For Dentists
What are the potential outcomes of a patient complaint?
In Ontario there are three potential outcomes for a typical patient complaint. The first and best outcome is that the RCDS dismisses the complaint without taking any further action. Obviously, this is a successful outcome. Occasionally, the ICRC will make a decision to take no further action while providing gentle practice advice to the dentist. Again, this result is a successful outcome. It doesn’t require the dentist to do anything, and the decision remains confidential. Typically, completely unmeritorious complaints will result in a decision by the ICRC to take no further action. If the ICRC has concerns about an aspect of the dentist’s conduct, they may provide practice advice, while dismissing the complaint. This can involve such advice as directing the dentist to communicate more clearly with patients.
The second potential outcome in respect of a patient complaint is that the RCDS makes what is known as a Specified Continuing Education and Remediation Program order, or SCERP order. This is a negative outcome, for reasons we will address below. SCERP orders are occasionally accompanied by a direction that the dentist appear before the ICRC to receive an oral caution. The most common type of SCERP order is for the dentist to be ordered to take a course or courses in an area of concern identified by the ICRC. Typically, a SCERP order to take courses will be accompanied by 24 months of practice monitoring that will commence once the dentist has successfully completed the course or courses ordered. The practice monitoring will focus on the specific area which has been identified by the ICRC as being problematic. For example, if a dentist’s records are found to be inadequate, the ICRC will order the dentist to takethe RCDS course on recordkeeping. After the course is completed, there will be 24 months of practice monitoring. The practice monitor, typically an RCDS staff dentist, will be sent to the dentist’s office to review clinical records prepared after the dentist has taken the course.
As indicated above, the SCERP order is reflected on the Public Register. The Public Register is accessible on the RCDS website. If a patient knows where to look, within a few mouse clicks, the patient will ascertain that you were ordered to take courses and have practice monitoring. Of course this creates a negative impression with respect to your reputation in the profession.
Our firm’s approach to patient complaints is to attempt to identify clinical deficiencies in the dentist’s actions, well prior to the ICRC making a decision concerning the complaint. For example, if we review a dentist’s records and can see that the dentist’s records are inadequate, we will strongly recommend that the dentist take the RCDS course on recordkeeping immediately. Another common problem with dentists’ records is that there is no proper record of the dentist’s informed consent discussion with the patient. We routinely recommend to dentists that they take the Ontario Dental Association online course in informed consent to address these issues. If we believe that there are other more serious clinical errors made by the dentist, we will strongly recommend that the dentist/client take a course or courses to address these clinical deficiencies.
The RCDS is very amenable to providing guidance to lawyers as to what particular courses a dentist may take once a clinical issue has been identified. Typically, our office will call the RCDS Educational Consultant and describe the nature of the clinical problem that has been identified. The Educational Consultant may recommend a tailored specific course that will address the clinical deficiencies identified.
We recommend this approach because if a clinical dentistry issue is obvious to our lawyers, then it will be obvious to the ICRC. In order to avoid the negative outcome of the ICRC making a SCERP order, we take a proactive approach. The ICRC’s typical approach to complaints that are not serious enough to warrant a referral to the Discipline Committee is to order the dentist to take courses. We routinely receive complaints decisions from the ICRC indicating that the ICRC would have ordered the dentist to take a course, but decided not to do so, because the dentist has proactively taken the courses the ICRC would have ordered. We will set out below excerpts from six separate decisions where the ICRC has, in effect, praised the dentist for taking courses proactively, and has chosen not to order the dentist to take such courses. Thevalue of this type of approach is incalculable when you consider that when the ICRC orders a dentist to take courses, this decision is posted on the public register on the College website. All of this can be avoided, and the dentist’s reputation can be protected if the dentist receives appropriate, experienced pro-active advice to take courses. We consider it one of the biggest benefits of a dentist retaining our firm to assist in responding to a patient complaint. Based on our experience, we have been very successful in spotting issues and problems in advance. When the ICRC is notified that the dentist has acknowledged a mistake and taken specified courses in advance, that demonstrates to the ICRC that the dentist has insight into the clinical deficiencies identified by the complaint. It also demonstrates remorse and contrition. All of these considerations will assist the ICRC in making a decision to take no further action.
Example 1
Dr. M. was the subject of a complaint about periodontal surgery. The patient complained that Dr. M. removed gum tissue and cauterized her gum without her consent. Dr. M. had sold the practice before the complaint, and the patient record could not be located. Dr. M. believed that there was proper informed consent to the gum surgery.
We reviewed the complaint, and advised Dr. M. to complete the RCDS course in recordkeeping, and the ODA informed consent course. In its decision, the panel expressed concerns about Dr. M.’s informed consent protocols, and said that they were inclined to require Dr. M. to complete a course in informed consent. The panel wrote “However, [we] acknowledge that Dr. M. has proactively taken a course in informed consent and assume that Dr. M. will apply the course principles…”
The panel was also concerned about Dr. M’s recordkeeping practices, but “accepted that Dr. M. has proactively taken the College’s course in dental recordkeeping…and assumes that Dr. M. is now familiar with recordkeeping responsibilities and obligations.”
Example 2
A minor patient’s mother complained that Dr. A. changed the treatment plan that she had agreed to without consulting her, and that Dr. A. was unresponsive when she sought more information about the treatment plan.
The panel that reviewed the complaint was concerned about Dr. A.’s recordkeeping. The panel said that Dr. A. had not recorded many relevant details,including at least one phone call with the complainant. The panel noted that it “would have been inclined to take some action regarding this concern.” While ultimately no action was taken, this was because:
the panel could see from a letter to the College submitted by Dr. A. that Dr. A. had completed the College’s full-day Dental Recordkeeping course. As such, the panel did not feel that it was necessary to take any action with respect to Dr. A’s recordkeeping issues.
Example 3
A patient complained that Dr. K. ground his upper wisdom teeth while fitting a new night guard, and that he was not told about this treatment before it was done. The patient claimed that when he asked Dr. K. about what was being done, he was told that the night guard was being adjusted.
After reviewing the complaint and the chart, we advised Dr. K. to take the RCDS course in recordkeeping, and the ODA course in informed consent. The panel that reviewed the complaint was concerned that although Dr. K. provided a clinical explanation for the treatment, it appeared that occlusal adjustments had been performed without informing the patient. The panel wrote:
[Our] concerns about the member’s conduct were ameliorated by the insight [shown]…The panel noted that [Dr. K.] has proactively completed a course in informed consent, which the panel expects should remediate [Dr. K’s] informed consent practices…the course Dr. K. completed is the one that the panel would have asked or directed Dr. K. to complete…had [Dr. K.] not already done so.
Example 4
Dr. X was the subject of a complaint regarding restorations. The patient complained that she was billed for 11 fillings that were not performed. The ICRC found that the type of restoration that the dentist performed was a non-preparation bonded composite restoration, which was an acceptable form of treatment for a 64 year old patient. The Panel expressed concerns with respect to the dentist’s recordkeeping and informed consent processes.
The Panel was concerned, that Dr. X’s informed consent and recordkeepingpractices with respect to Ms. Y’s treatment were not adequate. In particular, the Panel saw no indication in the record that Dr. X discussed with the patient the risk and benefits of this form of treatment. Given that this form of restoration has an increased probability requiring retreatment, the Panel feels that Dr. X should have clearly communicated this to the patient prior to initiating treatment. The Panel is also concerned that the record does not clearly indicate why he performed the restorations, nor did Dr. X document all the teeth that he planned to treat when he discussed the treatment plan with Ms. Y on September 14, 2017.
In light of these concerns, the Panel was inclined to require Dr. X to take courses in recordkeeping and informed consent. However, in his letter of response, Dr. X indicated that he had recently taken the ODA course on informed consent on May 22, 2018, in addition to the College’s recordkeeping course on May 22, 2018 subsequent to the treatment complained of in this case. Proof of completion of these courses was provided to the College. In these circumstances, the Panel’s concerns with respect to Dr. X’s informed consent and recordkeeping practices have been minimized.
Example 5
Dr. S., a general dentist, was the subject of a complaint from a mother on behalf of her minor son. The complaint was that Dr. S. extracted a permanent tooth instead of a primary tooth, contrary to the referral received from the patient’s orthodontist. The mistake was discovered by the orthodontist when the patient returned for treatment.
Dr. S. admitted that the wrong tooth had been extracted. It was clear that a panel reviewing the complaint would be concerned that this type of error occurred without Dr. S. being aware of the error until being notified by the referring dentist. Our advice to Dr. S. was to take a course in the anatomy of primary vs. permanent teeth.
As expected, the panel was very concerned about the mistake and its consequences for the patient. However, the panel decided to provide Dr. S. with advice and recommendations. In doing so, the panel noted that Dr. S:
demonstrated proactive remediation and a willingness to address this issue by taking responsibility for [the] error…and by taking a course thatincluded review of the anatomy of primary and permanent teeth and other relevant topics.
Dr. S. avoided a more serious outcome because the panel was satisfied that the member had shown insight into the circumstances that led to the complaint, and had taken action to prevent those circumstances from occurring in the future.
Example 6
Following a routine facility inspection with respect to sedation, Dr. H., a general dentist, was informed that the RCDS had concerns about the provision of oral sedation in the practice. When reviewing patient records, the inspector noted that Dr. H. had administered sedation in excess of 0.25 mg triazolam, which is consistent with oral moderate sedation. Dr. H. had not obtained RCDS authorization to administer oral moderate sedation.
Dr. H. acknowledged that errors had been made, and that the sedation records were incomplete. We advised Dr. H. to take a sedation course with a specialist in dental anaesthesia. Dr. H. agreed, and received the additional training.
The ICRC panel was inclined to require Dr. H. to complete a course in sedation dentistry. Dr. H. was not obliged to take this course because the panel:
felt that the course [Dr. H.] has completed…covered the issues it had identified and the SCERP did not need to replicate this course. Accordingly, the panel decided that the SCERP would only include practice monitoring.
By taking the sedation course proactively, Dr. H. demonstrated awareness of areas in which he could improve his practice. The SCERP, which only required practice monitoring, was a good outcome.
In all of these complaints, the panel said that absent the proactive courses, they would have ordered the dentists to complete courses in the areas of concern. These cases demonstrate that taking courses proactively is an effective method of improving complaint outcomes, and must be considered when appropriate.