John]
Yeah.

[Neel]
I might say, look, we’ll both take a hit on this, and would you like to go 50 50? That works quite a lot once you’ve had a little chat with them. If they’re uppity, obtuse, not so great, and you know that they’re not going to pay for it, then indemnity wouldn’t pay for it, because it’s not a legal cost. It’s not like a judge has said you owe some money. It’s not a payment for something that’s happened. It’s a refund, or it’s a contribution. So you could ask indemnity to pay for it, but I think you’d just shoot yourself in the foot, because I think all that’ll happen is over a very small amount of money, you’ll become a risk factor.

And I think in this case, they would say, this is practice. You’re dealing with it in practice. It hasn’t gone to the GDC. It hasn’t gone to lawyers. So, how you want to deal with it internally, and there’s a line where it’ll come into our boat into our hands, and there’s a line where it’s in your hands.

So I think probably in this, it’s better off resolved on a local level, and if it’s an associate issue, then it comes out of the associate wage. If your principal, you’ve been there 15, 20 years and you’ve got a great relationship and you’re friends and you take one on the chin for each other, then that’s a different conversation.

But really, as a self employed, and we’re looking at the taxing and all those things, why would somebody else pay for your mistake as a self employed business?

[John]
There’s two bits for me on that show, I think I can add value on here is the first thing with complaint resolution is just asking the patient what they seem as success at the end of how would you think this, what’s the best way for this to be resolved in your eyes?

Is it, would it be for free? Would it just ask them what the end point is. And again, I don’t, I try not to say, shall we-

[Jaz]
How would you like for us to put this back for you? I had an issue actually, it’s a great point by the way. I had something happen to my Jaguar, I used to drive a Jaguar XF and the garage cocked it up, they did something wrong with it and it delayed things, and then so literally the manager asked me how can we make you happy, how can we resolve this?

I was like, I would like some money off of this please, and he gave me 300 quid off, and I was like alright, that’ll do me. So that’s how I carried on, so that’s a great point.

[John]
Yeah, because sometimes that’s where which helps mitigate the feed and exactly you get a feel and sometimes there’s a third party. I’ll use it whereas principal or clinical lead. I can sort of say, look, tell me what you need and what you’d like to happen because I can then go back, speak with the dentist. We can chat down as a clinical group within the practice as a management team, and we’ll see if we can help you with that. So I won’t always guarantee that I can meet it there and then For them, I can just take that information and understand and then I can come back to them.

So if we meet as a third party, so if it comes in as a complaint or it’s escalated that way, then that’s our complaints procedure where we meet. Try to resolve at a local level, and then I’ll ask them, what does success look like? And then sometimes I can suggest enough. If we were to able to make that happen, would that be okay for you?

Yeah, that’d be great. And then it’s an easy conversation, say behind the scenes. And I think the second point when I’m chatting with the associates, particularly nowadays with HMRC is I don’t think we can be seen as a practice in a business to be mitigating. Things that they’ve done as an independent. I think that’s one of the key areas, isn’t it?

With underlining associate and self employed status is that you end up having to, in effect, fund things that haven’t then gone well and refunds and put things right that comes out of their pocket rather than a shared expense because that that might stray into are they employed rather than self employed.

So, I think there’s an element of that that I’ve seen before where people have sort of said no, actually contractually you need to pay for your own work if you’ve been paid for it in this way to put it right that way and then maybe behind the scenes you can mitigate as a 50 50, as long as it’s not happening that often, it’ll happen to all of us all the time in this case, when not if.

[Neel]
It is a blurry line that self employed employed is like how far do they need to bring their own equipment in ideally, do they provide locum so it is a tricky one but I think if it was a refund, as a principal, I might take a hit on it and go 50 50. If it’s a contribution towards-

[Jaz]
Or the same split as whatever they’re on, right?

[Neel]
Or whatever, yeah. And if it’s the endodontist, then I would say, look, really, this is for you to contribute to. And the endodontist might say, look, you referred me ten patients, I’ll sort you out here. It’s a conversation, as you said, with lots of people. But yeah, yeah, it’s a great point, John, and I forgot to sort of say, actually.

Just asking how can we help you? What would make, how can we want? We want a win win. What’s the win win for everybody here?

[John]
Yeah. Yeah.

[Jaz]
Okay. So we’re coming up to the end of this podcast. I’m going to ask you a final comment. So what we covered beforehand is the clinical element of you know sometimes just monitor the four R’s that you gave a brilliant and then if the patient chooses that they would like this treatment and you think it’s a suitable treatment, you’ve got to give the warnings and have the letter and give the fee for a potential root canal.

Now, hopefully these asymptomatic teeth, a low percentage of them hopefully will go on to need this kind of treatment, but it’s quite distressing for the patient. And if you’ve done all your hard work, then the patient will have already been aware of the risk and they will pay for the root canal and you just say, oh, I’m so sorry this happened.

Let’s extubate. Let’s get you out of pain. Let’s get you off to the endodontist kind of thing. Right? That’s the ideal scenario. But if they kick up a fuss, they either cause they have selective hearing or you didn’t do your due diligence, then you’ve got to have more conversations, just like the ones we discussed. So as a final comment, any contributions? John, I’ll start with you.

[John]
Yeah, no, you’ll get some people who simply have lost trust, lost faith in you, and they don’t want to come back again. Again, for me, it’s about mitigating, trying to turn that negative into a positive. Some case, it’s just a case of refunding.

Just say I’m really sorry it hasn’t worked out. We’ve done our best ability here, you paid this towards the crown. If this helps going towards you, the treatment, I’d like to, I would say, I’d like to think if we walk past each other in the street, we’ll be able to smile, shake hands if we needed to.

And I wouldn’t have to, obviously we’ve got a big Asda that’s just up the road from us. I would say, I’d hate to think I was hiding in the fruit and veg section to try and avoid you. Most of us are dentists to do a good job for patients and occasionally it doesn’t work out. It’s just unfortunately, culture and climate now looks for somebody to blame.

People demand perfection all the time and it just simply doesn’t exist. Things don’t play out and sometimes it’s nobody’s fault. It’s just biology and science and just stuff happens, unfortunately, and it’s trying to mitigate that. And occasionally you’ll come across that person who, for whatever reason, personality type, and they’ll have a trait.

That’s how they are in life. And you find them. And do you know what? You’re better off out of your life. Get rid of that stress. Give them the money back. Because as soon as that monkey comes off your shoulder, you’ll just feel better. Whereas if you carry internalize that stress and trying to make it right. You can’t fix everybody. And certain personalities just won’t mesh.

[Neel]
Obviously conclude, concur with everything John said. If you are in that situation where this happens to you, and you get away with it, don’t just think I’ve got away with it and keep making that mistake. Do your checklists, have a little look at what could I have done better.

Next time you might not be so lucky. If, if they’re not right for you or not right for practice, definitely, same with anyone in your life, family, friends, staff, whatever. Create a positive culture around you and have positive people. And like John said, nice people have nice friends and that’s definitely the case.

But yeah, just make sure you’ve got consent, your photos are prop your periapicals are in the right place. EPT, risk of doing, risk of not doing. I like the four R’s. Costs of failure, costs of complication, good contemporaneous notes. Intra oral camera, if it’s a crack, you tell people it’s a crack, they don’t understand.

You show them a crack, they go, oh my god. And they’re expecting it to go wrong, and thank god you intervened in time. So I really like intra oral camera, maybe more than the scanner. I know scanner’s flashier, but everyone will have one. But intra oral cameras, you can get them cheap on Amazon. So I would say photography and communication and rapport building.

And if you get into trouble, please learn from it. Don’t just keep going down the thing and blaming the system you’re working in. Just reflect on it and take it as a positive experience.

[John]
I’ll give one last anecdote there, Neel. Somebody once said to me, when you have a problem, there’s three things you need to remember.

What you’re going to stop doing, start doing, keep doing. So any time you have a problem, break down into those three areas and think, I’m not going to do that again. I’m definitely going to do that again. I’m going to keep on doing that again. And then usually you’ll reflectively learn and hopefully move forward. Because dentistry is constant reflective learning. That’s what it is. It’s a lifetime of reflective learning for me.

[Neel]
And good marriage advice, John, as well.

[Jaz]
Gentlemen, I also want to thank you for your time today, but because you come on the show, give up your time, I really want you to talk about your referral practice, John, any teaching that you do, how can we get in touch with you? What channels can we reach out to you on?

[John]
I do a little bit of teaching nowadays, but less and less. It’s just being away from home and tying away from families I’ve got a bit older. So I do a little bit basically, which is, my main area of focus tends to be treating wear case. So I treat and do a lot of wear cases all the time, as you saw with the lecture. So it tends to be on that education and a process that I’ve developed over years.

And there’s various systems. One of the systems that I align with is SmileFast, so a little bit of teaching on their program. And we run an advanced course. for them over two days. And that’s probably about all I do nowadays on that. And apart from if the BDA or anybody locally just asks to do stuff.

Harewood is just, it’s now owned by Bupa. That’s a referral only practice, which is in Leeds. And then mode of practice, which is a bit more community, sort of more normal, just day to day sort of stuff is at Farsley. We accept some referrals as well over there for that. And it tends to be where bonding failure cases where people have found that it hasn’t perhaps gone as they’d expected and they need a little bit of help. So we step in and help out colleagues really for me. That’s more as a SEMA role nowadays. Let’s help. If you’ve got a problem, it’s not a problem.

Send them over. We’ll see if we can help. It’s a lonely world is dentistry at times. And we don’t talk to each other enough and so I like to I’d say referral, but it’s just, I’ve got 30 plus years of experience and I’ve made every mistake going so sometimes as part of my reflective learning loop, I can fix or see sometimes I think I said I’ve moved into that phase of life where it’s become almost subconscious competence.

I’ve seen and done it so many times. I sort of know what the answer looks like because I’ve trodden that path so many times. So yeah, that’s what referral is for me is working just as part of people’s wider team to help them not, not have a bad day, really.

[Jaz]
Neel, you’re in danger of getting you surpass as a nicest man dentistry here. John, honestly, that’s really good of you. And it’s fantastic. Keep doing what you’re doing. Neel, tell us about PDI and how we can get in touch.

[Neel]
Yeah, more than welcome to get in touch with PDI. If you need any indemnity or, again, if you just need some informal advice, we’re always happy to help. Again, with John, it’s about helping colleagues. These situations can be stressful for people, and as I get it, as John said, it’s a lonely world. So, Neil, which is N double E L at professionaldentalindemnity. co. uk or Facebook, Instagram, Messenger, you know how to find me.

Jaz’s Outro:
Amazing. So there we have it, guys. What will you change about your practice to make sure you don’t get bit by this scenario ever again? We discussed lots of tangible points, lots of actionable points that I want you to make sure you pledge to change about your practice straight away. There are lots more scenarios where this came from, such as what should you do if you, for example, perforate the pulpal floor?

Or if your patient has some cosmetic work done by you and they’re unhappy afterwards, how do you manage these tough scenarios? So please do stay tuned for those, and if you want to get CPD for listening to this all the way to the end, you deserve it. You should head over to protrusive. app. The website is protrusive. app.

And if you answer a few questions, you get a certificate emailed to you by my team. And all it costs you to access everything on the platform is the cost of a Nando’s per month. Don’t forget that you also get access to VertiPrep for Plonkers. We’ve already had one webinar. The next live webinar is on the 29th of November.

So hope to see you there. And I just wanted to thank again to my team, Erika Allen Benitez, who is my producer, Mari, who manages CPD and the premium notes for this episode were done by Krisel Facun. And thanks to you once again, Protruserati for making it all the way to the bitter end. I really appreciate it.

I’ll see you same time, same place next week. Bye for now.