Episode 10: RISK MANAGEMENT MADE SIMPLE: TIPS EVERY DENTIST SHOULD KNOW

In this episode, Karen Wood discusses dental malpractice and risk management with Dr. Al Rizkalla. The podcast covers various aspects of dental malpractice, focusing on informed consent, documentation, patient interactions, and the critical role of detailed, ethical patient care. Dr. Rizkalla highlights common claims against dentists, the importance of effective communication with patients, and the necessity of thorough and accurate documentation. The episode also explores the significance of hiring well-trained staff and proactively using malpractice insurance resources, including risk management consultations and educational opportunities available through Dentist’s Choice.

HOST: Karen Wood manages the VDA Member Perks program. She has been in the dental field for over 20 years, having experience as a dental assistant, managing a periodontal practice, and working with dental teams as a sales consultant and trainer.   

GUEST(S): Dr. Al Rizkalla, Head of Professional Liability-Practice Risk Management – Dentist’s Choice graduated from Georgetown University School of Dentistry with honors in 1988. He also completed a General Practice residency at the Veterans Administration Hospital Center in Washington, D.C. Dr. Rizkalla was the President of the Northern Virginia Dental Society (NVDS) and also represented NOVA for several years as a member of the Executive Board of the Virginia Dental Association (VDA). In 2013, Dr. Rizkalla was appointed to the Virginia Board of Dentistry, and in 2016, he was elected President of the Board. 

He has held several positions in the VDA and the NVDS, including Continuing Education Chair, Peer Review Committee Chair, Executive Committee Chair, Ethics Committee Chair, and Dental Health and Public Information Committee. He is an examiner for the CWC testing agency and previously served on the examination committee of ADEX. 

Dr. Rizkalla is a fellow of the American College of Dentists, International College of Dentists, Pierre Fauchard Academy, and the VDA. Dr Rizkalla teaches Restorative Dentistry, Interdisciplinary Healthcare Ethics, and Practice Management. He is the recipient of the Lifetime Achievement Award by the NVDS.

MENTIONED IN THIS EPISODE:

VDA Member Perks: https://www.vdamemberperks.com/ The Virginia Dental Services Corporation (VDSC) was created as a subsidiary of the VDA to recommend products and services to the members of the VDA. By utilizing the VDA Member Perks-endorsed vendors, VDA members can enjoy the peace of mind that comes with using recommended companies, take advantage of special benefits, and receive discounted pricing, all while supporting the VDA. Since 1997, the VDSC has been pleased to provide over $3.7 million in funding to the VDA, VDA Foundation, VCU School of Dentistry, and others.

Dr. Al Rizkalla Adel.rizkalla@aspen-insurance.com

R.K. Tongue Co., Inc. https://rktongue.com/ 800-638-6353

Michael Urbanik murbanik@rktongue.com 410-369-3957 

EPISODE CREDITS:

Producer: Paul Logan

Host: Karen Wood

Guest(s): Dr. Al Rizkal

Subscribe, share, and send your feedback and topic ideas to thefulcrumpodcast@vadental.org.

The information, opinions, and recommendations presented in this Podcast are for general information only, and any reliance on the information provided in this Podcast is done at your own risk. This Podcast should not be considered professional, medical, or legal advice.

Music in this episode from Epidemic Sound

Transcript

[00:00:15] Karen Wood: Hello and welcome to another episode of the Virginia Dental Association's Podcast, The Fulcrum. My name is Karen Wood, and I'm the Director of Operations for VDA Member Perks, which is the member benefit program for all VDA members.

[00:00:29] Karen Wood: Our endorsed vendor partners provide discounts on products and services, as well as an elevated level of support and attention to the VDA members that use them.

[00:00:37] Karen Wood: For all matters involving insurance, we are fortunate to work with the team at R.K. Tongue Insurance. They have been dedicated, loyal, and a proven partner in advocacy and support to the VDA and the Member Perks program. One of the many advantages of working with R.K. Tongue is their commitment to education and guidance for dentists.

[00:00:55] Karen Wood: Today we're gonna be getting some expert advice on the topic of dental and malpractice, and review some of the more common types of claims that are happening now and how to avoid them. What you and your team can do to protect the practice and how to proactively use the resources and experts that a policy through RK Tongue offers.

[00:01:12] Karen Wood: Recently, RK Tongue announced the launch of Dentist's Choice Malpractice and Office Insurance. And in the process of researching and getting myself familiar with the offerings available from Dentist's Choice I was impressed to discover the tools and resources available to our members.

[00:01:26] Karen Wood: I was even more impressed when I found out that the head of Dental Risk Management for Dentist's Choice is Virginia's own Dr. Adel Rizkalla. The VDA gets to proudly claim him as we have benefited from his leadership for many years in many positions, including his time serving as the president of the Northern Virginia Dental Society, having him on the VDA Board and serving as the VDA's Chair on the Council of Ethics. He was also president of the Virginia Board of Dentistry. And after 30 years of private practice, Dr. Rizkalla is very excited and passionate about his teaching role as an assistant professor in the Department of Comprehensive Care at the Howard University School of Dentistry, where he instructs interdisciplinary healthcare ethics to medical, dental, and pharmacy students.

[00:02:10] Karen Wood: I could continue for a while listing more of his accomplishments and impactful positions held, but my point was to demonstrate the extensive experience that Dr. Rizkalla brings to his role with Dentist's Choice. So, I'd like to welcome you, Dr. Rizkalla, to the VDA's Podcast.

[00:02:24] Dr. Al Rizkalla: Thank you, Karen. It's an honor and a pleasure to be here.

[00:02:27] Karen Wood: Well, I was very excited to have the opportunity a little while ago to pick your brain, Dr. Rizkalla, and you and I discussed some of the common areas where dentists find themselves in trouble in terms of opening themselves up to an accusation of malpractice.

[00:02:39] Karen Wood: Having worked in a dental practice as a manager and as a chairside assistant, it really hit me how daily interactions with patients, the impacts a busy schedule can have on recording details for proper documentation, and a simple lack of information can lead to problems.

[00:02:53] Karen Wood: So, let's start with the patient interactions and dive into discussing treatment plans, option those plans, and how to properly obtain consent.

[00:03:02] Dr. Al Rizkalla: This is an area where we can talk for hours and hours. But let's start with consent since you mentioned it, informed consent, and I see it a lot on cases that come before the board and, and cases that, become legal, which is the lack of informed consent. Informed consent is all about a discussion that you have with the patient. You're supposed to first have a discussion, then you document the informed consent. And I see a lot of cases where it says, lack of informed consent, lack of comprehensive treatment plan. You know, so many offices, they have just a piece of paper and a team member that is not familiar with the treatment that's gonna be performed, they presented to the patient. So, you have really five elements of the informed consent, and all five elements have to be there for the informed consent to be valid.

[00:03:56] Dr. Al Rizkalla: First, the patient must be competent. The patient must be able to understand the information and has the ability to reach a decision on their own. That's the first part. The, and of course the second one is the disclosure. You know you wanna explain the, the proposed treatment, the alternatives, the the other options the risks, the benefits.

[00:04:21] Dr. Al Rizkalla: And a lot of time we forget the prognosis. And possible potential complications. And what is the risk if you don't do the treatment? And you want to answer all the patient's questions. A lot of the problems that arise with patient interactions, their money related.

[00:04:43] Dr. Al Rizkalla: So, as you are talking about the informed consent with the patient. Go over the cost, the financial obligation. One of the most common reason for claims against dentist is financial issues. Have a conversation about the cause, the cost, early on so the patient understand what's happening.

[00:05:00] Dr. Al Rizkalla: One of the things that's really important for everybody to understand is informed consent is for the benefit of the patient. I'll repeat that. Informed consent is for the benefit of the patient. You don't want your, your personal bias as you're presenting the informed consent.

[00:05:20] Dr. Al Rizkalla: And as you're having this conversation, this is a great time to manage the expectation of the patient and, and see if, if the patient has unrealistic expectation, this is the time to find out before we embark on treatments. Then you have comprehension. The first one was competence, but then you have comprehension.

[00:05:41] Dr. Al Rizkalla: The patients must have the ability to understand you know, so if a patient is in severe pain or they're anxious, or or they're distracted, these are factors that will impair their comprehension, and you need to keep in mind what's going on. If the patient is sedated prior to this, then you, you have a, an issue for their comprehension.

[00:06:04] Dr. Al Rizkalla: And of course, it has to be voluntary. When you present the information and you're having this discussion with the patient, you want it to be void of deception, coercion, or manipulation.

[00:06:15] Dr. Al Rizkalla: And then of course the last thing is authorization, which is the patient has to authorize, and it has to be verbal and by signing. And of course, a lot of questions that we get is you know, should a witness be there. It's a good idea to have a witness. It improves the validation of the informed consent.

[00:06:37] Dr. Al Rizkalla: A lot of what we do really relies on the ethical principles by the American Dental Association. You know. Patients' autonomy, the, this is one of the main things why, you know, informed consent is there. The patient has the right to choose and, and be part of what happens in dental treatment. Non maleficence, beneficence, justice and veracity. I mean, if I can talk about the ethical principles for long time, I I can, you know, because they, they provide guidance and justification.

[00:07:08] Dr. Al Rizkalla: They're the moral compass and they provide a lot of safeguard for what we do. And of course, finally what we talked about, which is voluntary. The patient needs to verbally agree and sign for it. 

[00:07:22] Karen Wood: Yeah. And going back to something you mentioned, um, earlier about, you know, patients could have concern for finances and you're disclosing what that is to the patient and they wanna pick and choose which treatments that they wanna have. Based on that, how much say do they have in that? 

[00:07:38] Dr. Al Rizkalla: Let me answer this by telling you a story. Patient walks in with a loose, upper, and lower complete denture. This is an actual case, by the way, and the dentist looks at the case and says, you know what these dentures, they need to be redone.

[00:08:01] Dr. Al Rizkalla: And the patient said, no, I am saving my money because I want to get implants, and I want to get dentures over it. I want you to do something temporary to hold me over until I'm ready to do that. The dentist said, no, it's not gonna work. Whatever I do is not gonna work. So, the patient insisted.

[00:08:20] Dr. Al Rizkalla: The dentist, decided, you know what, okay. I'll do it. After all, it's a temporary fix and I'll do it. So, she ended up doing a soft reline for the denture, and the patient walked out. The next day, the patient called and says, I want my money back. This is not working. Well, the dentist said, you know what? I informed you and I told you that it may not work. And it didn't work, but I told you that it's not gonna work. The patient said, well, I paid you I want my money back. And started yelling.

[00:08:59] Dr. Al Rizkalla: The dentist said, you know what you are yelling. We, we cannot have a reasonable conversation. Don't call back. And the end of the conversation, the next thing you know, the patient filed a complaint with the board. And now the dentist has to go through all the steps of a complaint. But that's because the dentist went outside. The patient insisted and the dentist said, okay, I'll do it. And, and many cases like this you're the dentist, you're the one that went to school. You're the one that's obligated to follow the standard of care. The patient should not dictate the treatment.

[00:09:41] Dr. Al Rizkalla: I mean, you can do things that are within the standard of care, if it's option one or option two, but your judgment is what reigns. Did I answer your question? 

[00:09:54] Karen Wood: Yeah. And staying with that, if the patient requested a refund of their money and the dentist decides to do that, is that any kind of admission of wrongdoing on the dentist part?

[00:10:07] Dr. Al Rizkalla: Excellent questions. Wow. Okay, so you wanna have a conversation with the patient if, if you are planning on doing a refund, you wanna have a conversation with the patient and you think of it as a business decision, because sometimes giving a refund could be a wise business decision that will avoid escalating things, but you want to have a conversation with the patient.

[00:10:31] Dr. Al Rizkalla: And then we talk about signing a release. Because without signing a release, sometimes that could be construed as admission of guilt. You, you know, signing a release, the dentist has to make a judgment call each time, because sometimes depending on the situation and the case and the treatment provided and the amount of money that you're refunding and so on, on one hand it's a business decision.

[00:10:55] Dr. Al Rizkalla: On the other hand, you may raise a red flag in the patient's mind. What am I signing? So, for Dentist's Choice, we go case by cases, and you want to call. A risk manager early in the process whenever this happens. So, we can go through the steps and assess the situation and give the proper advice.

[00:11:18] Karen Wood: And it sounds like the dentist should be the one having the conversation with the patient, not the office manager. Is that right? 

[00:11:24] Dr. Al Rizkalla: Amen. Amen and amen. Thank you, Karen.

[00:11:26] Karen Wood: Oh, I'm just telling no, there's no office manager that wants to have that conversation, so you're just giving permission away.

[00:11:32] Dr. Al Rizkalla: But you know, so many people, they just let the office manager deal with the patient and, and having a third party in between, sometimes it escalates things. When there is a patient that's not happy, the patient wants to be heard by somebody that provided the treatments.

[00:11:50] Dr. Al Rizkalla: Sometimes it's delegated to somebody that that's not providing the treatment, an office manager, but sometimes pride gets in the way. And you really want to deescalate the situation by providing a safe space for the patient to voice their concerns and listen to them. And listen to them actively and with empathy and put your yourself in their shoes and treat them as you would wanna be treated. 

[00:12:18] Karen Wood: That sounds like a good practice to have. And back on the documentation, 'cause of course, this is all gonna be in the records for the patient. We didn't talk about x-rays and how to present x-rays and how to document what you find in the x-rays.

[00:12:31] Karen Wood: And then there's also the overlap bite wings or something that's cone cut or a PA that doesn't show apices. What's the best way to handle that? 

[00:12:40] Dr. Al Rizkalla: Well, you always want diagnostic. Radiographs. 

[00:12:45] Karen Wood: So, if a patient is difficult, has Tori, you know, it's, it's almost impossible to get that. It's okay to leave with that x-ray and like document why the x-ray is that way.

[00:12:58] Dr. Al Rizkalla: You can, but you can always also resort to extra oral, like a panorex or something like that, to compliment it. I mean, you don't want to just keep exposing the patient over and over to some x-rays unnecessarily when you know you're not gonna be able to get it. Whether it's, uh, you know, the patient is in pain or there is a huge torus or something, but you can always resort to an extra oral and, and document this.

[00:13:23] Dr. Al Rizkalla: And by the way, you don't keep charging for it. If the patient is refusing radiographs and you cannot make a diagnosis, um, we will have a conversation with the patients.

[00:13:39] Dr. Al Rizkalla: Often I find if, if discuss a little bit of finances and you know, Mr. or Mrs. Patient we really need this radiograph to make a diagnosis. And in order to treat you properly, I need to see what's happening and we'll do it on the house. Sometimes this is the concern, and the patient say, okay, go ahead.

[00:14:00] Dr. Al Rizkalla: In special circumstances, let's say a patient comes in and says, you know, I may be pregnant. And, and if you know the patient, you know the circumstances, you can forego radiographs, one or two visits max, and I'm saying one or two visits, not one or two years, one or two visits. Other than that, it may be time to dismiss the patient. You know, the standard of care required that you have radiographs to make a diagnosis. 

[00:14:30] Karen Wood: Now in the realm of documentation and someone files a board complaint, and you know, an investigation is opened. What does that look like for the dentist? 'Cause you've you may have good documentation on this one patient, but from what I understand, it's, it doesn't stay there that they look at other, other patient's charts.

[00:14:49] Karen Wood: Is that correct?

[00:14:49] Dr. Al Rizkalla: Yes.

[00:14:50] Karen Wood: Okay.

[00:14:50] Dr. Al Rizkalla: Oh, yes, when a complaint is filed, an investigation is started by the Department of Health Professions Investigative Unit that's aside from the Board of Dentistry.

[00:15:02] Dr. Al Rizkalla: They investigate, they collect records, they get, not just one chart, but several charts because they wanna see the quality of care. And I'm gonna stress this here over and over again. Good documentation Equals good care. I'm gonna say it again. Good documentation equals good care. So, we can talk about documentation a little bit more.

[00:15:28] Dr. Al Rizkalla: Actually, we're talking about this, uh, collecting more charts. Here's a case that actually is in progress right now in another state. Due to a billing concern, a patient filed a complaint with the insurance company. The insurance company decided to do an investigation. So, they went in and not only they collected the chart of this one patient, they got 25 other charts, 25 other charts, and they looked at them and they discovered from the documentation of all these charts that the patients there are not getting good care. So, after they did their thing, they actually pushed this case over to the board of that particular state. Now I, I went on a tangent. I don't know if I answered your question or did I miss part of the question?

[00:16:24] Karen Wood: No, you did. And another question I have about, you know, looking at charts, does that include the ledger? 'Cause we just discussed not charging a patient for x-rays. 

[00:16:34] Dr. Al Rizkalla: Okay. So, if you do something at no charge, you don't have to put it in the ledger, but it's advised to put it in the ledger and you put in no charge next to it. Accuracy matters. And I think if, if your records and your ledger go hand in hand. It shows that this is an accurate practice and everything is recorded. As a principle, if you do something on no charge, also put in the ledger and put no charge next to it. 

[00:17:09] Karen Wood: And what's your opinion on using templates and the practice management software for, you know, the basic procedures that the doctors do all the time? 

[00:17:18] Dr. Al Rizkalla: Templates are great. They save time, and if you take your time and use the templates properly, it's great. A lot of practitioners delegate the records and, and using templates to another member of the staff for, you know, time and, and so on. Documentation and records are the responsibility of the clinician. No doubts about it. Doesn't matter who wrote them, but they are the captain of the ship and whatever in documentation you using templates or not.

[00:17:52] Dr. Al Rizkalla: If you use a template and I, I'll tell you a case that I'm dealing with right now where the template is used and, um, they cemented the bridge and on there the template says there is cementation of bridge , RelayX and, and Unicem is used and both of them are in the templates. Somebody didn't look at the record. Every entry has to be the unique encounter with this particular patient. So, templates are great, but you got to read them, make sure they are correct and sign properly. If there is a mistake, document why we are making a mistake. Put in this entry here is amendment because the other entry and explain what it is that you're correcting.

[00:18:41] Karen Wood: Okay, and let's discuss medical history, paperwork. It's been my experience that some patients give limited medical history information or don't disclose over the counter medications or vitamins they use regular as they see this is just a dentist visit. What do you suggest for reviewing medical history to make sure you're uncovering necessary information the patient maybe didn't feel that they needed to disclose, and maybe some examples on when to probe further.

[00:19:05] Dr. Al Rizkalla: Uh, medical history, one of the most important things these days, I mean, I gotta tell you. It's a huge and important steps in, in risk management. Today, people are living longer, taking more medication. I mean, every week there's a new medication that that's being introduced, you know. You gotta pay attention to medical history and document it properly. I mean, you have a patient that's 5'4", 300 pounds, 60 years old, and they check no to everything. I'm, I'm going to ask questions. And when you ask questions, you generate more answers. We all got this lesson in dental school, but we need to remember, especially in a busy practice, you know. You wanna be sitting at eye level with the patients and your body language needs to show the patient that you're interested in what they say and providing safe space for them. If somebody's taking, for example, Lexapro and, and Prozac and whatever for some, medical reason and maybe they don't think it's important to disclose this to the, to the dentist. You want to go over these things and let them know that yeah, this is a safe space. We're not just treating the mouth; the mouth is connected to the rest of the body. And we need to see all of this and talk about this. And by the way, this is a great time for risk identification. You know, as you carry on a conversation with the patient, you can see if this is a good indicator of, you know, of the future dentist to patient relationship and make a decision on that.

[00:20:35] Dr. Al Rizkalla: Yeah, medical history is so important and, another thing that this drives me crazy, you know, when you update the medical history. I don't like the N slash C no change. No, that's not enough. You want to ask the patient questions. You wanna say things like, have you had any doctor visits since last time you were here?

[00:20:58] Dr. Al Rizkalla: Let's go over the current list of medications and supplements that you're taking. Have you had any hospital visits since you were here last? Have you had any imaging since last time you were, you are here and document all of this. 

[00:21:13] Karen Wood: So, what if they tell you that they had a knee replacement six months ago? It's a new patient. When you're looking for that kind of documentation for if there's gonna be antibiotics needed before dental treatment, and you have to confirm that with orthopedic surgeon, I'm, I'm assuming. Do you have to have that in writing or can it, can be documented from over the phone.

[00:21:34] Dr. Al Rizkalla: I would prefer to have it in writing. You know, you have documentation if you happen to have a phone call, document who you spoke with and what time. But I prefer to have it in writing and especially with knee replacement. I want the orthopedic surgeon involved. Because orthopedic surgeons, yeah, the American Medical Association says you don't need to pre-medicate. But knee surgeons, some of them, they want the patient premedicated for the rest of their life. My wife's is one of them, her orthopedic surgeon, and I had a discussion with him about this. I had a, a heated discussion about that, but he said, I don't care. I want her premedicated with antibiotics before dental treatment for the rest of her lives.

[00:22:14] Dr. Al Rizkalla: I actually got that and put it in her chart, and I said, I need this, and, and by the way, would you please call in the prescription yourself? Whatever you want her on. 

[00:22:26] Karen Wood: Speaking about, you know, specialists and documentation, let's talk about when the dentist refers to a specialist and we can use an endo referral as an example. What should be in the chart about the decision to refer and what should be on the referral slip send to the endodontist? 

[00:22:44] Dr. Al Rizkalla: Another excellent question. So, specialists in general. They can be your allies, you know but you need to know when to refer and when not to refer.

[00:22:56] Dr. Al Rizkalla: What do I mean by that? When to refer? Meaning, I know that I'm gonna practice within the limits of my ability. If I don't have experience taking impact the third molars. I'm not gonna begin doing surgery. I'm gonna send it to the oral surgeon. If I see calcified canal on an elderly patient, and, and the canal is not clear, I'm not gonna start. You don't want to refer to specialists only when you're in trouble. That's not good practice. And the other thing, you also have to exercise judgment. You know, and, and this goes into my second point. You are the quarterback the specialist that can be your biggest ally. They need to know your ethical and competent behavior.

[00:23:39] Dr. Al Rizkalla: So, you have a tooth that has a vertical fracture that's visible on the x-ray. Then you send it to the endodontist say, can you save this? I mean, this doesn't speak well. Um, you want to communicate specifically what you want the specialist to do. Not just say, you know, please evaluate or something like that.

[00:24:00] Dr. Al Rizkalla: You, you want the periodontist to do crown lengthening and, and you have a tooth that, that has a hopeless prognosis that, that's not good referrals. What do you want on the documentation, on the referral form, and the patient needs to understand this. I am going for X, Y, Z. Now what comes back from the specialist? If something that they cannot do or, or what have you, that's another story. But you have to have enough specificity in the referral form that this is what you want 'em to do. And you wanna obviously document everything. A copy of this goes in, scanned and goes in the chart, and a copy is given to the patient.

[00:24:43] Dr. Al Rizkalla: And also, in any communication with the specialist, let's say you're doing endo on a patient, and something happens, and you stop in the middle of the procedure, and you go make a phone call. You wanna document this phone call and whatever advice you have given, you know, let's say you're doing, uh, endo on number 30 and you may have irrigated a little too much with hypochlorite.

[00:25:04] Dr. Al Rizkalla: And, and the patient started feeling something and you get scared, and you stop, and you go call your friend endodontist and say, oh, what am I gonna do? I says, well, at least, you know go irrigate it now with some local anesthetic. And you go do that. Well, you wanna document this conversation and this is the advice, I'm just using this as an example, you know. Anyway, go ahead. I keep rallying.

[00:25:28] Karen Wood: No, we can stay, we could stay in the weeds all day long. But, maybe let's go big picture for a minute and you can tell us what the most common claims that you find are being made against dentists. 

[00:25:40] Dr. Al Rizkalla: Well, let me tell you one thing. I think I mentioned this earlier. Regardless of the claim and dissatisfaction, a lot of it starts from finances. That's what instigate this. Whether there's a billing issue or whatever, then you have a claim. But as far as the, the severity of the claim, sedation is a big one. Third molar extractions, uh, by general dentist, I mean, this is from the National Advisory Council with third molar extractions and, and temporary or permanent paraesthesia. Almost 80% is due to general dentist practicing outside their scope of practice.

[00:26:20] Dr. Al Rizkalla: Sedation, not following the proper recommendation or the proper training. Making sure you monitor the patient, and you have all the equipment, and you have the right number of staff, trained staff the right postoperative instructions. And this is a big one for me personally, is the all-on-4 what they call all-on-X. And I think I; I wrote an article in the VDA Journal about that. You wanna make sure that you're selecting the patient properly. Doing things, um, you know, aesthetics. That's another, frequent thing. And, and you know, you, you see veneers being placed in, in a patient with periodontal disease or improperly done veneers. Yeah, those are common things. 

[00:27:10] Karen Wood: Okay. Let's go back to something that I mentioned in the opening about resources that are available for the clients of R.K. Tongue that used Dentist's Choice for their malpractice insurance. I saw on their website a couple of sample letters to use for dismissing patients. One was for non-compliance and another for not being able to reach a patient of record. Let's start with the patient that the front office has left messages for that has some minor outstanding treatment or is pretty overdue for a hygiene visit. And you know, an office manager, they're gonna wanna make sure that the active patient count is as accurate as possible for, for many reasons. And you've documented all the attempts to contact the patient in their chart. Tell me about the process for properly marking a patient inactive.

[00:27:51] Dr. Al Rizkalla: Well, let me first compliment you by saying that you documented all the attempt to reach the patient, because that's one thing that I see a lot is, lack of documentation for missed appointments or attempts to reach the patient. First of all, when you're ready to dismiss a patient, it, it's a sensitive process. And what I say to everybody is included in your office policy at the very beginning during the intake process. The patient is new and you're talking already about this missing patient? Yes, because I just planted the seed in their mind. So, if things go south, at some point we have a clear office policy. The patient is aware of it. And also, as you're discussing these office policy, is the patient gonna play by your rules or not? This is, again, when you embark on treatment and accept the patient, they need to understand that you have a policy and if they're playing by your rules or not, it's time to decide early on.

[00:28:50] Dr. Al Rizkalla: You know, it's a sensitive and a delicate process and it has, you know legal implication, patient abandonment, and so on. And you gotta follow the proper process. So, before you take any steps, like you said, you wanna review the records, you wanna make sure that you have entries about the no-shows and everything else on your attempts to reach out.

[00:29:09] Dr. Al Rizkalla: If we are focusing only on the patient that has a little bit of treatment, and you attempted to reach them. You want to document this, and you send a letter, you know, we've attempted to reach you so many times and, and you send a letter and, and I usually would say, you send it, one is certified, would you return receipt requested? And one just regular. So, you cover both bases. 

[00:29:32] Karen Wood: So, if you have the patient that. Isn't gonna play by your rules, or let's say they need, um, medical clearance, or maybe they were referred to a periodontist for treatment prior to completing a restorative treatment plan. What is the responsibility of the dentist to follow up with that patient? How do you best document it and how to ultimately dismiss the patient if it's necessary without it being considered abandonment? 

[00:29:54] Dr. Al Rizkalla: Well, you you referred the patient, and the patient is not following your treatment recommendations, and you attempted, and you documented how you attempted, you know, whether you tried to reach them or you brought 'em in, or you had a conversation. If there is such documentation, then dismissing the patient for not following your treatment recommendation is a very valid reason. 

[00:30:19] Karen Wood: So, if you can't reach the patient, should you reach out to the specialist and find out what they have documented for that type of contact? 

[00:30:26] Dr. Al Rizkalla: It doesn't hurt. Absolutely. It doesn't hurt. And, and, and you document that this is what you did. I mean, sometimes what you just said is very valid, because let's say the general dentist refer 'em to the endodontist and they go to the endodontist, and while they're at the endodontist, they say, you know what? I don't want to go back to this general dentist. Can you refer me somewhere else? We'll leave it at that. But they decide not to contact you anymore. Then you call that endodontist, like you just said, and you find out what's happening. And if they came and they got the treatment done, but then later on they decided not to come back to you. Again. Documentation, you document every single step and at some point, you send that letter like we have and, uh, the simple letters and send it. Yeah, very much so. 

[00:31:16] Karen Wood: I'm learning a lot 'cause a lot of these things I'm throwing out to you are things I've either read or experienced, so. So, let's say that I'm an office manager right now. I'm listening to this podcast, and I'm enlightened by the information and this conversation and realize that maybe we need to tighten up some of our policies on patient dismissal, do better at documentation or question anything else that you and I have discussed that gives 'em reason to pause and realize that there's room for improvement.

[00:31:41] Karen Wood: If the dentist is a client with Dentist's Choice, can the office manager reach out proactively and speak with the risk management specialist for advice? Or is that limited to the dentist 'cause they're the policyholder? 

[00:31:51] Dr. Al Rizkalla: No. The office manager can call, and it happens all the time. And and we give advice if the insured and, yeah. Absolutely. And it's a safe space. You know that there's no, uh, condemnation, there's no, um. Record. Oh, well, there are records, but it doesn't affect the the standing of the insured. This is a safe space where we keep record just to, so we know that we return the call, and we know that we're on top of it but does not affect anything else. This is a safe, confidential place where you can call with questions, and the earlier you call, the better it is. You don't wanna wait too long, and then you call when things have already progressed because then you're in a weaker position.

[00:32:40] Karen Wood: I think you and I could continue this discussion for hours. I'm not sure that we would retain a lot of listeners for that amount of time, but it's an important topic to discuss and to give advice that helps our members be more prepared and inform some on how to use their malpractice insurance to help avoid claims and be best prepared should that horrible position arise where they have to defend themselves against a claim.

[00:33:03] Karen Wood: And this is just one small avenue for education. There are more resources on the Dentist's Choice website. And dentists that are insured through Dentist's Choice have annual education with CE credits available to 'em, correct? 

[00:33:14] Dr. Al Rizkalla: Yes. Yes. And also, if it case that's not clinical, it goes to an attorney, very competent attorney, very competent risk managers. Absolutely. 

[00:33:25] Karen Wood: And on that, you know, that that annual CE that's available, does that provide a discount to them at all? 

[00:33:30] Dr. Al Rizkalla: It does. I don't know how much, but it does. 

[00:33:33] Karen Wood: Okay. And would the office manager be able to participate in that education? 

[00:33:40] Dr. Al Rizkalla: Absolutely. And we encourage it. We encourage office manager and staff because they are the ones that interact and interface with the patients. All team members have a significant impact on interaction with patient and the dentist-patient relationship.

[00:33:53] Karen Wood: I'm glad you said that. I think maybe 'cause I was an office manager and enjoyed being one, people hear me preaching about engaging with the office manager, but I think it's important that, you empower your, your team to support you. And a lot of this information they don't have access to.

[00:34:12] Dr. Al Rizkalla: I can't tell you how important it is to, to have the right people and train them properly, just like you said. 

[00:34:18] Karen Wood: I'm gonna put you on the spot, Dr. Rizkalla, and ask you to give VDA members a take home message on this very important topic.

[00:34:27] Dr. Al Rizkalla: My take home message would be number one is keep with advances in our profession and, and deliver evidence-based care. Stay within your lane. Don't exceed your level ability, and know when to refer to a specialist. Document, documents, and of course, hire the right individuals and provide thorough training on regular basis. On regular basis, that's important. And finally, treat your patients as you would want to be treated.

[00:34:59] Karen Wood: That is truly sound advice. I would love to thank you, Dr. Rizkalla, for your expertise and guidance, and I'm positive this was helpful and thought provoking for our members. Um, we'll have contact information for R.K. Tongue, Dentist's Choice, malpractice and office insurance, and for Dr. Rizkalla, the head of risk management. That'll all be in the show notes.

[00:35:18] Karen Wood: We will also include direct contact info for Mike Urbanik with our R.K. Tongue 'cause he would be the best person to reach out to with general questions about malpractice insurance policies.

[00:35:28] Karen Wood: Please like, subscribe, rate, and share this podcast. Let us know if you have any suggestions for future topics as our goal is to bring relevant and helpful content to VDA members and their teams.

[00:35:38] Karen Wood: Thank you for listening and we look forward to having you return for the next episode of The Fulcrum.