Ain’t Misbehavin’ - How DO You Deal With Disruptive Patients?

Feedback - (Friend Or Foe?).By DentistGoneBadd

Turn the clock back 40 years to the land where Mrs Thatcher was starting to flex her muscles, sharpening her deregulation scythe and readying to privatise any and everything. What changes do I see in Dentistry today? There is one element that dominates professional lives. Nothing to do with their talent, skills or clinical judgement. Even less to do with good working or patient relationships, teams or outcomes that matter.

I am talking about compliance. Defined as “The act of complying with a wish, request, or demand, a synonym is “acquiescence” or “passive assent or agreement without protest”, and a legal definition implies “the abandonment of a right”.

Last month I accused the GDC being a sledgehammer used to crack nuts. This time I am levelling my sights at another organisation better known by its TLA (three letter acronym), the newer kid on the block, the Care Quality Commission. Set up in 2009 with the intention of “regulating and inspecting health and social care services in England” it has rarely if ever been seen as an ally by those who it “governs or directs according to rule”.

It was parachuted into dentistry with little consultation, minimal clarity and maximal condescension. This is not an unusual occurrence for matters relating to dentistry, long considered the awkward mob by government and much of the rest of medicine. “Necessary when you need them but resented for their freedom” was how a Whitehall Mandarin patient of mine who commuted every morning from Peterborough to London having served his time in the Department of Health described Dentistry.

The CQC’s stated role is to provide people with “safe, effective and high-quality care, and to encourage them to improve”, yet without inspection of clinical standards how can they judge “care” properly?

This statement from their website, says much that is wrong with the CQC.

We inspect 10% of dentists in England each year. You can use our inspection reports to help you understand the quality of care. We do not rate dentist services but we do highlight if a service is meeting the standard of care we would expect.

It was always bad fit, the wrong solution to the wrong problem, a knee jerk reaction to medical tragedies, particularly the Shipman affair; it started badly when its disgraced first Chief Executive was forced to resign.

The fundamental problem (like the GDC in many ways) is that of it being a compliance-based programme where rules of conduct are put in place. Penalties, which can be severe, are waiting for anyone who is seen to be out of step from the norm. The rules are obeyed in order to avoid the repercussions, hence (like the GDC) fear becomes the driving factor.

The dental businesses are not judged on their moral compass, rather on a right or wrong tick box which, too often, is administered and delivered by individuals who, may be for the most part well meaning, but have little or no clear idea of 21st century dentistry.

How could this be improved? I know I have spent too much time in Ireland because the answer once again is, “You wouldn’t want to start from here”. The CQC is a massive bureaucracy little suited to examining dental practices and the systems for Dentistry should be clearly different from that for Care Homes and Hospitals.

Rewarding aspirational practice, understanding the real differences between good, less good and bad practices plus properly evaluating what is meant to be truly well run. I would like to see fewer “inspections” with all the connotations of confrontation and clipboards they bring. Instead there should be far more conversation, communication and encouragement to reach not just the basic but higher standards ethically, culturally and clinically.

Of course now we come to the elephant in the room. The NHS; committed to getting more bangs for its, ever diminishing and inadequate buck, to being in control of all things health related from education through research and education. It ensures the blame for bad news is always as far distant from the top as possible.

Dental businesses are for the most part separate entities, even large corporates serve different communities with different people. The quality of care (it’s about quality of care) cannot be measured by an “inspection” of an off-the-peg compliance system once a decade.

There must be clarity about what is expected, better two-way communications and some obvious effort to regain the shattered goodwill of a profession which feels compliance has been used as a weapon to control it rather than to improve patient care.

Dentists look at the CQC and how it deals with what they know then despair about the rest of the Health and Social framework where out-dated inspection methods are used to address the wrong problems.

Don't Panic! - You can handle the latest crisis...can't you?

The marketplace

We all, I would like to think, got into this profession for the reason of trying to help others and improve the health and wellbeing of patients. If we were in it solely for the money, there are plenty of other professions that can give the financial rewards without the types of stress that we face on a daily basis from all aspects of our wonderful profession.

Before I continue, I should note that yes of course we all need to make a living and there is nothing wrong with wanting to earn more. That is not my concern here, but more that I am worried that we are starting to see our patients as customers, and therefore trying to sell them a product rather than provide a health service.

A recent dental conference I attended had a stand hosting a lecture titled ‘How to earn an extra £100,000 a year through facial aesthetics’. Now my issue here is nothing to do with facial aesthetics at all, it could just as easily be swapped with dental implants, short term ortho, smile design or whatever aspect of dentistry one may be more interested in. For me, it’s more the headline like that got me thinking - are we becoming ever more financially driven and could this lead to us ‘selling’ patients treatments or rather a product they may not necessarily want or more importantly need. We are all part of the health care sector but are we making dentistry into an industry more than ever and forgetting that it’s actually a profession? I’ve even heard of undergraduates taking external courses on ‘how to sell private dentistry’ when they haven’t even passed their licence to cut exam yet so if that is the motivation from such an early stage, is there cause for concern?

There is already a misconception by members of the public that dentists are there to take patients money, so this made me think that we could be adding fuel to the fire.

This is not aimed at people wanting to be a successful practitioner and earn a good living or run a profitable practice, it’s a general concern about our profession losing its way a little bit and putting profits above patients.

We have all seen those cases on social media whereby unbelievably invasive dentistry has been carried out at both a financial and biological cost to patients, when really a much more conservative treatment plan would achieve just as good if not better results. I’m sure many of us have looked at those cases and thought that clearly there has been a financial objective here as why would a well-informed patient actually consent to some of these treatments.

That’s not to say that patients don’t have the right to elect to do these types of treatments and of course maintaining patient autonomy is key. However, with the continuing role and influence of societies’ obsession with achieving the perfect aesthetic (in many aspects not just dentistry), are we being lured into this type of dentistry by the financial gain and compromising our moral obligations to our patients? Is the ‘Love Island effect’ or the role of ‘social media influencers’ (not just celebrities but even dentists these days too) starting to influence us as dentists, not just our patients?

"Sunday in the City 338" by Carl Campbell is licensed under CC BY-SA 2.0