The dentist-patient relationship is built on trust, so when developing treatment plans it’s important to combine the patient’s needs and preferences with the best available scientific evidence.
Shared decision-making has been defined as: “An approach where clinicians and patients share the best available evidence when faced with the task of making decisions, and where patients are supported to consider options, to achieve informed preferences”.
Sharing Decisions with People; NHS Wales, 2014.
Patients’ interests first
It is not surprising that the Dental Council, which promotes high standards of professional conduct, expects the dental profession to act in their patients’ best interests at all times.
To mitigate the risks, it is important to reassess the clinical decision process to ensure that patients are fully informed, knowledgeable and wholly involved in their care. This is achieved through a process of shared decision-making.
Positive effect
In general terms, the more complex the intervention, the more in-depth the discussions required to be sure a patient is able to give valid consent. Studies show that shared decision-making has a positive effect on satisfaction and the perceived quality of outcomes (Figure 1). A review of our past cases reveals that the existence of so-called predisposing factors such as rudeness, poor interpersonal relationships, inadequate communication and inattentiveness will often motivate patients to sue or complain when there are precipitating events such as patient harm, adverse outcome or iatrogenic injury during clinical procedures.
FIGURE 1: Shared decision-making.
We are not machines
Complexity – in the clinical sense – relies on known interventions that mostly lead to known outcomes. That said, experience tells us that the biological response to treatment is not always predictable – and so things do not always work out as we may have hoped. A dentist today has to manage the clinical complexity associated with caring for the patient and the complex adaptive elements within the environment, all of which are inter-connected. It is a common finding in complaints – or claims for compensation – that an intervention is questioned or challenged by a patient on grounds of cost rather than clinical effectiveness. Further inquiry or investigation may then reveal ethical breaches in the decision-making process.
Identify
Providing high quality dentistry for a patient can be simple or complicated, and both simple and complicated care take place in a complex environment that has a significant impact on clinical decision-making. Patient involvement in the process is important to ensure that care is delivered in a way patients know to be in their best interests. The complexities of working in a third-party payment system, personal bias, constraints that may be ,imposed by the business, patient demands, choice and availability of resources, and varying competencies among clinicians, all create an interdependency that can significantly lead to suboptimal care. By identifying – and then controlling – the factors, and adopting an ethics-led approach to care, we can control and manage that risk.
Dr Raj Rattan MBE BDS MFGDP(UK) FFGDP(UK) PgDip MDE
Raj combines his work in general dental practice with his role of Associate Dean in the London Deanery. He is also a Senior Dento-Legal Consultant for Dental Protection and has worked with them since 1993.