Image courtesy of escapefiremovie.com
https://www.linkedin.com/pulse/escape-fires-dentistry-standard-care-benjamin-dyches-dds-jd?trk=prof-post
As we get started, I understand that the “standard of care” is a pet project of mine and you may not care about the concept as much as I do. That’s ok. Hopefully the care standard consideration has only been tangential to your daily practice. However, the odds make it highly likely that you will face a Dental Board complaint or lawsuit multiple times throughout your career (the average dentist has an open liability issue for almost 6 years of his career). [1] When you do, the standard of care used by your accusers will define the outcome. The standard of care issue came front and center for me as I dealt with a Dental Board complaint myself and ultimately played a major role in my decision to attend law school.
Beyond the individual patient and provider concerns, however, a system for creating care standards will ultimately define dentistry’s relationship with the federal government in a way that allows the profession to remain in the driver’s seat. Let’s face it, it’s probably just a matter of time before we become entangled in federal billing protocols. There is a lot to be learned through the mistakes of others. But before we jump to that discussion, let’s take a step back and talk about the standard of care. Your decision to become a dentist likely included a desire to help people. You wanted to ease pain, cure disease, and help improve well-being and quality of life – a set of rational called “moral compass reasoning.” All of these are admirable pursuits and they could find the most educated, the most skilled, and the best-intentioned clinician in a ton of trouble if something goes wrong.[2] When that happens, explaining your course of action to a judge and jury with “I did it the way I learned in school,” “I did my best,” or “I did it the way all of my colleagues are doing it,” sound like “excuses for failing a high school shop class.” [3] To truly properly care for your patients, all dentists are ethically and legally bound to follow some combination of the moral compasses. Years before he took office as the head of Medicare and Medicaid, Dr. Don Berwick published a speech in his healthcare manifesto called “Escape Fire: Lessons for the Future of Healthcare.” His speech draws a parallel between the broken healthcare system and a forest fire that ignited in Mann Gulch, Montana. That forest fire, which seemed harmless at first, was waiting to explode. A team of fifteen smokejumpers parachuted in to contain the fire, but soon they were running for their lives, racing to the top of a steep ridge. Their foreman, Wag Dodge, recognized that they would not make it. With the fire barely two hundred yards behind him, he did a strange and marvelous thing. He invented a solution. His crew must have thought he had gone crazy as he took some matches out of his pocket, bent down and set fire to the grass directly in front of him. The fire spread quickly uphill, and he stepped into the middle of the newly burnt area, calling for his crew to join him. But nobody followed Wag Dodge. They ignored him, clinging to what they had been taught, and they ran right by the answer. The fire raged past Wag Dodge and overtook the crew, killing thirteen men and burning 3,200 acres. Dodge survived, nearly unharmed. Dodge had invented what is now called an “escape fire,” and soon after it became standard practice. Healthcare in general, is in Mann Gulch. Dentistry has historically managed to skirt around the edges of the major healthcare legislation. Since 1965, most dental, vision, and hearing expenses have been excluded from Medicare coverage. Medicaid coverage is determined by the providing state, but most states offer very limited or no coverage for adults. Because most dentists are not billing a federal entity, they are largely exempt from the typical self-referral, anti-kickback, and Federal False Claims Act (FCA) concerns. But things are changing, and if dentistry doesn’t take this time to create an escape fire, it will find itself in the heart of the blaze with the rest of America’s healthcare providers. The mandate for all health care systems is clear: improve outcomes, reduce cost and eliminate waste. These ambitious goals require an explicit standard of care to instruct dentists, patients, and attorneys about the social expectations of doctors treating specific problems instead of an implicit standard of care that is never fully articulated. The goal of this series of essays is twofold: First, to illustrate the vagueness and confusion inherent to the current system and how conflicting standards ultimately prejudice both patient and provider. Second, to examine the potential solutions and suggestions in the path forward. The essay will be broken into the following parts:
I am positive that you will learn some things that will affect how you think about every procedure in your day. I know this information can save more than a few white hairs – it may just make the difference in your career. [1] Seth A. Seabury, Open, Unresolved Malpractice Claims, http://content.healthaffairs.org/content/32/1/111.abstract [2] The doctor-patient relationship and malpractice. Lessons from plaintiff depositions. Beckman, et al., Arch Intern Med. 1994 Jun 27; 154(12):1365-70. [3] https://www.dentalaegis.com/id/2008/10/standard-of-care-in-dentistry
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March 2016
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