How do/would you break the news to a patient that you screwed up?

[Vapor1122]

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I haven't started clinic yet, but I'm well aware that at some point or another, I'm going to screw up on a patient. Let's say, for example, you grossly overexpose the pulp, and now you're looking at RCT; how do you break that kind of news without looking totally incompetent?

 

[Luxator]

You simply say that the extent of decay has extended into the pulp chamber or 'nerve' of the tooth, and it is likely that they will require an RCT. Its their tooth, their problem. How do they know that YOU exposed the pulp, and that it was not THEIR decay?

If they had sought treatment earlier or had maintained their oral hygiene adquately, they wouldnt be in the position to have their nerve exposed by decay or otherwise.

They own the problem, not you. Speak accordingly.

"Your decay seems to have extended into your nerve Mrs Jones. What this means is that your nerve is now infected with decay and needs a Root Canal Therapy in order to keep the tooth. This happens when tooth decay is allowed to penetrate deep into a tooth." If they say something like "how come i didnt feel a toothache", just say teeth are funny things and a big hole in one person can go without symptoms, and a small hole in another can be agonising. This holds true in my experience.

 

[americanpierg]

You simply say that the extent of decay has extended into the pulp chamber or 'nerve' of the tooth, and it is likely that they will require an RCT. Its their tooth, their problem. How do they know that YOU exposed the pulp, and that it was not THEIR decay?

If they had sought treatment earlier or had maintained their oral hygiene adquately, they wouldnt be in the position to have their nerve exposed by decay or otherwise.

They own the problem, not you. Speak accordingly.

"Your decay seems to have extended into your nerve Mrs Jones. What this means is that your nerve is now infected with decay and needs a Root Canal Therapy in order to keep the tooth. This happens when tooth decay is allowed to penetrate deep into a tooth." If they say something like "how come i didnt feel a toothache", just say teeth are funny things and a big hole in one person can go without symptoms, and a small hole in another can be agonising. This holds true in my experience.

LOL boy do I feel sorry for any of your future patients. This is why they have classes on ethics in medicine.

 

[davefan]

LOL boy do I feel sorry for any of your future patients. This is why they have classes on ethics in medicine.

Why? Luxator explained it pretty well. The kid isn't going to "grossly over expose the nerve" as he put it. More than likely a pulp exposure will be due to where the caries extends. Like luxator said, it's their mouth and their problem and we are here to help. Simple as that. Nothing ethically or morally wrong with that! I feel sorry for you if you feel differently. That sir is what you call dentistry...

However, if you did have an iatrogenic pulp exposure, just tell it as it is. The pulp was exposed and now we are looking at endo or a direct pulp cap etc.. Nothing hard about that.

 

[Daurang]

LOL boy do I feel sorry for any of your future patients. This is why they have classes on ethics in medicine.

What luxator said was more than appropriate. Quite often the lesion is small on the xray but is bigger in real life and vice versa.

 

[tinman831]

What the OP described is more or less, always a possibility when dealing with trying to restore a tooth. I think what the OP was trying to ask was, if you make a blatant error such as perforating the tooth when performing the root canal or just working on the wrong tooth. I would say that your relationship with your patient would dictate the final outcome. A patient is a lot less likely to sue you if they like you 😉 That and provided you kiss a lot of arse and bend over backwards to make sure they are taken care of in the end.

 

[HupHolland]

I agree with Tinman. Dentist's get sued because of poor patient management, not because of the work they do. We all make mistakes, but informing the patient of the risks PRIOR to the procedure and admitting error are 2 things that will make the likelihood of being sued close to 0%.

Now, if you make a gross mistake like working on the wrong tooth, then please for heaven's sake tell the patient. Patient management, patient management, patient management !!

Hup

 

[DrJeff]

Having a good, open, and cordial relationship with your patients goes a LONG way towards helping things out if any "weird"/unexpected things happen during the course of treatment.

Bottomline, explain things to your patients, both before and after treatment starts/finishes - not only does it take care of a lot of things, but it also will increase your patient's perception of you and your skills the vast majority of the time 👍

 

[doc toothache]

Mechanical and carious exposure are not exactly one and the same.

 

[Streetwolf]

Do you mean while you're in dental school?

Step 1 - DON'T FREAK OUT.
Step 2 - Don't hint ANYTHING to the patient. Not yet.
Step 3 - Calmly find the attending and tell them - AWAY from the patient - what happened, in detail.
Step 4 - Listen to the attending and do what they say / let them talk to the patient.

If you pulped out when you were supposed to stop halfway to the pulp, they'll probably provide the RCT for free. If you worked on the wrong tooth, they'll fill that tooth for free and most likely give them a free filling on the correct tooth. Of course a lawsuit is ALWAYS a possibility (we do live in America right?) but you *should* be protected by the school. In other words the patient will be suing the school and possibly the attending working with you and NOT you yourself.

==

In private practice if it was a close call like you were near the pulp and accidentally went too deep, you could probably get away with the whole "the caries went down that far" line. Like the patient knows any better. Or take the high road and offer them discounted or FREE work to fix the problem. If you straight up work on the wrong tooth or something crazy like that, get ready to throw lots of free work their way.

 

[Luxator]

LOL boy do I feel sorry for any of your future patients. This is why they have classes on ethics in medicine.

I'm a practicing dentist, and one of the big things i learned while starting out in the real world, is that 90% of your success is all about how you handle and speak with your patients.

Admitting fault is not a bad thing if you honestly made an obvious mistake (taking out wrong tooth etc), and you should take the steps to correct it where possible, but in the situation of a pulp exposure, its often hard for either YOU or the PATIENT to know/prove if it was your heavy hand or the depth of the caries. So in these instances you'd be pretty foolish accepting guilt by default. It makes you look incompetent and inexperienced. Not good for the relationship.

However if you calmly and casually explain what has happened as though youre not suprised (you shouldnt be- they happen) you look in control, calm, confident and able to handle the situation.

One tip that will save you sh** load of headaches in practice is to always keep in mind that the patient owns the problem, not you. That doesnt mean act like you dont give a damn about them, be a caring, helpful dentist but at the end of the day you're there to fix their problem.

Sorry if I sound repetitive.

 

[doc toothache]

You simply say that the extent of decay has extended into the pulp chamber or 'nerve' of the tooth, and it is likely that they will require an RCT. Its their tooth, their problem. How do they know that YOU exposed the pulp, and that it was not THEIR decay?
If they had sought treatment earlier or had maintained their oral hygiene adquately, they wouldnt be in the position to have their nerve exposed by decay or otherwise.
They own the problem, not you. Speak accordingly.

I'm a practicing dentist, and one of the big things i learned while starting out in the real world, is that 90% of your success is all about how you handle and speak with your patients.

Admitting fault is not a bad thing if you honestly made an obvious mistake (taking out wrong tooth etc), and you should take the steps to correct it where possible, but in the situation of a pulp exposure, its often hard for either YOU or the PATIENT to know/prove if it was your heavy hand or the depth of the caries. So in these instances you'd be pretty foolish accepting guilt by default. It makes you look incompetent and inexperienced. Not good for the relationship.

One tip that will save you sh** load of headaches in practice is to always keep in mind that the patient owns the problem, not you. That doesnt mean act like you dont give a damn about them, be a caring, helpful dentist but at the end of the day you're there to fix their problem.

While there may be cases where the proximity of decay and pulp may be questionable, a periapical radiograph should help in establishing the likelihood of a carious exposure and the need for making the proper qualifying remarks before you let Mr. Whistle go wild. In the Land of Oz, a patient own(s) the problem, not you, while in the real world, once you start pocking on their tooth, it magically becomes your /our problem. They may not know the difference between mechanical/accidental and carious exposure but you can bet that they can find one of your colleague who can make that determination.

 

[mrlantern]

I'm a practicing dentist, and one of the big things i learned while starting out in the real world, is that 90% of your success is all about how you handle and speak with your patients.

Admitting fault is not a bad thing if you honestly made an obvious mistake (taking out wrong tooth etc), and you should take the steps to correct it where possible, but in the situation of a pulp exposure, its often hard for either YOU or the PATIENT to know/prove if it was your heavy hand or the depth of the caries. So in these instances you'd be pretty foolish accepting guilt by default. It makes you look incompetent and inexperienced. Not good for the relationship.

That's why I'm not too content with this profession. There's a lack of general respect for what we do. Whenever we break out the bad news, patients think it is OUR fault and that they shouldn't have to pay an extra dollar out of their pocket for the $300 root canal or, more likely, implant-supported removables because their new $400 dentures don't have adequate suction due to resorbed ridges. And then they start going blah-blah to their family and friends how they think you're a shady practitioner and that dentists can't be trusted.

You mentioned about the need for communicating well with patients. I agree that this plays a good part on what patients think of your dentistry. But I don't find this practical in our insurance-driven world. It TAKES time to communicate in this kind of depth. You DON'T get paid for this lost time ( and NO patient believes in paying for consults or office visits ) and this will eat into your profitability.

 

[mrlantern]

If you pulped out when you were supposed to stop halfway to the pulp, they'll probably provide the RCT for free. If you worked on the wrong tooth, they'll fill that tooth for free and most likely give them a free filling on the correct tooth. Of course a lawsuit is ALWAYS a possibility (we do live in America right?) but you *should* be protected by the school. In other words the patient will be suing the school and possibly the attending working with you and NOT you yourself.

In private practice, I notice that most GPs who have less than 5 yrs of experience and work in insurance mills have problems with complete dentures and molar endos.

How likely is it for a lawsuit if you perforate a tooth, do a crappy rct, or fabricate dentures that patients aren't happy with? And how much monetary damages are we talking about?

 

[tinman831]

How likely is it for a lawsuit if you perforate a tooth, do a crappy rct, or fabricate dentures that patients aren't happy with? And how much monetary damages are we talking about?

I'm not sure of the exact numbers, but we were told that Endo is the most sued procedure/dental specialty out of them all.

 

[Luxator]

While there may be cases where the proximity of decay and pulp may be questionable, a periapical radiograph should help in establishing the likelihood of a carious exposure and the need for making the proper qualifying remarks before you let Mr. Whistle go wild. In the Land of Oz, a patient own(s) the problem, not you, while in the real world, once you start pocking on their tooth, it magically becomes your /our problem. They may not know the difference between mechanical/accidental and carious exposure but you can bet that they can find one of your colleague who can make that determination.

The only way you 'magically' own the problem is if you allow the patient to sense that through your language (body or verbal). I urge you not to depart from the assumption that they own the problem. Listen to the way that doctors speak with their patients about medical/surgical procedures. I cant say theyre all like this, but the ones ive seen have a way with conveying care and confidence while simultaneously conveying that they are doing their best with the circumstances at hand, and that nothing is guaranteed.

Agree 100% with radiographs helping to determine probability of an exposure, and the need for qualifying remarks. Spot on there. If youre upfront and manage their expectations (this goes for dentures and everything else) 99.9% of the time things will go smoothly even if complications occur.

However, I challenge you to find anybody who can prove with absolute accuracy that any exposure is mechanical rather than carious. Pulp horns can be quite high up occlusally in some teeth. The fact is that unless you were there watching the whole process you or anyone else could never say for sure. Anyone who thinks they can would merely be guessing.

If you practice the way we were taught (or the way I was taught) the highspeed handpiece has no place past the DEJ (Dento-enamel junction) in a vital tooth. Anything deeper than enamel should only be removed with a slowspeed handpiece or a excavator instrument. If this protocol is followed then you can rest assured that any exposure is as a result of carious dentine, and not your hand. It requires excessive amounts of physical effort/pressure to efficiently remove healthy tooth structure by a slowspeed bur or excavator.

My advice in previous posts assumes this protocol is followed. If you go using the highspeed diamond bur well into dentine, then youre much more likely to cause an iatrogenic exposure which may be detected in some exceptional instances.

 

[Daurang]

In private practice, I notice that most GPs who have less than 5 yrs of experience and work in insurance mills have problems with complete dentures and molar endos.

How likely is it for a lawsuit if you perforate a tooth, do a crappy rct, or fabricate dentures that patients aren't happy with? And how much monetary damages are we talking about?

I think that most GPs, like me, started having problems with complete dentures AFTER 5 years of practice. We don't need them, don't wanna deal with them, don't wanna be married to them anymore. I haven't done one in probably 6 months and is so much happier as a result.

You usually can tell from the first or second visit if the a denture patient will be PITA; just refer them out to your worst enemies. If denture is already finished then just refund their money (plus the headache) and then refer to your worst enemies. I was lucky/unlucky enough to have my lab tech died on me so I got used to being dentureless for awhile. Now I just tell my patients my lab died on me and the patients move on.

 

[DrJeff]

I think that most GPs, like me, started having problems with complete dentures AFTER 5 years of practice. We don't need them, don't wanna deal with them, don't wanna be married to them anymore. I haven't done one in probably 6 months and is so much happier as a result.

You usually can tell from the first or second visit if the a denture patient will be PITA; just refer them out to your worst enemies. If denture is already finished then just refund their money (plus the headache) and then refer to your worst enemies. I was lucky/unlucky enough to have my lab tech died on me so I got used to being dentureless for awhile. Now I just tell my patients my lab died on me and the patients move on.

With respect to dentures, or any procedure that I generally speaking don't enjoy doing, I've adopted the theory that my business partner has about procedures that you don't enjoy doing, charge more for them, a lot more for them!

That way, you're offering the service to the patient, if it's too much $$, they'll go elsewhere on their own(problem solved) or they they choose to have the tx done with/by you, you're making a few extra $$ for the "mental torture" that the particular procedure is for you! 😀

 

[Masseter]

I like how it works in Canada.

We can do the dentures as a GP, but let's say you're not too fond of them, you can prescribe the denture to the patient and have him see a Denturologist. The denturologist job is to do dentures. He can't do anything more than that.

I think some states do have the equivalent right??

 

[doc toothache]

The only way you 'magically' own the problem is if you allow the patient to sense that through your language (body or verbal). I urge you not to depart from the assumption that they own the problem. Listen to the way that doctors speak with their patients about medical/surgical procedures. I cant say theyre all like this, but the ones ive seen have a way with conveying care and confidence while simultaneously conveying that they are doing their best with the circumstances at hand, and that nothing is guaranteed.
However, I challenge you to find anybody who can prove with absolute accuracy that any exposure is mechanical rather than carious. Pulp horns can be quite high up occlusally in some teeth. The fact is that unless you were there watching the whole process you or anyone else could never say for sure. Anyone who thinks they can would merely be guessing.

There is no need for the challenge since, after all, there is one person in the room that is privy to the "absolute accuracy that any exposure is mechanical rather than carious". Your insistence on the adoption of your philosophy regarding ownership of the problem is misdirected; the only protagonists that truly matter are the patient(s), state board members and, in the worst case scenario, the judge/jury.

 

[jay47]

I agree with Tinman. Dentist's get sued because of poor patient management, not because of the work they do. We all make mistakes, but informing the patient of the risks PRIOR to the procedure and admitting error are 2 things that will make the likelihood of being sued close to 0%.

Now, if you make a gross mistake like working on the wrong tooth, then please for heaven's sake tell the patient. Patient management, patient management, patient management !!

Hup

Now assuming that you did inform your patient that you screwed up. You offer them a free root canal or other compensatory measures. They get angry and decide they want to sue you.

How much could they really sue you for? Assuming you didn't cause them any pain, and offered to perform the other procedures for free. What sort of damages are we really looking at here? I mean, you offered to remediate the problem you caused with appriate measures, and they already had a significant problem if you are drilling that deep.

Someone expand....

 

[mrlantern]

I
You usually can tell from the first or second visit if the a denture patient will be PITA; just refer them out to your worst enemies. If denture is already finished then just refund their money (plus the headache) and then refer to your worst enemies. I was lucky/unlucky enough to have my lab tech died on me so I got used to being dentureless for awhile. Now I just tell my patients my lab died on me and the patients move on.

Then who foots the lab bills? Who pays for all the overhead expenses and the hours put in for denture appointments? Do cardiothoracic and neuro-surgeons return out-of-pocket and insurance payments if their patients die or become disabled from surgical complications? Do dermatologists waive their fees if they create scars from mole removals?

I can understand why dentists might want to refund money to patients but I think such an action hurts our profession in the long run.

 

[mrlantern]

Now assuming that you did inform your patient that you screwed up. You offer them a free root canal or other compensatory measures. They get angry and decide they want to sue you.

How much could they really sue you for? Assuming you didn't cause them any pain, and offered to perform the other procedures for free. What sort of damages are we really looking at here? I mean, you offered to remediate the problem you caused with appriate measures, and they already had a significant problem if you are drilling that deep.

Someone expand....

I don't have absolute answers for you but there are some things to keep in mind:

1) If you offer a free rct, you're admitting that you're at fault.
2) Pain is inherent with going to a dentist.
3) Any surgery carries with it certain risks. Drilling and extracting are no exceptions.

 

[tinman831]

Now assuming that you did inform your patient that you screwed up. You offer them a free root canal or other compensatory measures. They get angry and decide they want to sue you.

How much could they really sue you for? Assuming you didn't cause them any pain, and offered to perform the other procedures for free. What sort of damages are we really looking at here? I mean, you offered to remediate the problem you caused with appriate measures, and they already had a significant problem if you are drilling that deep.

Someone expand....

Damages are awarded on a case by case basis and it's up to the plaintiff to prove that their injuries amount to the compensation sought. Simpler cases such as failed root canals can range in the thousands all the way to a couple million for a wrongful death (can't recall the exact number but that was the highest number for damages levied against a dentist).

 

[anschutz1913]

I like how it works in Canada.

We can do the dentures as a GP, but let's say you're not too fond of them, you can prescribe the denture to the patient and have him see a Denturologist. The denturologist job is to do dentures. He can't do anything more than that.

I think some states do have the equivalent right??

LOL if the denturologist screws up then you can always just blame the tooth fairy

 

[jay47]

I don't have absolute answers for you but there are some things to keep in mind:

1) If you offer a free rct, you're admitting that you're at fault.
2) Pain is inherent with going to a dentist.
3) Any surgery carries with it certain risks. Drilling and extracting are no exceptions.

True, and it is likely the patient will never know, but I suppose that you just have to do the best job you can all the time.

 

[Daurang]

Then who foots the lab bills? Who pays for all the overhead expenses and the hours put in for denture appointments? Do cardiothoracic and neuro-surgeons return out-of-pocket and insurance payments if their patients die or become disabled from surgical complications? Do dermatologists waive their fees if they create scars from mole removals?

I can understand why dentists might want to refund money to patients but I think such an action hurts our profession in the long run.

I understand why you may not want to return some or all the money. My overhead is 30% so writing off the $200-$400 denture lab bill once a year isn't gonna bankrupt me. I save a lot of chairtime($$$) and mental anguish(priceless) by not repeatedly adjusting or relining or redoing their dentures only to probably refund money to the unhappy/unwilling patient anyway. Half the patients I refund the money to continue to come back and refer other family members; so the numerous chairtimes I'd have wasted on them is more productively spent making money on their family members.

 

[Masseter]

LOL if the denturologist screws up then you can always just blame the tooth fairy

It is a regulated profession.

Also... I bad can you screw up a denture? I mean... it fits or it doesn't... it's not like you're going to crush it in pieces in his mouth... 🙄

 

[tinman831]

It is a regulated profession.

Also... I bad can you screw up a denture? I mean... it fits or it doesn't... it's not like you're going to crush it in pieces in his mouth... 🙄

Improperly made denture can cause problems ranging from denture sores all the way to TMJ disorders. It's not as easy as just sticking a piece of plastic on someones mouth and calling it a day.🙂

 

[teeth63a]

These are my favorite scripts, learned from lecturers in school, mentors, and things that I've made up myself:

1) Prepare your patient for the worst case scenario. If it happens, you're a genius for predicting the future. If it doesn't happen, you're a hero for avoiding disaster.
"Mr Jones, looking at the xray, I see the cavity is pretty close to the nerve. If the cavity goes into the nerve, you may need a root canal procedure. Believe me when I say I'm trying to avoid that. If it doesn't I'll lay down some medicine [DPC/IPC] to help the nerve heal. (after procedure) Mr Jones, the cavity stopped just short of the nerve, I put some medicine in before I put the filling. If everything goes our way [not your way, but our way] it will be achy for a few days then settle down. If it gives you a toothache then we need to consider doing a root canal procedure down the road."

"Mr Jones, this abscess has been here for a very long time. Sometimes the anesthetic doesn't get you numb 100% because of the infection, but I'll try my best."

2) Choose your words carefully (as mentioned before). My favorite opener is "Despite my best effort..." (learned from Dr Pride of Pride Institute).

"Mr Jones, despite my best effort to avoid it, the cavity was right at the nerve, so we'll need to start a root canal procedure." (neutral statement).

"Mr Jones, despite my best effort, this crown is not the best possible crown [open margin, oepn contact, whatever] that I can make for you, and I *want* you to have the best possible crown. We'll need to take another impression, and I'm sorry for the inconvenience.

"Mr Jones, despite my best effort, this little piece of tooth [root tip] absolutely does not want to come out. Rather than doing potentially more damage, I will leave the root tip in/refer you to a specialist."

Phrase it in such a way that you state specifically the facts, without placing the blame on yourself (whether or not it really *is* your fault).

3) Try hard to avoid conjoinders like "but" or "however" as subconsicously this may raise read flags in the patients brains, since good news rarely follows those words.

4) Use simple language that they can understand. "The cavity was right at the nerve" is much easier to understand than "There was a carious exposure of the pulp horn".

5) Listen to what your patient has to say without interrupting them. If your patient is a talker , guide the conversation. One good communication cue that I learned is repeating/rephrasing a patient's key fear/concern, this tells the patient that you really are listening. Avoid "uh-huh", and "yeah", use "I understand", "yes".

"Mr Jones, if I understand you correctly, you want to take care of the broken teeth in the back before we do the cosmetic work in the front?"

6) Make yourself the dental hero/dental Superman, and that you're looking out for them, and you'll earn their respect, which in turn can help avoid litigation. I can't stress that empathy is critical.

Phobic patient: "You're hurting me!"
Me: "I'm not trying to hurt you on purpose, I'm trying to help you. Relax and I'll get this done a lot faster."

(when a procedure is taking longer than I expected)
"I know this isn't fun, but hang in there, we're almost done!"
"You did great today, we got a lot done!"

7) No matter what you say or how you say it, you won't win a few people over. Let it go, and as long as you've practiced the standard of care, you have nothing t o worry about.

These are the scripts that I actually use. It does sound corny when I read it, but believe me, they go over well with patients.