Ethical dilemna

[Smilemaker100]

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This morning , I was doing a hygiene check for one of the patients who used to be a regular patient of the clinic's owner. He had not been to the dentist for a few years. I work as an associate at this practice and do hygiene checks for the other doctors whenever they are not around.

The patient in question had multiple troublesome dental problems- a three unit bridge in which one of the abutment teeth had an abscess, tooth #9 which had a radicular fracture (in the apical 1/3rd), numerous periodontally compromised teeth and #31 which had a RCT, crown and abscess-virtually no bone support.

As I went through the Xrays and explained the multiple issues occuring in his mouth, the patient kept asking my name, how to write and pronounce it and went as far as asking for my business card so I gave him one. However, as I explained the treatment plan, I kept reiterating, "You will want to discuss this in further detail when you see Dr X next time as you have been a patient of his for many years."

Later on, when I went to my operatory, I overheard the patient asking various questions about me- which university I graduated from, when I graduated etc. I got the impression that he was interested in becoming my patient. I felt kind of uneasy as this was the other doc's (owner) patient.

I could have actually profited from persuading this patient to become one of my own especially given the number of treatments his mouth will require to be completely rehabilitated. I think that I took the right professional approach from refraining.

My question is: did I approach this situation ethically? What would you have done/not done? 😕

 

[Midoc]

Doing what is ethical and doing what is right in the owner-dentist's mind might be two different things. Considering that the patient was inactive from the office for multiple years I do not think it would be considered unethical to inquire if the patient would like to resume treatment at the office under your care. However, the owner-dentist might feel your poaching his patients no matter anyone's ethical opinion is. Regardless, the patient may request to be seen by you when he next schedules an appointment.

 

[Smilemaker100]

Doing what is ethical and doing what is right in the owner-dentist's mind might be two different things. Considering that the patient was inactive from the office for multiple years I do not think it would be considered unethical to inquire if the patient would like to resume treatment at the office under your care. However, the owner-dentist might feel your poaching his patients no matter anyone's ethical opinion is. Regardless, the patient may request to be seen by you when he next schedules an appointment.

Yes, I completely agree. But the owner seems to trust me with his patients because I have been handling a lot of them lately. In any case, the patient insisted on having my business card so it is really in his hands now.

 

[airvent]

Its just one patient and it was hardly your intent. If the patient chooses you , you should accept him. No worries, unless the owner has only two patients

 

[Smilemaker100]

Its just one patient and it was hardly your intent. If the patient chooses you , you should accept him. No worries, unless the owner has only two patients

Yes, I realize that it was just ONE patient. However, I want to make sure there was no harm done. I try to lead as ethical a life as possible. It's just who I am. I know that I shouldn't "take my job home" 🙄 as the saying goes, but very often, I will reflect over PR or technical aspects of the profession or certain questions which were raised by my patients. I find myself reading up all the time on all kinds of things related to dentistry. I really am passionate about it. Is that necessarily a bad thing?

 

[Smilemaker100]

This morning , I was doing a hygiene check for one of the patients who used to be a regular patient of the clinic's owner. He had not been to the dentist for a few years. I work as an associate at this practice and do hygiene checks for the other doctors whenever they are not around.

The patient in question had multiple troublesome dental problems- a three unit bridge in which one of the abutment teeth had an abscess, tooth #9 which had a radicular fracture (in the apical 1/3rd), numerous periodontally compromised teeth and #31 which had a RCT, crown and abscess-virtually no bone support.

As I went through the Xrays and explained the multiple issues occuring in his mouth, the patient kept asking my name, how to write and pronounce it and went as far as asking for my business card so I gave him one. However, as I explained the treatment plan, I kept reiterating, "You will want to discuss this in further detail when you see Dr X next time as you have been a patient of his for many years."

Later on, when I went to my operatory, I overheard the patient asking various questions about me- which university I graduated from, when I graduated etc. I got the impression that he was interested in becoming my patient. I felt kind of uneasy as this was the other doc's (owner) patient.

I could have actually profited from persuading this patient to become one of my own especially given the number of treatments his mouth will require to be completely rehabilitated. I think that I took the right professional approach from refraining.

My question is: did I approach this situation ethically? What would you have done/not done? 😕

I forgot to add that the patient had actually seen the other doc for an emergency last week for a periodontal abscess. So he has had contact with his old doc recently but only this ONE time since about 2 years ago.

 

[DrJeff]

S, if you're in a practice where the owner is insecure about some patients switching from him to you, then get out of there now. After having been in a couple of practices, I've found that Docs and patients have different personalities, and sometimes when a new personality is introduced in the mix(you) patients will find you to be a breath of fresh air and switch to you. Many times, the senior partner may ask they hygenist what it is that you do different that he/she doesn't do, and then start incorporating that into their own daily routine.

What you did is completely 110% ethical, so don't worry about it. You'll know you're doing something right with the patients when you hear the senior docs starting to use some of your phrasings/wordings to the patients. If your going to be in that practice for a long time, you'll likely as the docs start to use 75% of the same phrases with the patients. I think my wife basically sums up the relationship between me and my business partner in the following way: At home I have my real wife, at work my business partner is my "work wife" 😀

 

[toofache32]

At home I have my real wife, at work my business partner is my "work wife" 😀

Which one nags you the most?

Couldn't resist.

 

[DrJeff]

Which one nags you the most?

Couldn't resist.

I'm not touching that one with a 10 foot pole! 😱 🙄 😉 😀

 

[Smilemaker100]

S, if you're in a practice where the owner is insecure about some patients switching from him to you, then get out of there now. After having been in a couple of practices, I've found that Docs and patients have different personalities, and sometimes when a new personality is introduced in the mix(you) patients will find you to be a breath of fresh air and switch to you. Many times, the senior partner may ask they hygenist what it is that you do different that he/she doesn't do, and then start incorporating that into their own daily routine.

What you did is completely 110% ethical, so don't worry about it. You'll know you're doing something right with the patients when you hear the senior docs starting to use some of your phrasings/wordings to the patients. If your going to be in that practice for a long time, you'll likely as the docs start to use 75% of the same phrases with the patients. I think my wife basically sums up the relationship between me and my business partner in the following way: At home I have my real wife, at work my business partner is my "work wife" 😀

No, I don't think the senior doc is insecure. We get along very nicely. He has actually cut down on is hours- he takes off every Friday so I am sure he realizes that implies that I will attend to his patients. He has been obliged to take off some days here and there and seems perfectly comfortable with me treating some of his patients.

The other associate and I get along very well. Funnily enough, even though this fellow has had about 2 years of private practice experience, he has recently come to me on a number of occasions seeking my opinion/advice. 🙂

 

[Smilemaker100]

I'm not touching that one with a 10 foot pole! 😱 🙄 😉 😀

 

[J2AZ]

He may not want to switch at all but rather complain about you to his regular doc. After all, why would he ask several time who you are and how you spell your name? The only time I ever do that is when I want to log a complaint.

 

[Smilemaker100]

He may not want to switch at all but rather complain about you to his regular doc. After all, why would he ask several time who you are and how you spell your name? The only time I ever do that is when I want to log a complaint.

Nope, quite the contrary. I spent quite a bit of time explaining everything with Xrays and diagrams and he seemed impressed with that. He also asked numerous questions and I replied to them all. He seemed very outgoing and nice to me. And told me it was a pleasure to meet me.

I gave the patient no valid reason to complain. All I was doing was a check up. I was there to do a comprehensive exam, check out the Xrays, reveal any dental problems and treatment plans. I think I was quite thorough.

 

[gryffindor]

I am unclear as to why you are freaking out over treating this one patient.

Does the office schedule the patients for you? What does the office do if one of the other hygiene-check patient called and requested you? It's not your fault if the the patient wants to see you and not the other doctor. Are you afraid the doctor is going to fire you b/c this guy is gonna call and request you and not him?

Why don't you just wait till the patient calls for the appointment and deal with it then? It's not like you went out of your way to "steal" the patient. Heck, if you are allowed to treat the hygiene-check patients of the office who need work and this guy wants to see you so badly, then go for it! But if not, then it will be a discussion between the front desk and the patient, and possibly the owner doc if the front desk tells him of the scenario, as to which doctor the patient will see.

This is how the owner doctor at one office I work at avoids this scenario - If I find anything at the hygiene check that needs treatment, I am not allowed to open my mouth and tell the patient anything. I have to tell him and he comes over, re-examines, and tells the patient what they need and which dentist the patient will see. At the beginning, this system made me feel like I wasn't really being treated like a dentist. But now I realized I don't care - I just follow his system b/c at the end of the day, it's still just a paycheck.

 

[DrJeff]

No, I don't think the senior doc is insecure. We get along very nicely. He has actually cut down on is hours- he takes off every Friday so I am sure he realizes that implies that I will attend to his patients. He has been obliged to take off some days here and there and seems perfectly comfortable with me treating some of his patients.

The other associate and I get along very well. Funnily enough, even though this fellow has had about 2 years of private practice experience, he has recently come to me on a number of occasions seeking my opinion/advice. 🙂

As you're finding out right now, the GPR you went through last year is worth about 5 years of private practice!

 

[Smilemaker100]

As you're finding out right now, the GPR you went through last year is worth about 5 years of private practice!

Yes, right on DrJeff ! 👍 🙂 I constantly push the bar and test my limits. But my education hasn't stopped with the GPR. I am continually reading up on various dental related topics. My latest read is the textbook "Bell's Orofacial Pains: The Clinical Management of Orofacial Pain" by Jeffrey Okeson who is a specialist in TMJ and Orofacial Pain.

Funnily, I never thought that the Dawson course on occlusion would come in so handy! 👍 For example, this very morning, I had a patient who had TMJ pain on the left side for about 2 years which concided with a few amalgam fillings which were done on the left side. Sure enough, when I checked the bite, I identified some interferences. The patient was SO relieved when I ajusted her bite! And even more happy, I am sure, when she found out I didn't charge her for ajusting her bite as she was a patient I had seen this morning for a recall exam. 😀

I have encountered a significant number of patients in our patient pool afflicted with TMJ problems. 🙁 There is only ONE specialist in TMJ and orofacial pain in the ENTIRE city! A mere consult with him costs about 200$ Cdn ! 😱 So I am reading up quite a bit on it lately. The worst thing that can possibly happen to me is to have a patient before me who has a TMJ problem and I don't know how to handle it. I don't like having patients who leave the clinic unsatisfied or discouraged. 👎 After all, I like to think of myself as a smilemaker not a frownmaker! 😀

 

[Smilemaker100]

I am unclear as to why you are freaking out over treating this one patient.

Does the office schedule the patients for you? What does the office do if one of the other hygiene-check patient called and requested you? It's not your fault if the the patient wants to see you and not the other doctor. Are you afraid the doctor is going to fire you b/c this guy is gonna call and request you and not him?

Why don't you just wait till the patient calls for the appointment and deal with it then? It's not like you went out of your way to "steal" the patient. Heck, if you are allowed to treat the hygiene-check patients of the office who need work and this guy wants to see you so badly, then go for it! But if not, then it will be a discussion between the front desk and the patient, and possibly the owner doc if the front desk tells him of the scenario, as to which doctor the patient will see.

This is how the owner doctor at one office I work at avoids this scenario - If I find anything at the hygiene check that needs treatment, I am not allowed to open my mouth and tell the patient anything. I have to tell him and he comes over, re-examines, and tells the patient what they need and which dentist the patient will see. At the beginning, this system made me feel like I wasn't really being treated like a dentist. But now I realized I don't care - I just follow his system b/c at the end of the day, it's still just a paycheck.

The office schedules the patients for hygiene appointments according to the availability of the patient. We have an office which runs 8am-9pm Monday through Friday and 9am-5pm on Saturday. When the patient schedules, it won't necessarily be at the time that their doctor has their shift, unless they request it. Sometimes, when the senior doc is not around, the patients will request getting their check done when he is around. On other occasions, they don't mind if I do it.

So far, according to my experience at this clinic, if a patient requests to be seen by me, then the office will book them with me. I actually think the senior doc is delighted when patients like me. He has cut down his hours by one day a week so naturally, some of his patients will be transferred to the associates.

 

[DrJeff]

Yes, right on DrJeff ! 👍 🙂 I constantly push the bar and test my limits. But my education hasn't stopped with the GPR. I am continually reading up on various dental related topics. My latest read is the textbook "Bell's Orofacial Pains: The Clinical Management of Orofacial Pain" by Jeffrey Okeson who is a specialist in TMJ and Orofacial Pain.

Funnily, I never thought that the Dawson course on occlusion would come in so handy! 👍 For example, this very morning, I had a patient who had TMJ pain on the left side for about 2 years which concided with a few amalgam fillings which were done on the left side. Sure enough, when I checked the bite, I identified some interferences. The patient was SO relieved when I ajusted her bite! And even more happy, I am sure, when she found out I didn't charge her for ajusting her bite as she was a patient I had seen this morning for a recall exam. 😀



I have encountered a significant number of patients in our patient pool afflicted with TMJ problems. 🙁 There is only ONE specialist in TMJ and orofacial pain in the ENTIRE city! A mere consult with him costs about 200$ Cdn ! 😱 So I am reading up quite a bit on it lately. The worst thing that can possibly happen to me is to have a patient before me who has a TMJ problem and I don't know how to handle it. I don't like having patients who leave the clinic unsatisfied or discouraged. 👎 After all, I like to think of myself as a smilemaker not a frownmaker! 😀

Is Okeson still advocating the use of low dose Amytryptilline for management of certain TMJ cases? If you feel like Rx'ing that, then you've got some serious guts! When I was a 1st year GPR, Okeson came and spoke at a Hartford Dental Society meeting and all the residents went and saw him. I was sitting next to Dr. D and when Okeson and starting advocating low dose Amytryptilline, Dr D turns to me and goes to me (paraphrasing in the PG-13 version now) "that guys got a bigger set than I ever will!"

As for the Dawson/occlusion info, as you're seeing, there really is some great info in that book, and the man, even in his 80's still gives some really good C.E. lectures, although as of late he's starting to soften his view on a hard anatomical CR and is putting a bit of credence into a slight "functional" CR, although not as much as the Bill Dickerson and the neuromuscular occlusion crew (ala Las Vegas Institute). Another really good occlussion speaker to see is Frank Spear out of the Seattle area, he's a bit of a hybrid between the "Dawson diciples" and the "LVI cult followers" and one of the best C.E. lecturers that I've seen to date.

Other really good C.E. speakers that I've seen so far (based on info given and lecture style) have been Joe Massad for removeable prosth, Steve Bucchanan on Endo, both Carl Misch and Dennis Tarnow on Implants, and Ross Nash and Bill Strupp on restorative. There unfortunately have been many more that I wish I hadn't seen, or if one of those were speaking on a nice weather day, then often I'd be on the golf course by lunchtime! 😀

 

[Smilemaker100]

Is Okeson still advocating the use of low dose Amytryptilline for management of certain TMJ cases? If you feel like Rx'ing that, then you've got some serious guts! When I was a 1st year GPR, Okeson came and spoke at a Hartford Dental Society meeting and all the residents went and saw him. I was sitting next to Dr. D and when Okeson and starting advocating low dose Amytryptilline, Dr D turns to me and goes to me (paraphrasing in the PG-13 version now) "that guys got a bigger set than I ever will!"

As for the Dawson/occlusion info, as you're seeing, there really is some great info in that book, and the man, even in his 80's still gives some really good C.E. lectures, although as of late he's starting to soften his view on a hard anatomical CR and is putting a bit of credence into a slight "functional" CR, although not as much as the Bill Dickerson and the neuromuscular occlusion crew (ala Las Vegas Institute). Another really good occlussion speaker to see is Frank Spear out of the Seattle area, he's a bit of a hybrid between the "Dawson diciples" and the "LVI cult followers" and one of the best C.E. lecturers that I've seen to date.

Other really good C.E. speakers that I've seen so far (based on info given and lecture style) have been Joe Massad for removeable prosth, Steve Bucchanan on Endo, both Carl Misch and Dennis Tarnow on Implants, and Ross Nash and Bill Strupp on restorative. There unfortunately have been many more that I wish I hadn't seen, or if one of those were speaking on a nice weather day, then often I'd be on the golf course by lunchtime! 😀

This latest Okeson textbook was published this year and now that you mention it, I leafed through the textbook to see what he would mention in regards to TCAs and TMJ dysfunctions. He says "although TCAs increase the available 5HT in the CSF (in reference to chronic pain cases), they may not have inherent analgesic properties. In normal subjects, they have no greater effect on pain than does placebo." He makes no reference to TCAs as a pharmacological option for TMJ cases.

It's interesting how there are so many schools of thoughts in the same profession! So which school of thought do you adhere to in regards to TMJ disorders, Dr Jeff? Dawson's occlusion/CR theory or the Las Vegas Institute which revolves around the neuromuscular apparatus or both theories? Funnily enough, when I mentioned the Dawson course to one of the owners of the clinic I work at, they told me that they were more familiar with the Las Vegas line of thought! LOL !

I am familiar with Dr Carl Mirsch since I bought his textbook "Contemporary Implant Dentistry" as a dental student as we had 3 implant courses in dental school (two preclinical-lab-hands on and one theoretical). I found a number of the chapters useful but I must admit that I haven't worked my way through the ENTIRE book 😱 LOL! Dr Mirch seems to be THE guy for implantology as he was the president of many implant organizations and is currently co-chairman of the board of directors of the "International Congress of Oral Implantologists."

Thanks for your recommendations. 👍

 

[DrJeff]

This latest Okeson textbook was published this year and now that you mention it, I leafed through the textbook to see what he would mention in regards to TCAs and TMJ dysfunctions. He says "although TCAs increase the available 5HT in the CSF (in reference to chronic pain cases), they may not have inherent analgesic properties. In normal subjects, they have no greater effect on pain than does placebo." He makes no reference to TCAs as a pharmacological option for TMJ cases.

It's interesting how there are so many schools of thoughts in the same profession! So which school of thought do you adhere to in regards to TMJ disorders, Dr Jeff? Dawson's occlusion/CR theory or the Las Vegas Institute which revolves around the neuromuscular apparatus or both theories? Funnily enough, when I mentioned the Dawson course to one of the owners of the clinic I work at, they told me that they were more familiar with the Las Vegas line of thought! LOL !

I am familiar with Dr Carl Mirsch since I bought his textbook "Contemporary Implant Dentistry" as a dental student as we had 3 implant courses in dental school (two preclinical-lab-hands on and one theoretical). I found a number of the chapters useful but I must admit that I haven't worked my way through the ENTIRE book 😱 LOL! Dr Mirch seems to be THE guy for implantology as he was the president of many implant organizations and is currently co-chairman of the board of directors of the "International Congress of Oral Implantologists."

Thanks for your recommendations. 👍

I'd classify my occlussal beliefs as more like Frank Spears hubrid of the 2 biggies. I'll put people into CR, but only if they noramally function in that location(or really close to it), if they have a big CR/CO discrepency, than as long as that "comfortable" CO position is reproduceable, then I go with that position.

As for Misch, I remember the first 15 minutes of the first time I saw him speak. I was basically sitting there listening to this guy and thinking "what an arrogant little a-hole this guy is!"(let's just say he really, really likes to let people know how great his list of accomplishments is). But then he got into the meat of his lecture, and unlike ALOT of folsk on the lecture circuit, he actually gives you ALOT of practical, usefull information, and keeps doing it throughout the entire lecture 👍

Unfortunately, after seeing many, many people lecture, you fing the lecturers common scenarion is as follows:

First 15-30 minutes : tell how great I am over and over

Next Hour: tell everyone what I plan to tell them today, and reiterate how great I am.

15 minute cofee break

Next 1:15-1:30 show 3 or 4 HUGE cases(bigger thah 99.5% of us will ever do/find the patients to afford these $50,000+ tx plan). Once again reiterate how great I am.

Lunch for the next hour

Following hour - tell everyone how great I am, and what I plan on telling them

Break for 10 minutes (lead into this break with the statement "and after the break I'll tell you all my secrets!")

Last 30 minutes, tell everyone how great I was, and how they can;t wait to come back i the future, and lastly getting people into 6 DFlags to enjoy the tmosphere!

Finsish up by telling everyone "you were a great group and I had so much info to disemminate to everyone- tell people that they can see you at their own retreat based CE course. reiterate how great they arE 🙄

 

[Smilemaker100]

I'd classify my occlussal beliefs as more like Frank Spears hubrid of the 2 biggies. I'll put people into CR, but only if they noramally function in that location(or really close to it), if they have a big CR/CO discrepency, than as long as that "comfortable" CO position is reproduceable, then I go with that position.

As for Misch, I remember the first 15 minutes of the first time I saw him speak. I was basically sitting there listening to this guy and thinking "what an arrogant little a-hole this guy is!"(let's just say he really, really likes to let people know how great his list of accomplishments is). But then he got into the meat of his lecture, and unlike ALOT of folsk on the lecture circuit, he actually gives you ALOT of practical, usefull information, and keeps doing it throughout the entire lecture 👍

Unfortunately, after seeing many, many people lecture, you fing the lecturers common scenarion is as follows:

First 15-30 minutes : tell how great I am over and over

Next Hour: tell everyone what I plan to tell them today, and reiterate how great I am.

15 minute cofee break

Next 1:15-1:30 show 3 or 4 HUGE cases(bigger thah 99.5% of us will ever do/find the patients to afford these $50,000+ tx plan). Once again reiterate how great I am.

Lunch for the next hour

Following hour - tell everyone how great I am, and what I plan on telling them

Break for 10 minutes (lead into this break with the statement "and after the break I'll tell you all my secrets!")

Last 30 minutes, tell everyone how great I was, and how they can;t wait to come back i the future, and lastly getting people into 6 DFlags to enjoy the tmosphere!

Finsish up by telling everyone "you were a great group and I had so much info to disemminate to everyone- tell people that they can see you at their own retreat based CE course. reiterate how great they arE 🙄

Well, well,well, Dr Jeff LOL! Thanks for telling me the way it is. Your description reminds me of some of the pompous asses I had throughout my university studies. LOL! Oh yes, the pleasant memories... 🙄

So in essence one should just stick around after the break after the lunch hour in which the speaker will "share his secrets"

 

[Midoc]

Misch's office is about a mile from where I live now and I drive past it on the way to school. I've seen him around the clinic doing CE courses but I've never heard him speak though.

 

[DrJeff]

Well, well,well, Dr Jeff LOL! Thanks for telling me the way it is. Your description reminds me of some of the pompous asses I had throughout my university studies. LOL! Oh yes, the pleasant memories... 🙄

So in essence one should just stick around after the break after the lunch hour in which the speaker will "share his secrets"

Yes, arriving "fashionably late" does have it's advantages! On a side note, I have noticed that if you attend a multi-day CE course at some typical "resort" and/or dental school location that they tend to have ALOT more substance and much less "listen to me say how great I am" talk compared to lectures at either a big meeting(i.e. ADA, Yankee Dental, Greater New York meeting, state/local society meeting)

 

[toofache32]

Is Okeson still advocating the use of low dose Amytryptilline for management of certain TMJ cases? If you feel like Rx'ing that, then you've got some serious guts! When I was a 1st year GPR, Okeson came and spoke at a Hartford Dental Society meeting and all the residents went and saw him. I was sitting next to Dr. D and when Okeson and starting advocating low dose Amytryptilline, Dr D turns to me and goes to me (paraphrasing in the PG-13 version now) "that guys got a bigger set than I ever will!"

What's your apprehension about Elavil? There are side effects, but that doesn't necessarily make it dangerous. Like all drugs, I guess you have to know the side effects and interactions with glaucoma, thryoid problems, and maybe other stuff I can't remember now. Of course, it's pretty low-dose therapy we're talking about for TMD.

 

[Smilemaker100]

Yes, arriving "fashionably late" does have it's advantages! On a side note, I have noticed that if you attend a multi-day CE course at some typical "resort" and/or dental school location that they tend to have ALOT more substance and much less "listen to me say how great I am" talk compared to lectures at either a big meeting(i.e. ADA, Yankee Dental, Greater New York meeting, state/local society meeting)

I wasn't such a happy camper at the Dawson occlusion course. Tampay Bay was absolutely beautiful. The first two days were lousy weatherwise but on the last two days, it was gorgeous! Unfortunately, I had to leave early as I was on call and one of the rez who was stuck at the hospital had to cover for the rest of us. So I never really got to enjoy Tampa 🙁

It's so damn difficult to sit through an ENTIRE day of lecture, regardless of how interesting it is. But I did really appreciate Dawson's assistant (forget his name) who demonstrated how to do a thorough TMJ examination and used the Doppler- that was so cool! 👍