Hammers, nails and the small matter of opinion.

Toby Talbot, Specialist in restorative dentistry, prosthodontics, endodontics and periodontics, with over 20 years as an expert witness with a specific interest in dental negligence litigation claims, considers why clinical opinions differ so widely when the diagnosis of a particular patient remains constant.

It is poorly understood by patients that visiting a surgeon or physician can result in so many different choices and widely different treatment strategies that complicate the decision-making process.

Where a clinician has trained, and by whom, will invariably influence their strengths and weaknesses, their knowledge and their skill base. Particular personal interests will also contribute influence. And the authority of their teachers and mentors will leave a lasting impression strong enough to sway opinion – the robust and passionate authoritative presentation of a professor can easily leave an influential legacy in a clinician’s professional life. Of course, science should prevail and the clinician should constantly review the literature and temper their opinions accordingly.

But let’s consider an example. A patient is seen by his dentist with a complex problem associated with the failure of a bridge. Is the tooth restorable or not? Uncertainty prevails as the x-ray only gives limited information. Referral to an endodontist who specialises in root canals is recommended. The appointment is made, but then subsequently cancelled. The patient now is then seen by an oral surgeon. Extraction of the tooth is recommended and an implant supported crown is prescribed. The patient is finally seen by an endodontist. Following removal of the bridge and investigation of the tooth it’s proposed to save the tooth and avoid the costly and unnecessary surgery of an implant. What on earth is happening here?

The surgeon has a dental degree, with knowledge and skills honed to perfection for the removal of teeth atraumatically, and the deft placement of implants. It’s what he does best. It’s what he likes doing. It reflects his skill set. No surprise then that it’s what he recommends.

The endodontist has a dental degree and an armamentarium of tiny Swiss-made drills and files with which to burrow into canals so small she works with a microscope on the end of her nose. Of course, the tooth can be saved. It’s what she knows. It’s what she does
best. It’s what she recommends.

So, who’s right? Well, both potentially. Or they’re both wrong because another dentist, a specialist in restorative dentistry perhaps, may consider the third option of root amputation.
What are the drivers for the patient? How important is this tooth to them? Is it a purely a functional issue? Is it a cosmetic issue? Or is it a wholly emotional issue whereby (don’t scoff) the loss of the tooth is seen as loss of self? Perhaps one more nail in the coffin. Or is it a combination of all these things? In other words, which of these treatment plans fits the patient’s expectations, preferences or resolves their specific concerns?

This clutter of possibilities becomes a problem, and a source of litigation, if the patient is informed that a tooth cannot be saved and an implant is the only treatment open to them. The oral surgeon will believe that. Note that few general dentists will contradict the authority of the oral surgeon. If, at a later date, the patient has the implant treatment and this fails, or there are any number of subsequent unforeseen consequences, it’s not surprising that if the patient discovers latterly that the tooth could have been retained, it leads to a civil action for compensation.

In this case, the failure in duty of care is a failure to obtain clear consent. The Montgomery case moved the goal posts from an emphasis on informed consent following advice from one of any number of competent professionals, to that of informed choice all treatment options must be given with all the attendant benefits and risks outlined. However small a risk might be, if its consequences are potentially significant, the patient must be informed. Of course, this relies on all clinicians being aware of all the options available. And all the risks.

But is this really possible? Just how much time does any clinician have available to read up on every research publication and to keep abreast of all subjects. I may find myself totally knackered at the end of a busy day in surgery. Will I go home and read an article on the latest method of restoring a tooth? Or will I prepare myself a G & T before dinner and

fall asleep in front of the television? The public may like to think that all general dental practitioners will read their British Dental Journal cover to cover each month. As a specialist in my own field I read several publications every month and constantly review other specific publications of personal interest. But I’m single. And an OCD nerd. I have no kids and I’m totally immersed in my work. It’s my vocation. If this is the standard the general public expects of all clinicians, then I’m afraid they must dream on.

Some years ago, a simple research project was carried out in a postgraduate dental hospital. A dental patient with quite complex problems to resolve was presented to 10 dentists with a variety of training and experience. Each was invited to conduct a consultation and examination of the patient and devise a treatment strategy for this particular patient. The outcome was interesting. Only Seven practitioners even agreed on the diagnosis, and every one of the treatment plans differed. It was concluded this was due to the individual training and experience of each individual clinician. Every one of the clinicians defended their individual treatment strategies as being the best for that particular patient. Were they all right? Or would the researcher supervising the exercise actually contradict every one of them? Probably the latter.

A patient travelled hundreds of miles to ask me for a third opinion after two treatment proposals were provided by her general dentist and an oral surgeon. My treatment option differed widely from both the others. She was disappointed because she was hoping I was going to endorse at least one of them. Now she’s even more confused about which direction to take. All the clinicians have dental degrees. The patient remains constant. None of the treatment plans bore any resemblance to each other. Should she now seek a fourth opinion? Or should she attend the most enthusiastic? The most convincing? Actually, she chose the treatment strategy from the clinician she ‘liked most’. I see a parallel in politics during elections – never mind the content of their well-prepared manifestos, crosses in boxes are often earned because “he seemed like a nice man.”

 

Let’s look at another example. The patient who asymptomatically finds themselves with an elevated PSA level. Is it prostate cancer or just innocent benign hypertrophy? Off they trot for an MRI. A discrete lesion within the gland is recorded. No lymph node involvement. Then they trot once more for a general anaesthetic for multiple template biopsies. Gleason score 3+4=7 indicates a moderately staged cancer that appears contained macroscopically within the capsule of the gland. Now what?

Three consultations follow because the patient has the intellectual capacity and time to review the scientific literature and explore his options.

Consultant #1, based in a provincial city wants to carry out curative ablation surgery. In other words, chop it all out. Job done. Cured, but guaranteed impotence and bladder incontinence for life.

Consultant #2, based in a dedicated, private prostate cancer unit in the US wants to carry out brachytherapy and external beam radiotherapy with concomitant female hormone or testosterone blocking medication that gives a 40% chance of impotence and 3 months of needing ‘diapers’. Lovely.

Consultant #3, based in a European centre of excellence run by an internationally established professorial unit dedicated to prostate cancer treatments, wants to carry out just brachytherapy. No external beam radiotherapy, no hormones, no surgery. No impotence or bladder dribbling anticipated.

Seems a no-brainer, but what about the ‘fit’? The male, living alone, aged 80 years, who is already impotent and has been getting out of bed throughout the night for years for a pee doesn’t view the morbidities as an issue. The sexually active, vigorous 65-year-old with a young partner most certainly does. So, what’s the problem? The first patient elects option 1 or 2, the second patient elects option 3. Simple, surely?

Consultant #1 is a brilliant technical surgeon. He’s been playing with his robotic Da Vinci kit for years and he’s honed it to perfection because that is what he loves doing. He is the consummate technician. He also hasn’t got any radiotherapy kit because it costs £50 million to set up. He also doesn’t have the oncologist and physicist support and radio- nuclear know-how. But where he may fail in his duty of care is by not telling the patient about the other philosophies and alternative options, even if he hasn’t the knowledge or kit.

Interestingly every one of the above clinicians is convinced they are offering the best cure rate or ‘survivability’. But, at what cost to the patient? Have they spent enough time with the patient to ensure their particularly treatment plan is the right fit for the patient?

So, where do you go to get a consensus of opinions that do not contradict each other? That’s easy. But unfeasible. Go to any dental or medical school and consult with any one of the recently qualified clinicians. They will all have been indoctrinated by their teachers and at that point in their careers, few of them actually have opinions that they can call their own. The vast majority will mostly agree, most of the time. If, at that time they start to contradict their ‘masters’, they will be regarded as dangerous mavericks or geniuses, or both. One month out of their schools, their opinions will begin to diverge.

So, aside from the risky use of inexperienced but helpfully unopinionated youngbloods, what to do? Patients, and their counsel, should it come to it, need to accept the ‘art’ of healthcare provision. Medicine and surgery are not just sciences.

Irrespective of choices and outcomes, if the clinician is a good listener and establishes a good relationship with the patient, then, irrespective of outcome, the patient will be convinced that they have been looked after even if the results are less than hoped for. No patient, in my 20+ years of experience of medico-legal work, has ever sued a clinician for being too nice.

The nature of the consultation will invariably influence the final treatment strategy proposed. This is the art of medicine. The brilliant consultant and who is also good communicator is much more likely to get it right. A consultant with communication skills on the autistic spectrum, might be the more brilliant technician, but is more likely to get it wrong. In the case of the prostate patient mentioned earlier in this article, the first consultant, a brilliant surgeon with the technical abilities of a Swiss watchmaker, failed to listen to his younger patient and proposed radical surgery despite the patient emphasising that functionality was more important than the cure.

If all you have is a hammer, everything is a nail. And every nail is potentially a staple in the corner of law suit.

All the views and opinions expressed by the author are personal but I would welcome public debate on all the issues included.

Toby Talbot BDS MSD (Washington) FDS RCS

Email: toby@talbotclinic.co.uk

Website: www. talbotclinic.co.uk

Tel: 01225 426 222

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