Tuesday, May 25, 2010

Peer Review

Hey all,

Summer is definitely here in Central Florida. The highs have been the mid-90s (for you Canadians that's Fahrenheit, eh?), and its flipping hot. I must be getting old because I keep thinking about a summer mountain home for when I getter closer to retirement.
I am not handling the heat so good anymore.

Well, as I write things I will occasionally get a personal e-mail from readers. Sometimes they get my e-mail address because occasionally I will post it. (Jgammichia@aol.com if you need me). And occasionally I will get an e-mail from a dentist friend that a certain blog really hit home.

One of my friends wrote me about one of his situations, and I asked him to write a blog entry. This is a guy that my classmates and I always respected, a guy that was and is very passionate about people and about teeth. He works and lives in a small town in North Florida. He got into a situation that ended him up in Peer Review.

For those of you who don't know what Peer Review is, it is an organized dentistry thing.
I think this started a while back before our society got so litigious. So when a patient felt like they didn't get the best care or felt cheated in some way they had a governing board to review their case.

Now it is used in the same way. Some patients are not the suing type but would like the case to be reviewed. And quite frankly, sometimes it is in the best interest of the dentist to have someone look at a certain case before the patient gets all sue happy. The review board might tell a certain patient to "lay off".

So without further ado here is his story...

Have you ever said to yourself, “I wish I would have written that down!” or, “I wish they would have signed that?” Well, this doesn’t happen to me anymore because I write EVERYTHING down and they sign EVERYTHING.

“Oh, you don’t need to use the restroom? Can you please sign this waiver stating that if you happen to soil your clothing while you are here, that it is not my fault and that I freely offered my restroom to you?” OK, it’s not that bad, but close. Strange how the pendulum can swing the other way when something happens to you.

Here is my story:

Mr. P has been a patient of mine for 8 years. I will add that he is a little on the quirky side, but that didn’t matter to me, he trusted me, and I did my best to maintain his dental health. About 4 years ago, Mr. P was at my office for his yearly exam and radiographs (He put himself on 1 year recall because he says he is meticulous about cleaning his teeth almost to the point of obsession).

His previous dental work included some crown and bridge, large amalgam restoration, and large anterior composite restorations, all from a previous dentist.

So, during this appointment the hygienist tells him that his plaque control wasn’t up to par. Of course he does not believe her because, after all, he spends the first 15 minutes of every morning brushing his teeth. She takes an intra-oral photo of the plaque accumulation and shows it to him. His radiographs showed that he had recurrent decay on #8, recurrent decay around #4, and recurrent decay around #12 (which was part of a 3 unit bridge). We told him about it, and treatment planned accordingly.

He came in to see me to repair #8 a few weeks later. #8 now has 4 large composite restorations all fused together. We talked about eventual crowns on the anterior teeth, replacing the crown on #4 and replacing the bridge on the upper left. He said he was on a limited income, divorced, and didn’t want to sell his motorcycle, which was his only pleasure in life and Hollywood was not going to be calling him anytime soon.

I DIDN”T write any of that down. If I had only known!

I didn’t see him again for another year when he came in with a tooth ache on #2. #2 had a large 4 pin buildup amalgam that was unopposed. The radiograph revealed a radiolucency at the apex of one of the roots. I suggested that he have the tooth removed. He didn’t want to lose any teeth, so he opted for RCT and crown.

He had the RCT done and the crown but complained that the tooth still hurt and said that the endodontist did not know what he was doing. The final endo looked fantastic.

Long story short, he had the tooth removed, and wanted me to refund the crown money. He said it was my fault that I sent him to the endodontist. Well, I did.

The endodontist did not refund his money. In the meantime, #4 is getting worse, #12 is getting worse.

More time elapses, Mr. P comes in complaining of pain in #30, which was an old gold crown. After I scrapped the plaque off from around the tooth, there was recurrent decay right on the root surface. I told him that his home care was not as good as he thinks it is and he has to pay more attention to removing the debris from his teeth. At this point, I take a look at #4 and #12. They both need RCTs now!

I create a retreatment plan and delete the first treatment plan from 3 years ago to “keep it clean”...MISTAKE.

He tells me he can’t afford that and those teeth don’t hurt. I didn’t write that down. Months go by, and he comes in again with a chipped restoration on #9. I look at it and notice on the lingual of #8 that there is a suspicious opaque look right at the gingival margin. I take my explorer, and it literally sinks below the gumline about 9 mm. I talk him into letting us take a radiograph and there is a HUGE hole into the pulp with an apical abscess.

Nothing showed up on the last fmx. I try to explain what’s going on, and all he wants is the chip on #9 fixed because #8 doesn’t hurt. I give him a referral to another endodontist and tell him that time is of the essence because the tooth will not be restorable if we do not jump on this.

I didn’t write that down.

Four months later he comes back in with #8 hurting. Now it is non-restorable. He asked me how in the world this could happen since he comes in once year to get his teeth cleaned. I told him the decay was on the root surface of his tooth, which can progress very quickly if not taken care of (another mistake). He leaves.

Three weeks later he returns to the office with 50 pages of downloaded material on “root caries” from the Internet. Well, technically he didn’t have “root caries” he had recurrent decay that progressed to the root surface. He then wanted a complete treatment plan of EVERYTHING he needed. So my financial person remade another new treatment plan and deleted the old one to make everything clean in the computer. (MISTAKE)

So now he needs about 10,000 dollars of work. Mr. P looks in disbelief. He tells me he can’t afford that, so I suggested having the teeth removed, and wearing denture. (which ,of course, I would NOT be making). Mr. P reluctantly proceeds with the denture. Two weeks later I receive a letter, from Mr. P, telling me that he wants to talk to me and my attorney about my neglect and how I should pay for all of the extractions he had done as well as the denture (and some pain and suffering).

I wrote him back telling him that this meeting will not take place. He somehow gets referred to the peer review board and the process begins where I have to prove what I have done.

Now, this is when the sleepless nights start. This is when I can't eat because I want to throw-up. Seriously, this can wreck you for a long time. It wrecks you during all this, and it makes dentistry not as fun because you are a bit jaded.

So we started the peer review case. I knew some of the guys, but that didn't matter. It was still bad. Bad in a sense that they went through my records with a fine toothed comb.

It all finally came down to the board to review my “notes” and “radiographs” and “treatment plan”. Well, guess what? There was only 1 treatment plan, 4 years after the original radiographs! Mr. P told them that he was NEVER told about all the work he needed, and I just pretty much let him fall apart. (He did come across to our board members as aloof and quirky, see earlier comment).

Fortunately, and they were far from perfect, my notes reflected some of the work he needed. They sat me down and with a desperate explanation about deleting old treatment plans. I felt like I was in trouble. I know in my heart I didn't do anything wrong, but if you don't have the written word to back it up, it almost didn't happen.

But I had one thing in my favor....Remember the intra-oral photo of all the plaque accumulation? It saved me as well. I was cleared of all wrong doing.

Cleared is such a strong word. Let’s keep in mind that I lost about 12 pounds through the whole ordeal. So, looking back, my note taking was horrible, and my lack of attaining signatures was horrible. You can imagine things are very different now because I seemed to have a dodged a huge bullet. I wouldn't wish this on anyone. I have learned from my own story, and I hope you will too.


I can tell you that I haven't have someone sign something in a long time. If they refuse x-rays, they sign something, and I can think of one other time I have someone sign something.

I am rethinking this...

Let's talk about this...

Let's ask this guy some questions about his story.

Any of you been through a similar situation?

Have a good Wednesday,


jamie said...

these are the kind of stories that i dread. i definitely try to document all that i can, but it sure is tough. i keep my fingers crossed that i don't run into things like this. i hate that this can happen, but i also see it from the patient's point of view...there are, unfortunately, alot of unethical dentists out there that do take advantage of people. so, i don't think that peer review is a bad thing...i just hope that those on the committee are fair and open-minded. this is the world that we live in.

oh ya, john....quite complaining about the heat, ha! foracast for saskatchewan later this week is 38 F and raining...wanna trade? ha!

ps. i'm still cheering for the magic these days...i think they can still pull off a crazy comeback! take care


Anonymous said...

That is why written charts are still in my office. Once pen is put to paper the ink stays there. Document everything. I tell my assistant if the pt comes in and says they have a vacation trip planned to the planet MARs they need to write it down. Why the hell would you delete old treatment plans? And your progress notes should reflect your treatment plan briefly anyway. As long you and the rest of us learn from this. It is ok. One of the last CE lectures I went to said that people will get more sue happy because economic times are so tough as a way of making money and getting work done. I think he is right.

Anonymous said...

Thank you so much for sharing this hair-raising story. It serves as an important reminder of what can go wrong without lots of documentation and signatures when needed. Document, document, document. CYA. Stay cool there in FL. Not sure how you manage to run in weather like that but when inside crank up the A/C and enjoy the cold beverage of your choice.


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