The sword of Damocles
According to classical legend, Damocles was a courtier to king Dionysius II of Syracuse. Frustrated by Damocles' sycophantic fawning about how fortunate the king was to have wealth, power and authority, Dionysius offered to exchange places for a day, which Damocles readily accepted.
However, to demonstrate the perilous nature of his position, Dionysius arranged for a large sword to be suspended by a single hair over Damocles' head as he sat on the throne. Damocles quickly realised that under the perceived threat of imminent danger, he was unable to enjoy his new-found fortune and begged the king to release him from the exchange. The Roman philosopher Cicero is quoted as saying of the story, 'there can be no happiness for one who is under constant apprehensions.'
This parable may resonate with those UK dental professionals who feel that despite the fact that dentistry is a rewarding and worthy pursuit, their careers and livelihoods are under constant threat from a variety of sources. In a recent survey of UK dentists by NHS Digital, 61% of practice principals and 50% of associates self-reported that they had low or very low morale. Amongst the most commonly cited reasons were falling incomes, regulation and the risk of litigation.
'Climate of fear'?
Another parallel might be found in a study by UCL, which states that, 'Fear of crime is perpetuated by the opinion of others, and often doesn't correlate to the actual likelihood of experiencing crime.' The study shows that there can be a generalised fear of crime even in places where crime rates are low. UCL study lead Rafael Prieto Curiel observed that, 'The fear of crime can be considered contagious, because social interaction is the mechanism through which fear is shared and chronically worried populations are created. Even those that have never been a victim of crime can be seriously worried about it.'
In my view there are many similarities between such anxieties and the current atmosphere in UK dentistry. It should be encouraging to note that in reality the actual likelihood of a career-changing sanction from the GDC or series of negligence claims is relatively low. For example, in 2017 the GDC's Professional Conduct Committee imposed erasure or suspension in just 134 cases - or 0.1% out of 116,173 registrants.
Nevertheless, when colleagues hear of the difficulties of others - for example, when anecdotally reported on social media - they can quite understandably fear for their own futures. The GDC acknowledges this 'climate of fear' in its recent publication Moving upstream, which sets out some of the steps already taken and planned for the future to address the issue.
There are some positive signs that complainants are now being better signposted to where they can most appropriately raise their concerns. This has resulted in a reduction in the number of fitness to practise (FTP) referrals to the GDC, from a peak of 3,107 in 2014 to 1,642 in 2018 - a fall of 47% (from Moving upstream, p. 15). Clearly such a significant reduction means that going forwards there will be fewer dental professionals embroiled in the GDC's FTP process, which can be stressful and protracted - a sanction in itself.
In its 2017 publication Shifting the balance, the GDC committed to reviewing and improving its FTP procedures. That process is ongoing and you can be assured that the DDU is actively contributing to that review, raising issues where our members' interests are concerned and offering positive solutions where appropriate.
Our colleagues in the DDU's claims team have been exceptionally successful in defending members' reputations and rebutting claims. Under their expert guidance in 2018, notwithstanding the fact that dental claims are often carefully selected by specialist law firms, 69% of dental claims were successfully defended without the payment of compensation.
It should be encouraging to note that in reality the actual likelihood of a career-changing sanction from the GDC or series of negligence claims is relatively low.
There are some simple but practical self-help solutions that we can all put in place to reduce the likelihood of successful claims and GDC cases.
- As part of the consent process, take time to explain to patients the material risks of treatment and the alternatives, including no treatment. Make a careful note of these discussions in the clinical records.
- Provide a written treatment plan and fee estimate and be sure to warn patients of the cost implications if circumstances change.
- Recognise the limits of your own clinical skills. Be prepared to refer the patient to an appropriate colleague if complications are likely, or if the patient has a complex history.
- Follow available relevant guidance to make sure your treatment would be supported by a responsible body of clinical opinion.
- Make sure patients understand the importance of looking after their own oral health. Record advice provided to patients about diet, oral hygiene, attendance patterns and factors such as smoking, drinking, medications and co-morbidities.
- Be open and honest with the patient if an unforeseen complication or error occurs during treatment. You should immediately tell the patient (or their representative), apologise, and offer an appropriate remedy or support to put matters right, if possible. Explain the short and long-term effects of what has happened in full.
- Make sure the whole dental team understands the practice complaints procedure. Acknowledge complaints early to reduce the risk of escalation and seek our advice with a view to resolving the complaint quickly and at a local level.
- Get early DDU advice if you need support with an incident that might lead to a claim.
A career in dentistry can be fulfilling and rewarding, but it is important to keep risks in perspective and to manage them appropriately. When you encounter bumps along the road or difficult times and you feel the sword hanging over you, be sure to share your concerns - with colleagues, your network of friends and family, and with the DDU, who you can always contact for help and support when you need it.
Head of the DDU
John Makin BDS PgDL PgCDE FHEA is head of the DDU. He qualified in Manchester in 1983 and has worked as a general dental practitioner in Lancashire and Devon before joining the DDU as a dento-legal adviser. He was involved with foundation training for many years as both a trainer and VT adviser/training programme director with the Manchester and Exeter DFT schemes.
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