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Treatment planning with integrity

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Treatment planning with integrity

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Bruce B. Baird, DDS

Editor's note: Part 1 of this series appeared in the March 2015 issue of DE.

In part one of this series, we discussed communication skills to improve relationships with our patients. In this installment, we'll dive deeper into treatment planning with integrity and-more importantly-the barriers that stand in our way.

Each day I receive emails or phone calls from dentists who express hesitation when it comes to treatment planning. If you're like me, in the early stages of my career I had great intentions but poor execution when it came to diagnosis. I hadn't found a systematic way to treatment plan and communicate my findings to patients without simply "blowing them out of the water." I fell victim to the scheduling trap of booking new patients in hygiene for a cleaning first. Along with a tight schedule, my fear of rejection kept me from presenting the best. My internal dialogue back then sounded something like this:

"If I share all that I see, the patient will want a second opinion, and we all know that every dentist treatment plans differently."

1. "My patients only want to do what insurance covers-why overwhelm them?"

2. "I'm not comfortable treating full-mouth cases yet."

3. "Let's just take care of the things that hurt or the things the patient asks for directly."

I don't believe I was alone in that type of thinking. In fact, it's more prevalent today than it was in the 1980s, which is when I broke these habits. I recently heard Gordon Christensen, DMD, speak out on the subject, saying that single-tooth dentistry has risen from 70% in 2008 to 90% in 2014. Are patients healthier? Or are we more afraid than ever to share the whole truth, perhaps just following "what insurance will pay for"?

As many of you know, I have no problem sharing my opinions. However, the opinions I have about diagnosis and treatment planning aren't just mine, they are backed by the ADA and the top researchers in our field.

Let's examine what the ADA Code of Ethics has to say about treatment planning with integrity. What we find are several ethical principles that apply directly to patient care. We learned this in dental school, and although the code is voluntarily applied to the profession, we accept to live up to this standard as part of ADA membership. The four pertinent ethics codes are:

1. Patient autonomy

2. Beneficence

3. Veracity

4. Nonmaleficence

Here is the ADA's description of each:

Patient autonomy [self-governance]

Under this principle, the dentist's primary obligations include involving patients in treatment decisions in a meaningful way, with due consideration being given to the patient's needs, desires, and abilities, and safeguarding the patient's privacy.

Beneficence [do good]

The most important aspect of this obligation is the competent and timely delivery of dental care within the bounds of clinical circumstances presented by the patient, with due consideration being given to the needs, desires, and values of the patient. The same ethical considerations apply whether the dentist engages in fee-for-service, managed care, or some other practice arrangement [. . .]

Veracity [truthfulness]

Under this principle, the dentist's primary obligations include respecting the position of trust inherent in the dentist-patient relationship, communicating truthfully and without deception, and maintaining intellectual integrity.

Nonmaleficence [do no harm]

Under this principle, the dentist's primary obligations include keeping knowledge and skills current, knowing one's own limitations and when to refer to a specialist or other professional, and knowing when and under what circumstances delegation of patient care to auxiliaries is appropriate.

My treatment planning philosophies radically changed more than 15 years ago when I attended a lecture on treatment planning based on risk factors by John Kois, DMD. Prior to this, my focus was on procedures. Today, I focus on best patient outcomes and prevention. Patients will often ask, "Hey, doc, can you fix this tooth?" I then say, "A better question is, can I fix it so it has a chance of lasting the rest of your life?"

Dr. Kois taught me how to evaluate periodontal risk, biomechanical risk, functional risk, and esthetic risk. I have added two additional risk factors: "physiologic risk" (to take into consideration obstructive sleep apnea) and "psycho risk" (to determine whether or not this is a patient I even want to treat).

During Dr. Kois's lecture, I had an epiphany. I had always felt that any treatment failures were my fault, not the patient's. Obviously (in my mind), my margins weren't good enough, or maybe the occlusion was off . . . and on and on. What a relief to know that I was not always at fault, and that oftentimes the patient's inherent risk factors or lifestyle choices were the cause of failure. What a liberating feeling to learn that "It's not my fault!" (Repeat that several times over the course of the next few days!)

The concept of treatment planning based on risk factors helped me develop a way of communicating that involves the patient in his or her treatment choices. The pressure to have 100% case acceptance was gone. My job was to become a trusted advisor, to help the patient understand, in the simplest terms possible, what I see, the consequences of treatment, and the consequences of delaying care. My role is to stay true to my training and best practices. The patient always remains in control of the timeline and how we work together to make it affordable.

I don't have a one-size-fits-all treatment plan or a daily goal of the number of crowns I need to diagnose. My goal is to start fresh with each patient, and to have the courage to tell patients what I see in a way that they can understand. (See the first article in this series for more detail on this point.)

Today's takeaway is this: Your professional code of ethics obligates you to involve patients in their health-care decisions. It says you will be truthful and complete in your diagnosis. In addition to keeping this in mind, there are several things I would encourage you to do:

1. Partner with a colleague who challenges your thinking. Compare cases and constantly ask, "Why?" or "What else could be done?"

2. Join a study club led by strong clinicians who will expand your diagnostic skills.

3. Become a master of influence, learning to connect with people on a genuine level. This may involve public speaking or communication courses, or bringing on a personal coach to help you discover the gaps.

Treatment planning with integrity means having the tough conversations, every day, even when you are rushed or distracted. It means having compassion for your patients and slowing down long enough to help them make great choices. Now that we've laid the foundation for why I treatment plan comprehensively, we'll move into more details about treatment planning by risk factors in the next installment.


Bruce B. Baird, DDS, has been named one of the nation's most productive dentists, and is the founding partner of Productive Dentist Academy, a national consulting firm providing in-office training, strategic business planning, and marketing services. In 2011 he began tackling the issue of access to care by founding Comprehensive Finance, which provides dentists the administrative support to extend patients' payment options. Email info@productivedentist.com to receive a complimentary practice assessment.

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