50 Lashes by the GDC – Time for Change at the GDC?

From Volume 47, Issue 1, January 2020 | Pages 7-12

Authors

Conor O'Malley

BDS MSc MFGDP MGDS FFGDP

Articles by Conor O'Malley

Article

Conor O'Malley

I graduated from Glasgow University in 1995 and after a VT year in Maryhill, in 1996, I joined a large family practice with nine surgeries in Hamilton, just 12 miles south-east of Glasgow. The practice was established in the 1930s and most of our patients had been with us for many years.

I was lucky, as the older partners encouraged myself and my two fellow associates to further our education. We took turns and each went back to Glasgow Dental School and did a Masters Degree run by Professor Trevor Burke and Dr Crawford Bain. It was hard work but great fun. We got a good education, learned new skills and made life-long friends.

We went back to Hamilton and started looking after the patients to the best of our abilities. The older partners retired, the younger guys took over. Over the years we refurbished the practice, went fully computerized, moved to the ground floor, went digital and built a dental laboratory in the basement. Of course, not everything worked. We had our failures, that is part and parcel of the job. When they happened, we managed them by saying sorry to the patient, reassuring them that we were trying our best and giving a full refund of any monies paid – no debate. Patients knew we were trying our best and were happy with this. We realized we learned more from the failures than from the successes.

GDC Fitness to Practice Investigations were something that went on elsewhere. They happened to other dentists – we read about them in the GDC Gazette. We whispered to each other when a local dentist was involved. It was not something that happened to us. We were conscientious and caring dentists.

New patient

Traditionally, our existing patient base refers our new patients to us. As a rule of thumb, if the referring patient is nice, the friend or family member is cut from a similar cloth. It's like a vetting system for new patients. We kind of know what we are getting in advance.

In recent years, we set up a practice website and it does attract some new patients (though not many) who have no connection with the practice. For such patients, we don't have the benefit of a referring patient to tell us about them. We get unknowns!

One such elderly lady (MB) showed up in my surgery in March 2014. She travelled out from Glasgow to the practice.

  • She presented with 6 lower anterior teeth, 5 of which were periodontally involved (grade 3 mobility) and an upper denture (Figure 1);
  • She requested that her lower teeth be removed and an implant-retained lower bridge placed;
  • We removed the teeth and placed 5 lower implants between the mental foramina in June 2014;
  • After uncovering the implants in September 2014, we fitted a 10-unit bridge with temporary cement in October 2014;
  • We made a new upper denture in December 2014;
  • I modified the porcelain on the lower implant bridge at the patient's request in February 2015 as she didn't like the pink porcelain;
  • The bridge debonded in September 2015. It was recemented with Poly F® (Figure 2);
  • 39 appointments over 18 months, 4 appointments cancelled, 3 by the practice and 1 by the patient.
  • Figure 1. (a, b) Pre-operative views.
    Figure 2. (a, b) Post-operative views.

    During treatment, a few unusual things came to light about the patient which were not apparent at the start.

  • She was estranged from the rest of her family;
  • She would arrive hours before her appointment to chat to the reception staff;
  • She gave several staff members presents at Christmas 2014;
  • When we signed her up on our DPAS maintenance scheme she became very angry as she considered that they started the monthly direct debit a month early (which they didn't) (May 2015);
  • She was shouting down the phone to the same receptionist to whom she had given Christmas presents a few months previously;
  • She requested that no further appointments be made (May 2015);
  • The bridge, which was cemented with temporary cement, debonded in September 2015 and again she phoned, shouting down the phone to the reception staff;
  • She accused us of:
  • – Not making any follow-up appointments for her;
  • – Not telling her the bridge was cemented with temporary cement;
  • I reminded her that it was cemented with temporary cement and we had taken the bridge out the previous November and February for modification. I also reminded her that she had refused any further follow-up appointments in May 2015. She accused me of lying. She was visibly shaking with rage.
  • At this point I suspected that this elderly lady was not recollecting the detail of the appointments or the treatment and had become increasingly angry and aggressive towards both our reception staff and me over the last 5 months.

    She left the practice saying she wanted no further appointments. The treatment was carried out to a satisfactory standard, so we wished her well.

    Complaint

    It came as no surprise when the patient sent me a photocopy of a complaint that was sent to the Dental Complaints Service (DCS).

    However, what did surprise me was what she accused me of (this is taken straight from the DCS Enquiry sheet):

  • Extracting her teeth with excessive force which caused her cellulitis in her FEET;
  • Not prescribing correctly, she accused me of prescribing flucloxicillin for her implant surgery;
  • Extra expenditure on unnecessary upper and lower dentures;
  • Making her a substandard denture in our new practice lab;
  • Frequently cancelling her appointments for my holidays, and trip to the USA for the Chicago Mid-Winter Meeting;
  • Seeing her during my lunchtimes;
  • Cleaning out our dirty downstairs basement before one of her appointments;
  • Not contacting her for 20 weeks;
  • Giving her a kidney infection by asking her to swallow the water during the scaling of her abutments;
  • Bruising her face when I recemented the implant-retained bridge;
  • Not listening to her re the implants she wanted and ‘going my own way'.
  • When I read this, I was in a state of shock and was incredulous!!! She had never mentioned excessive force at any stage. The teeth which were extracted had grade 3 mobility. I remembered her having cellulitis during the treatment, but it was in her feet!! It had nothing to do with my treatment. I have never prescribed flucloxicillin in my life. We gave her amoxicillin for the implants. The flucloxicillin was probably prescribed by her GP for her feet. The dentures (which we gave her FOC) were not made in our new basement lab as we only do crowns and bridges inhouse. They were made by the local denture technician of 30 years' experience. A kidney infection from a scaling!! Come on! We had only cancelled 3 appointments out of 39 (because labwork wasn't back; one she had cancelled). She had told us not to make her any more appointments. Bruising on her face from recementing the bridge, surely this isn't even possible. She described my dental treatment as abusive????

    I had mixed feelings. On one hand I was mortified that I had failed to meet this elderly lady's expectations. I felt like I had failed in my duty of care, despite trying my very best.

    On the other hand, the complaint looked ridiculous. Surely this was obvious to anyone who read it. Even worse, it looked vindictive as well. This was a real attack on my patient care, my character and me. None of these issues was raised at any stage in the previous 18 months.

    In my 20 years of practice I had never previously found myself in this position. I contacted the MDDUS, got an advisor appointed, sent her all the patient notes and sat back to see what would happen.

    DCS passing case straight to GDC?

    Then on the 18 January 2016, I was informed that the case was passed on to the GDC for Fitness to Practice Investigation. I was flabbergasted that the DCS would pass this case on without even giving me right of reply. What is the point of the DCS if this is what they do?

    My inadequate notes!!!!!

    It was the first time in my 20 years of practice that I had to sit down and forensically look at my notes for a case from start to finish. I quickly realized that they were awful! I actually had forgotten to write notes on four appointments. The notes I had written were, at best, sparse. Worst of all, my initial examination notes were missing. I definitely wrote some but, as I have done before with Software of Excellence, I ticked the box but had not followed them through. Then, when the patient chose the implant bridge option rather than the denture/locator option, my nurse deleted them when she deleted denture/locator treatment plan – my fault not hers. I knew at this point that this was not good.

    Thankfully, I had pre-op/mid treatment/post-op pictures, signed consent forms, radiographs, study/treatment models and lab slips.

    Fitness to practice investigation

    Even writing this today is difficult: mortifying for someone who tries hard to be a conscientious professional. I had to send everything to the GDC at Wimpole Street by the 1st February 2016.

    Thankfully the Clinical Assessor who actually examined MB in person said:

  • The provision of care provided in regard to the extractions and the placement and the restoration of implants did not fall below the standard reasonably expected of a dentist working within the same discipline;
  • The patient's concerns re appointments being cancelled or rescheduled, whilst being inconvenient, did not affect the overall standard of care.
  • So, although the treatment was considered to be of adequate standard, they considered that there were still sufficient grounds for the allegation that my fitness to practice was impaired to stand. The summary of allegations read:

  • Not carrying out sufficient diagnostic assessments;
  • Not carrying out sufficient pre-treatment investigations;
  • Not adequately explaining the treatment plan to the patient;
  • Not providing the patient with all treatment options;
  • Not discussing the full risks and benefits of the proposed treatment;
  • Your radiographic practice;
  • Your antibiotic practice;
  • Using excessive force during treatment;
  • You failed to maintain adequate standard of record keeping;
  • You failed to obtain informed consent.
  • This had added several extras to the patient's initial complaint. What was going on? This appeared to be growing legs!

    GDC warning for 3 months

    I almost got referred to a full Practice Committee Investigation for this case. I got to the penultimate stage, the Investigation committee. This I considered ridiculous, considering that MB's initial complaint was so ludicrous.

    Thankfully, they decided there was no real prospect of ‘my ongoing fitness to practise being impaired' and the case was closed with a warning (Figure 3).

    Figure 3. Stages of the fitness to practise process.

    The following warning was published with my name on the GDC website:

    **The warning is to be published from this point.**

    The Investigating Committee considered allegations in relation to the Registrant's standard of care, record keeping and informed consent. The Committee considered that there is a real prospect of most of these factual allegations being found proved, and that the Registrant's actions may amount to misconduct.

    The Committee also determined, however, that there was no real prospect of the Registrant's ongoing fitness to practise being found to be impaired as a result of these allegations and it was proportionate to close this matter.

    The Committee has had regard to the GDC's Standards for the Dental Team (September 2013) including paragraph 3.1 which states that ‘You must obtain valid consent before starting treatment, explaining all the relevant options and the possible costs' and paragraph 4.1 which states that ‘You must make and keep contemporaneous, complete and accurate patient records'. The Committee considered that the Registrant's conduct amounted to a departure from this Guidance and that it is necessary to issue a warning to the Registrant concerning his future conduct. Publication of this warning is necessary to declare and uphold proper standards of behaviour and conduct, and maintain public confidence in the profession.

    The Committee therefore formally warns the Registrant that:

  • – Failure to obtain and record informed consent can have serious effects on the individual patient, and on the wider trust and public confidence in the profession. The Registrant must ensure that he obtains full, informed consent prior to carrying out any procedures, and this should be fully documented. The Registrant is reminded that this warning will form part of his Fitness to Practise history, even after it is no longer published, and may need to be disclosed as required.
  • On reflection

    I look back at the whole episode now and realize how traumatic those few years were for me. It took me quite a while before I could reflect on it in a rational manner. I sat down to write this on several occasions but promptly stood up again. I simply wasn't ready or able. The following are nine reflective thoughts.

    1. The patient being sold short by DCS. No local resolution

    The patient obviously had her own issues. I now realize that if you come across a patient who decides to put you in the crosshairs, you are in trouble. And my notes were simply not good enough to protect me.

    However, in her initial complaint to the DCS, her preferred outcome was to have the work independently assessed and for me to pay for any reparations. I was more than happy to do that. If she were directed back to the practice, we would have gladly given her all her money back and arranged for someone local to make good any of her concerns.

    Instead, the DCS directed her complaint straight to the GDC, bypassing any possibility of local resolution and incurring far more cost for the GDC. And ultimately the patient received no recompense.

    The patient's request was ignored. No common sense was applied.

    2. Stigma

    There is of course a stigma involved with having a Fitness to Practice Investigation. Dentists simply do not talk about it. They are embarrassed! They often just want to put it behind them and move on.

    This was my initial reaction to it. However, after speaking to a few colleagues and, in particular, Colin Campbell, who has been very open about his own FtoP investigation, it made me realize the importance of sharing my experiences.

    It is helpful for colleagues who find themselves in similar situations to know what to expect. It is important to share our failures and near misses so that we can all learn.

    3. No dissemination of GDC required standards

    Prior to the case, I never knew that I had to bespoke my consent form. No one had told me this previously, and I do over 50 hours of verifiable CPD per year.

    Also, my radiographic reports were only one or two words, I only passed comment on pathology. I didn't realize that it needed to be an opus commenting on all the normal appearances as well. I still think that this is a ridiculous standard. There is no mention of this in the joint FGDP/Royal College of Radiologists Radiographic Guidelines. I was referred to the original NRPB document from 1998.

    I also never knew that hopes and aspirations had to be included in the examination.

    I had to get a Fitness to Practice Investigation in order to learn what standard of record keeping they were looking for and the GDC's subjective interpretation of these standards. And they absolutely hammer you if you do not meet their interpretation of the standard.

    4. GDC blame culture

    The GDC gave me a public warning for my record keeping (in particular my reporting on radiographs) and my consent process, none of which did the patient complain about. If it is meant to teach the registrant a lesson, it is draconian and out-dated. Public humiliation is the GDC's modus operandi. It belongs in the Victorian era. It is the regulatory equivalent of 50 lashes to an innocent person. I would suggest that this is not fit for purpose in modern healthcare. It stigmatizes and traumatizes the Registrant.

    Furthermore, I had no follow-up from the GDC since the flogging. I was just sent back to the trenches with my lashes as warning to myself and others not to do it again. No support mechanisms in place, no follow-up to make sure that systems are still in place to prevent a repeat performance. There was also no proper feedback mechanism for the Registrant as to how he/she found the whole process.

    I appreciate that the GDC is there to protect the public, but it also owes some duty of care to its Registrants, who pay for the whole process.

    5. Second victim

    I was outwardly keeping a brave face on all of this. I kept telling myself that the treatment had worked and that the patient's list of complaints were verging on the ridiculous. Surely common sense would prevail.

    However, in reality I found myself barely even able to read the GDC correspondence. Each piece of paper carried an electric shock. I was pretending that it wasn't affecting me. I was going to work and still treating patients but, in reality, I wasn't sleeping, and I was in bits.

    Once it was over, I had no follow-up from the GDC or my defence organization. I was given no support or information on how to deal with the whole process or how I was to learn from this.

    My method of coping was to overload myself with work and to start a PhD to try to prove to myself that I wasn't a bad dentist. It all ended in tears in 2017 when I was diagnosed with burn-out and had to abandon my PhD and take 2 months off work. I then got some counselling.

    To be honest, I should have done it after the GDC ruling but I was pretending that it wasn't affecting me. No one advised me that it would be a good idea.

    I wish someone had told me:

  • That I would be traumatized by the process;
  • Not to do anything rash in the immediate aftermath (ie like starting a PhD);
  • To get some counselling just after the verdict.
  • 6. Defence Union offering no defence

    I don't want to sound ungrateful, as I know all the hard work my advisor, who I really got on with, put into the case. But in hindsight, to call what they did on my behalf a defence is a stretch of the English language. They bow down to the GDC and basically put Registrant over a barrel and tell them to take it. They are complicit with the entire process of the blame culture that the GDC operates.

    At no stage did they challenge anything such as:

  • The ridiculous claims made by the patient, such as assaulting the patient during extractions, kidney infection from a scaling, cellulitis in her feet, giving her flucloxicillin etc;
  • The DCS passing the case to the GDC without giving me right of reply;
  • The GDC adding their list of extras to the charge sheet;
  • Saying I failed to obtain informed consent when I had a signed consent form and had given the patient pictures of the different outcomes;
  • The verdict – they told me not to appeal. Surely they must have some insight into the emotional toll it takes on the Registrant? Again, once the case was over they signed me off, job done.
  • 7. The perfect storm

    It did make me think about what colleagues who had/are having/will have GDC complaints.

    At least in this case the treatment worked. Over 20 years in practice I have had many things that didn't work: cases where implants have failed. Thankfully, they were reasonable patients who understand that we are doing very complicated work often in compromised situations.

    Imagine if this patient's treatment had not worked; if her implants had failed. It would have been the perfect storm. I probably would have taken more care with the patient records, but the whole process would have been twice as traumatic.

    And I never had a full FtoP hearing. I cannot imagine what that must be like.

    8. Giving up dentistry

    For a period towards the end of 2016, and the start of 2017, I seriously considered what was the point of being a dentist if one patient can nearly ruin you. I felt that I was judged by the GDC on one case, or more specifically on the record keeping for one case, rather than the treatment provided. Twenty-five years of good patient care was not considered.

    All I could think of was that I could not go through that again. The problem was that dentistry was all I could do.

    I was lucky to have my family, partners and friends to fall back on to help me through this difficult period.

    9. Black Box Thinking (Figure 4)

    An older and wiser friend and colleague gave me a book to read. Black Box Thinking by Matthew Syed. I found it brilliant. It made sense of the whole process.

    Figure 4.

    I learned terms such as ‘blame culture' and ‘just culture'. I learned that the medical profession has a history of operating a blame culture. I realized that healthcare providers make errors in busy environments when they are working hard, under pressure and trying their best. Everyone makes these errors but most do not come to light. These errors should be shared in a non-threatening environment, so that everyone can learn from them.

    I learned the concept of the second victim in the process of overly harsh regulation.

    I felt solidarity and anger when I read about the story of how the GMC had struck off Dr Bawa Garba (Figure 5) in 2017 when they actually used her honest reflective commentary as testimony against her in her GMC Fitness to Practice Hearing. I could only imagine what that young doctor must have gone through during the whole process. I celebrated, like we all did, when the GMC reversed that decision in 2018.

    Figure 5. Dr Bawa Garba.

    Change for the GDC?

    There is no doubt in my mind that the GDC has to change. The damage that it is doing to the profession is considerable. My concern is that it does not seen to be aware of this. It is completely oblivious to the effects of its heavy-handed regulation.

    I read the 2017 GDC publication Shifting the Shifting the Balancea better fairer system of dental regulation with great interest. It talks about right touch regulation and looking upstream to prevent problems happening. The irony being, of course, that the GDC does not have the ability to look upstream in its own four walls and lays the blame for everything at the door of the Registrants.

    As a profession, we have been too passive in letting the GDC run amok without holding them to account. We have been naïve thinking that, while we are busy working treating patients, they will always act in the best interest of both the profession as well as the patient.

    However, in the last few years there has been a groundswell of opinion questioning the GDC. I first remember Stephen Hancock, the editor of the BDJ, highlighting the effect of harsh regulation on the practicing patterns of a dentist in his 2014 BDJ Editorial ‘Defensive Dentistry.’1 Following on from that, Martin Kelleher's excellent Dental Update article in 2015 ‘…who will guard the guards?…’2 where he correctly calls out the GDC, questioning its ability to regulate appropriately. More recently, in 2018 Mark Bishop's BDJ article ‘The patient-dentist relationship and the future of dentistry’ calls for wholesale reform of the GDC.3

    This summer, Mark Bishop has just been elected to the Principal Executive Committee of the BDA with a mandate of bringing grassroot reform to the GDC.

    We as a profession are grateful to our colleagues for the stance that they are taking to make the GDC more accountable to the profession and I would encourage everyone to get behind Mark's cause.

    Conclusion

    To finish, I have always been of the opinion that, if you take it upon yourself to be critical of anything you should be prepared to make suggestions on how to improve whatever you feel is not working.

    So here is my tuppence worth:

    Suggestions for Improvement

  • The GDC adopting a Just Culture and:
  • Not hanging their registrants for one case;
  • More leniency on record keeping oversights, no-one's record keeping is 100%;
  • Feedback of standards to all dentists from the GDC;
  • Supporting the registrants through a complaint.
  • Local Resolution for Dental Complaints. It would be:
  • Much more cost-effective;
  • Quicker.
  • The Dental Complaints Service not passing a patient complaint straight to the GDC without giving the registrant right of reply;
  • A robust defence from the Defence Union
  • it is the least we should expect for the money we pay in indemnity fees.