Special Second Opinion: Prevent a Tulsa Repeat by Richard Mounce, DDS

Prevent a Tulsa Repeat

by Richard Mounce, DDS
Second opinions are common in health care, whether a doctor is sorting out a difficult case or a patient is not sure what to do next. In the context of our magazine, the first opinion will always belong to the reader. This feature will allow fellow dental professionals to share their opinions on various topics, providing you with a "second opinion." Perhaps some of these observations will change your mind, while others will solidify your position. In the end, our goal is to create discussion and debate to enrich our profession.
- Thomas Giacobbi, DDS, FAGD, Editorial Director, Dentaltown Magazine

Dental professionals are as shocked by the allegations coming from Tulsa at this moment as the general public. The basic rules of sterilization and assurance of patient safety being broken are tough to wrap one's head around. The events raise many difficult questions: How and why did this happen? How can we prevent such a situation from occurring again? Is more regulation the answer?

More regulation is not the answer. With all due respect, we cannot legislate against every random act of stupidity, malice and neglect. There is ample evidence that some people, despite regulations and all manner of prohibitions, will commit irrational and malevolent acts against basic human values.

Such events happen because of neglect, apathy, indifference and a lack of management systems and leadership. It is my observation as a specialist and practice owner that unless staff are trained, retrained continually, given checklists and supervised, whatever policies and procedures one might set up initially will either fail to be carried out or morph with unintended consequence through a lack of application.

In any event, leadership is essential to guarantee that the substance of what must be done in the office to protect patients (over and above the legal requirements) must be present. In essence, the doctor owns all the actions of the staff at every level. Hence the training, monitoring, retraining, continuing education, and policies and procedures to assure patient safety is never delegated away from the leader, generally the doctor.

Leadership is hard work. Some staff, for reasons well beyond the scope of this article, either don't want to or are not cognitively able to comply with instructions. At times it can feel as though the doctor and the staff are playing tug-of-war. At the end of the day though, the doctor is the team's captain and he or she selects who plays on the team. Those who will not comply and commit to the goals of the team should be released to play on another team where they might be able to contribute more constructively. Patient safety is not open to discussion or negotiation. The leader assures that it is present.

Asking what general dentists can do to assure that their specialists are adhering to optimal procedures across every spectrum is complex, but important. Ideally, GPs should know their specialists personally and be on a first-name basis. They should meet for a meal at least every six months, speak on the phone about cases when needed and share knowledge when asked. The specialists should welcome the GPs into their offices. The greater the degree of connectedness between the two parties, the better.

It is my observation that this ideal relationship happens at times, but more often than not, only to a limited degree. While situations and relationships vary widely across an infinite number of parameters (distance between offices, region of the country, numbers of GPs versus specialists, economic condition of the community, presence of large corporate dental groups, age of the population, age of the GP, age of the specialist, where the two doctors were trained, where the two doctors were born and raised, family relationships, etc), at some levels, there are barriers to developing the optimal relationship that could or should exist.

Some GPs tell me they feel some specialists in their community are aloof, elitist, unavailable, do not want to share their clinical techniques and knowledge, talk down to the GPs, are greedy, etc. This leaves the GP often feeling unappreciated, especially given a relationship where the GP is feeding the specialist.

Conversely, specialists tell me that some GP offices are impenetrable, meaning that they cannot get past the front desk, calls to have lunch or meet go unanswered and the GP has little or no interest in developing a relationship at any level, even if they refer occasionally.

Being in contact at some level helps ensure both the specialist and the GP that conditions, such as those alleged in Tulsa, are not happening at their referrers' offices. A relationship includes active communication, and benefits all parties, especially the patient. Knowing a patient is severely phobic and might wish to have sedation is vital information for the endodontist. Referring a phobic patient with an iatrogenic event (separated file, perforation, etc) who is in pain and not giving the specialist the heads up pre-operatively puts the specialist behind the eight-ball.

Alternatively, it is absolutely unproductive for a specialist to criticize a GP. In my view, if the GP has committed a truly grievous breach of etiquette, perhaps the specialist should tell the GP that they cannot see their patients moving forward, but this is a rarity and something I personally have only done once in almost 22 years of being an endodontist.

Honesty is the key. In 2011 my wife and I moved to Rapid City, South Dakota, from the Portland metropolitan area. When introducing myself to the GPs in the area I had an experience I appreciated that stuck with me. After saying hello, the GP, whom I was meeting for the first time, looked me straight in the eye and told me that he would never send me a case because he did all his own endo.

I respect the individual for being direct, honest and upfront. While his clinical decisions are his and not mine, he was not afraid of hurting my feelings and treated me like an adult. I am confident had he and I worked together, if my office failed to meet his expectations he would have let me know. This level of communication is one component of a successful partnership.

In my head and in my heart, I am grateful for my referring doctors and want to build them up and help make their practices successful. Criticism is not part of my mental conversation about referring doctors. As I reflect on my referral relationships that are productive and working well, honesty is a commonality in the relationship and a key factor in developing trust and a deeper caring. Taken to its extreme in the reverse, a lack of this relationship and leadership is the likely source of the alleged events in Tulsa.

Author's Bio
Dr. Richard Mounce practices endodontics in Rapid City, South Dakota. He has lectured and written globally in the specialty. He owns MounceEndo, LLC, marketing the rotary nickel titanium MounceFile in Controlled Memory and Standard NiTi. He can be reached at richardmounce@mounceendo.com, www.mounceendo.com or via Twitter @MounceEndo.


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