S6 E06: Ethics and Dental Dilemmas

[00:00:00] Ioannidou: What should we do if a patient puts you in a very uncomfortable or weird, unexpected, surprising situation? Or what if one of the team members raises a red flag?  

Hello everybody. I'm Dr. Effie Ioannidou.

[00:00:17] Wright: And I'm Dr. ArNelle Wright. Those are such good questions by the way, to open this show because I'm excited.

This is a fan favorite. Today we're gonna be exploring the ethics behind everyday sticky situations that we dental professionals face behind the scenes. So let's go ahead and dive in.

[00:00:39] Announcer: From the American Dental Association, this is Dental Sound Bites created for dentists by dentists. Ready? Let's dive right into real talk on dentistry's daily winds and sticky situations.

[00:00:56] Ioannidou: Hello everybody. We are back with one of our most popular episode themes. We are talking about sticky situations.

[00:01:06] Wright: Hey, hey. Yes, so the kind of sticky situations that don't often come with a clear playbook.

[00:01:12] Ioannidou: But we are so lucky. Our profession does have a code of ethics.

[00:01:18] Wright: Yes, it does.

[00:01:20] Ioannidou: Better have and, and this code of ethics gives us direction.

It gives us a framework and a path so we know how to move forward and. Even if sometimes situations are uncomfortable and unclear.

[00:01:36] Wright: Yes. So well, we're gonna go ahead and jump into the show today. We are joined by someone who knows this topic very, very well, and I'm so excited that he's joining us today because we haven't seen each other in a very long time.

So it's good to have this opportunity to connect and catch up. And today we have Dr. James Purvis, who's gonna help us navigate some ethical dilemmas that are shared by real dentists. And students. So welcome to the show, Dr. Pervis.

[00:02:05] Purvis: I cannot believe I get to see you via the screen. I miss that we haven't been able to see each other in person, Dr. Wright. But, um,

[00:02:10] Wright: I know.

[00:02:11] Purvis: I consider it a pleasure to be here and I'm looking forward to this conversation. Undoubtedly, when people talk about ethics and when we get a conversation like this going, people come to the room, love it. They love, love to hear these things. They wanna talk about these things, and there's never been a more important time than right now to share.

So let's go. I'm excited.

[00:02:30] Ioannidou: This is so great. So, James, tell us a little bit about yourself and how you got interested in the, um, ethics and the, the, the moral, uh, dimension of the dentistry and, um, you know, what brought you to this, uh, theme? I.

[00:02:46] Purvis: Certainly. So my, my grandfather was a dentist, uh, he's a dentist in the Navy, active duty and reserve all the way through the Korean War.

And he had a private practice after that. He practiced until he was probably 72 or three years old. And I remember as a kid, uh, hearing him talk about his experiences in dentistry and undoubtedly the stories that stuck with me the most were not his. Clinical situations, but certainly the ethical components of his practice, the relationships he had with his team, with his patients, and the things he learned and why he loved it so much.

And so when I got into dental school, I quickly found our local chapter and I went to Chapel Hill, the University of North Carolina at Chapel Hill, and we had a local chapter of what at that time was the Student Professionalism and Ethics Club, which was a. Sort of parceled out chapter based organization that ultimately became the Student Professionalism and Ethics Association, or sp a as we know it now, yes.

But at the time I was the president of the Chapel Hill chapter and there was a call, uh, mainly from some west coasters, uh, California. Utah, Nevada, they wanted to create a national organization. And so our dean at the time and our vice dean, who's now our Dean, Janet Gut Miller, she agreed to send me out there and I was honored to serve as the first national speaker of the house for SPE a back in 2000 and.

10 or 11 and ultimately, uh, get that chapter going and we turned it into a nationwide thing. And so when it came time to practice, I fell in love with the ethical things that make dentistry, dentistry, um, being a general dentist in Eastern North Carolina, if you practice around here long enough, you've gotta get creative.

It's highly relational. I work in a small town, you know, everyone. And ultimately the relationship, I mean, just before I, I hopped on this podcast, I had to literally jump off a patient that I had done a procedure on the day was calling me about something and I, I hopped on with her and she'll be seeing me first thing in the morning and who knows where that's gonna go, but.

Everything is ethics. And when I began involvement in organized dentistry at the ADA, I was blessed to become part of the new dentist committee. But I, I view it an equal, if not greater blessing, that it led me to cja, uh, which is an amazing council. And for those that might not know C j's, the Council on Ethics, bylaws and Judicial Affairs, and we'll get into more of what we do later.

Uh, but certainly it opened my eyes to the breadth of. Ethics and the need for ethics training and education, not only within the dental school community, but within the dental community itself. And so I love ethics. Um, these are the, these are the fun things to talk about. They're sticky, they're hard.

There are no right answers. There might be some wrong answers, but this is what it's all about. And I, I think that ethics facilitate. Conversations at levels that other topics may not quite get into. And I think it lends itself to good community and certainly good conversations. So looking forward to this today.

[00:05:39] Wright: We are so glad to have you. Wow, what an introduction. And I think you might've left something out, aren't you a podcast host? Can you talk about that while you're on the topic of cja? Just go ahead and talk about being a podcast host, what you all talk about. Talk about what CJA does, what it promotes.

Share with us a little bit more about that.

[00:06:00] Purvis: So certainly cja, it's, it is the easiest counsel in the ADA to remember what they do because the name is in the title. We are the Council on Ethics, bylaws and Judicial Affairs. Mm-hmm. So, ethics. We talk about ethics, we talk about all the different things in dentistry.

That are ethical. Uh, everything from AI insurance, um, claims, uh, malpractice, how we treat people. I mean, we, we talk about these things at our, at our meetings. Occasionally we'll issue advisory statements or we'll come out with things or we have PO policies and things that we agree on, but. For the most part, we're just discussing these things at the highest levels and bringing folks in from every background to discuss what they struggle with, um, what are situations and practice that they deal with.

And then as a council, talk about how organized dentistry, specifically the ADA, can serve members as they encounter these situations. Um, ethics bylaws. We love bylaws. Um, I love bylaws. I'm a me too. I'm a nerd. I could sit up at night and read all kinds of bylaws, but, you know, we look at the governing documents of the organization.

We look at the, the, the, the articles that define how we do things at the ADA. And occasionally there are times where those bylaws need to be updated or changed, or we need to do some things that make them more modern or current. And when that happens, CJA is often called on to look in there and at least provide opinions or even edit the bylaws and submit that to the house for approval.

And so, mm-hmm. C j's a great starting point for anyone that has interest in bylaws or would like to see bylaws changed or updated. And then judicial affairs, obviously the ADA has a code of ethics. All members are held to that code. And if there are already complaints or. Anything brought up in that regard, we can adjudicate at the highest level, ethics complaints and hopefully resolve them.

Um, and, and mediate and find ways to learn from these situations where all of our members can benefit. And so that's in a nutshell what CJA does. I was on the council, uh, for the last. Well, two years I just rolled off. They kept me out as a consultant for, for the podcast.

[00:08:06] Wright: Mm-hmm.

[00:08:07] Purvis: So I've had the pleasure of serving with cja as their podcast host for the last season of Dental Dilemmas.

Uh, before that was Dr. Alex Melian, who's another great host. Uh, we're not actively recording right now, but. All of the episodes are archived. You can find them under dental dilemmas. And again, that's the sija podcast. It's a, it's a really unique podcast. We bring in, uh, people from all varieties of practice, every practice modality you can think of, dental students, young dentist, more experienced dentists, a specialist, general dentist, you name it.

And we talk about everything and we view it through the lens of the ADA dental code of ethics. It is a great. Great time. I've loved my opportunity to have a small part of it, and so I would encourage anybody to look up dental dilemmas. Anna, take a look at the podcast.

[00:08:55] Wright: Mm-hmm.

[00:08:56] Purvis: That is cja in a very brief nutshell.

I could talk about cja all day. I'll spare you from it, but I enjoy it. It was an honor to serve on the council. Like I said, I still remain as a consultant and keep up with my sija friends often.

[00:09:09] Wright: Oh, good.

[00:09:09] Ioannidou: First of all, I do admire, uh, a, a set of codes. Uh, specifically when they have to do with ethics number one, because the word ethic is a Greek word, so as everything else.

So, you know, it's ethos. Right? So tell me a little bit in, you know, because in, in my mind, um. Uh, ethics. What is the code of ethics? I, I, I define it as a, a code of principles, moral principles that we have and we share as an organization. Am I right? Am I far from this?

[00:09:41] Purvis: Effie, you're, you're right on the money.

Um, it's, it's a code that we live by, and specifically in dentistry, it's a code that we practice by. It's how we treat others. Um, and the more I study ethics, and the more I get into them, the simpler that they become. If we are, at the end of the day, treating people like our family. Particularly the family that, that we like, um, or treating people the way that we wanna be treated.

Mm-hmm. Ultimately, you're gonna find yourself doing the right thing. Now, the ADA code of Ethics has five parts, and those within the sea of council, we, we really get to know, well, the first principle is justice. Um, and it is what it sounds like. It's just doing the right thing for everybody. Mm-hmm. Trying to make sure everybody, regardless of who they are.

What they look like, their background, any predetermining factor, they are treated with love and care and respect. Um, and that the care that we provide for them is to the utmost of our ability. There's veracity, which is the second principle, which is truthfulness, um, telling the truth. I've got a 5-year-old and I feel like when he comes home from preschool.

I'm using the code of ethics to resolve playground conflicts that he may have had. And it's, it's very simple, all the way from his playground up to my operatory. It's are, are we telling the truth? Are we sharing? Are we, are we giving back what we took? Are we being honest? Are we being forthcoming? Are we communicating?

So, um, justice and veracity are the first two, and then patient autonomy. Patients have the right to make their own decisions. We can guide them in that. We can share with them what we would do, and we can provide them all kinds of options. But ultimately, at the end of the day, that patient is responsible for their treatment decisions and ultimately they're the ones that we should allow to make those, uh, within reason and patient autonomy that.

It comes up more, at least in my opinion, than almost any of the other parts of the code of ethics, allowing our patients to make informed decisions, but making sure that they're the ones doing it. Mm-hmm. And this is very nuanced. It gets involved in, in insurance, um, things that we're allowed to do, things that we can code for, things that we shouldn't code for.

Yep. Uh, how much is this gonna reimburse us? What are we gonna get paid for this? How much is it gonna cost? Is that influencing our decision? It certainly shouldn't. So patient autonomy is, is enormous. And then the last two were kind of, they go hand in hand. You have beneficence, which is doing good for patients, and then non maleficence, or as my attorney friends make me say non malfeasance.

Mm-hmm. Which is basically doing, basically doing no, no wrong. And so those two. Are sort of the, um, the counterparts to each other, but they round out the code of ethics. So yes, to answer your question, Effie, it is so important to have a guiding light in a code of ethics. And even within the five different parts of our ADA code, they all go in hand.

These situations come up and on the Dental Dilemmas Podcast, we'd always say, well, which. Which part of the code does this pertain to? Well, it's all of them and some of them may be more pronounced than others, but

[00:12:40] Wright: mm-hmm.

[00:12:40] Purvis: In general, you can tease out something within the code in all aspects to help you as you're making these decisions every day.

[00:12:50] Wright: So good.

[00:12:50] Ioannidou: This is great and, and I think it's important for people to, you know, and, and in my mind to understand the distinction between the code of ethics and. And the law. Yeah. Right. Because many people are very confused by this. They're like, oh, why do we need code of ethics? We know what is legal, what is not legal?

Uh mm-hmm. You know, I wish life was that simple.

[00:13:12] Purvis: Absolutely. I mean, if, if something is legal, it doesn't necessarily make it right.

[00:13:16] Ioannidou: Right.

[00:13:17] Purvis: Or it, or it doesn't necessarily make it the correct thing to do. In that situation. Something may be very right to do, but in that situation, there might be something that's even more appropriate or, or more Right.

And this is why we love ethics.

[00:13:30] Ioannidou: No, I love it.

[00:13:31] Wright: I do too. I mean, so side note, you might not know this, and I don't know if you might not know this either, but I am a part of CJA here in my state, and so I too have such a love for code of ethics parliamentary procedure, and that love really started when I was an undergrad because I was parliamentarian of my sorority.

And once I started learning like about Robert's rules and all of those things, it just, you know, increased from there. So you show our Making Council of Ethics, bylaws, and judicial affairs look very, very good. And I admire you so much. So thanks so much for all the information you've shared.

[00:14:07] Ioannidou: Yeah. This is so great.

And, and be, we thought that, uh, it'll be nice and useful for our listeners to, to share some real life examples of how we apply the code of ethics, right? Yeah. In real life experiences. So we had some of our community members that. Jumped into sharing their sticky situation with us, and, uh, now having these examples.

It'll be interesting for us together with James to discuss how the code of ethics applies, uh, and, you know, analyze this from the ethics perspective. So why don't we do this and start with Dr. Connie Wang's story.

[00:14:46] Wright: Let's do it.

[00:14:47] Ioannidou: Let's do it.

[00:14:49] Wang: Hi guys. My name is Dr. Connie Wang. I'm a general dentist practicing right outside of Boston, Massachusetts, and I'm the podcast host for the podcast called Just a Quick Pinch, and I have a sticky situation for you guys to ask.

So this is a question that I know a lot of, especially new dentists face when they're starting practice, and that is how to talk to a brand new patient that you're meeting for the first time and. They left their beloved previous dentist, maybe their previous dentist retired, and you have to break some bad news to a patient that either the work that their previous dentist did has to be redone or that they have a lot of new things going on.

So personally, how I handle the situation all depends on the questions that I'm asking. I find it's really helpful when I'm meeting a new patient to just get on the same page and figure out what it is that they care about. And so to do so, I do have five questions that I really like to ask every new patient.

First question I like to ask, especially if I have to recommend a lot of new treatment, is, was this a surprise to you or did you know something was going on in your mouth? This question is just really helpful because it helps me figure out where they're at, and that way if they did know something was going on, it helps them accept some responsibility in the situation.

It makes the conversation easier, and I know how to approach it. If it was a surprise also, then I know how to handle it because I just gave someone some really bad news and they were really surprised. That's a feeling that we can all relate to and know how sticky that can be, right? So that's the first question.

The second question that I like to ask new patients is, what have you heard about this treatment before? This is also really helpful because what this tells me is what the patient really cares about. If someone keeps mentioning, oh, I've heard crowns cause pain and sensitivity, I go, bingo. That's what they're afraid of.

If someone tells me, I've heard crowns take multiple appointments and let, that tells me, oh, they don't want to take extra time off of work, things like that. The third helpful question that I like to ask patients whenever I'm meeting them for the first time, especially if I can tell that there is some type of resistance to the treatment I'm recommending, is I can tell this treatment is not jiving with you, right?

I can tell that you feel as though this is not the right choice for you. Can you explain why this might not be the right choice for you? I like it because one, it acknowledges that I see that someone's uncomfortable with what I'm presenting to them, right? It gets me on the same page. They feel heard and understood and seen, and it also just gives me so much more helpful information because a lot of times asking questions like, why is this not the right choice for you?

Really pulls out nuggets of information that you wouldn't have gotten otherwise. The fourth question that I like to ask patients whenever I'm getting to know them for the first time, and let's say I'm recommending something that's a little bit different than what their previous dentist would be recommending.

I like to ask them, okay, let's say we do it the way that you want. If this fails in one year, are you gonna be mad at me that we did this? Or are you gonna be happy that you got at least one year out of it? This is a great question to ask because it just brings people's walls down. I see people give a giggle or laugh and it just gets us back on the same page and humanizes the dentist almost.

Because it, it shows that, listen, I'm not trying to make things harder for you, but I don't want you to be mad at me in a year. I've had some really great conversations with patients and it goes either way regardless of what they answer. This question helps you build trust. And then the fifth and final question that I like to ask patients whenever I'm getting to know them for the first time.

At the very end, I like to ask, is there something that we didn't get to talk about today that I need to know about you? You'd be surprised how many nuggets of information that I actually get when I ask this because a lot of times people hold in something inside and then at the very end, once they feel like they've trusted you long enough, they feel like they can start to admit.

And to vent. And that's when you really get those golden nuggets of information. So those are the five questions that I try to ask patients whenever I'm meeting them for the first time. It helps build trust, it helps gets to the root of what's really bothering them, and it also just helps me get a better understanding of where they're coming from, who they are, and what treatment would best suit them.

So anyways, I'm interested to hear what you guys think the right way to handle these situations are.

[00:18:39] Wright: I think we are gonna have our guest share what your thoughts are from your expertise with CEBJA.

[00:18:44] Purvis: So she's hit the nail on the head. Uh, this is, this is something that happens every single day to dentist, young dentist, more experienced dentist, no matter where you are, how you practice, you're gonna run into this.

And, and it happens both ways. I mean, you, you can have a. A retiring dentist or someone who's just sort of been coasting along and managing a lot of conditions that might need to be proactively treated. And suddenly this patient's in your office and you see a a decade of managed neglect, for lack of a better term.

And then you can also see patients that come from another office where they have completely been. Uh, oversold and snowed over, and there has been way too much proactivity, not even proactivity, but things done that really don't even need to be done. And suddenly these patients are in your chair and they're looking to you as, as a source of trust, and it's a source of wisdom.

And they, they, they, they need someone. That can look at them and tell them exactly what it is that, that they need. And I love opportunities like this. Um, we get a lot of, uh, newer patients in our office that have moved from elsewhere. I practice in New Bern, North Carolina and New Bern is a retirement community on the coast.

And my average new patient is probably 62 years old. They've probably moved from another state and they've chosen to retire here. And so. It is not like I can just call their previous dentist and get some insight as to what they might be thinking. It's more of, I don't know who they used to see and in many cases I don't really know their, their dental history.

And so now they're here. I've taken the appropriate radiographs, I'm sitting down from them and their eyes are wide, and they're looking at me thinking, what is it that needs to be done here? Mm-hmm. This is where the code of ethics really comes in. Look at patient autonomy. You're gonna share all of your thoughts and your dreams and your ideas for this patient's smile.

But if you don't know their thoughts and their dreams and their ideas, you have done them an enormous disservice. The things that matter a heck of a lot to me might not matter at all to those patients. Um, and there might be cosmetic desires or health desires that they have that I might not even think of, and things that I need to make sure that I accommodate for that patient.

So always starting with figuring out what the patient's end goals are. Making sure that you're being truthful. The principle of veracity. If something is deficient, if there's something that needs to be addressed, talk to the patient about it. You don't have to throw anybody under the bus, but you can accurately and kindly convey to them what the current oral state is.

That they're dealing with. If there's a restoration that's deficient in some way, you don't have to throw up your arms at anger. You can simply say, look, here's here, here's a restoration. Let's look at the x-ray together. Look, there's a little area here at the margin that might not be fully closed, or there might be a little bit of decay.

That's for me here. I'm not happy with that. Let's, let's talk about how we can optimize this restoration or how we can maybe replace it and. There are ways you can go about that. And then certainly beneficence and non malfeasance, making sure you're doing good for that patient, and certainly making sure that you're not harming that patient.

And so I think the dentist that brought this up is incredibly wise in, in, in talking about this and bringing it to the forefront because every single practitioner, they're gonna deal with this.

[00:22:05] Wright: One way or another. Yeah.

[00:22:06] Purvis: Yeah. I mean, ArNelle, you see it, I see it. It's common. It's all over the place and the more honestly you can convey to that patient that you care about them, and that their health is your primary focus, and that you also wanna do that within the boundaries of their desires, their aesthetic, their cosmetic, their functional desires within reason. I think you've gone a long way with that patient and start with what can be a really good relationship.

[00:22:32] Ioannidou: Yeah.

[00:22:33] Wright: Yeah. I was gonna say, you know, the one thing that you said that also Dr. Wang said, in so many words; I was just gonna say, you should listen twice as much as you speak. And so asking those questions and then just waiting to hear, I feel like it, this never fails me in practice. Like the patients will literally lead me to where they're trying to go, and we will together, we'll come upon like where we need to start with that treatment or where we need to end. I'll understand their expectations. I'll understand, their past experience. I'll learn so much about them just by taking the time to listen to their story.

Now I know that, you know, we have to keep a schedule and things like that, but it's so important, especially with a new patient. And if there is another dentist, you know, that they're coming from or if they're getting second opinions, because that's a common thing that happens in this day and age. Patients, they tend to shop around.

So for me, I wanna learn as much about that past experience as possible so that I can talk you through; well actually, you know, it's not necessarily that they did the wrong thing. You know, I never try and say no, that the past, it is, that they sucked or that was trash. I just wanna learn more about the procedure, about the experience, and about what the next step is so that we can take those steps together.

[00:23:59] Ioannidou: And also the circumstances that past decisions were made. Right? It's really important to put everything into a context, and many times the patients are a very great source of this story.  We tend to, you know, you see this sometimes in dental school, you know, coming from dental education, I can say that sometimes you see this in dental schools, that students with a thought that the procedure is more important and the credit that to, to get this and be in the procedures rolling and getting the appropriate credit and moving from one year to the other.

They tend to be in a hurry in their communication with the patient. I remember those days I used to be a student and we had some priorities. But I think conveying this and training students like this with the priority of listening to the patient and building this trust, what you're talking about, I think it's really very important.

[00:24:55] Purvis: Effie, you hit on something that is incredible. And you, you alluded to it without saying it, but it's; dentistry is not procedural, it's relational.

[00:25:04] Ioannidou: That's right.

[00:25:05] Purvis: We are not technicians that do procedures.

[00:25:08] Wright: Mm-hmm.

[00:25:09] Purvis: We are providers who foster relationships.

[00:25:13] Ioannidou: That's right.

[00:25:14] Purvis: And patients, the sooner we can figure out what makes them tick and what matters to them and the things that they truly care about, the sooner we can get that relational part of the component where it needs to be. Certainly the more likely we're gonna be to do the technical and procedural things in a way that they love and that they begin to trust.

[00:25:39] Wright: So good.

[00:25:40] Ioannidou: Yeah, that's really this, it's really important.

[00:25:42] Wright: We'll be right back.

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[00:26:34] Ioannidou: Welcome back to Dental Sound Bites. Today we're exploring the ethics of your dental dilemmas. With Dr. James Purvis.

[00:26:42] Wright: And so, Effie, you spoke about dental students and so that is a great time for us to hear or head into our next sticky situation that we have, which is Jaylon Johnson, a dental student who is gonna share his dental dilemma. So let's take a listen and see, how we can answer this.

[00:27:02] Johnson: Good afternoon everyone. My name is student Dr. Jaylon Johnson, and I'm a rising fourth year dental student here at Tufts University School of Dental Medicine. I wanted to share a couple of experiences that I faced while being in clinic and just show you some sticky situations that dental students may fall in.

So in the first scenario, I was actually assisting and the provider I was assisting, you know, we had a faculty member who was start checking and they actually began drilling on one of the patients without anesthesia. The patient was nervous, she was, they were scared and I kind of let the faculty member know that it may not be the best situation to continue drilling without, you know, making sure she didn't feel anything.

The faculty member at the time was a little bit dismissive, towards the recommendation, and eventually they listened to me. And the patient really trusted me and understood, and appreciated the care that I had for her, and she ended up becoming my patient. So, that's one ethical situation.

The second one was a patient who was transferred to me from the previous provider for being rude and dismissive. When I call the patient, you know, she was very happy, she seemed like she would love to be in my care. And at the time of our appointment, my assistant was a Hispanic dental student, and she was immediately rude towards him.

She was, like I said, dismissive, and she made the statement that he didn't have anything to say to her. Like, don't say anything to me if you're not my provider. He came and told me, and once I went into the operatory, she began to challenge my suggestions. She challenged my treatment plan.

So I basically I just let her know, Hey, you're the patient. You know you have patient autonomy, but you know, if you want to leave, you can, but if you want me to continue to be a provider and you want me to follow the standard of care that we do here at Tufts, then you have to abide by, you know, the rules that we have in place. The patient ended up, you know, staying, she became my patient and she appreciated, you know, the challenges that I had for her. She said she never had a provider who, you know, kind of challenged her the way that I did, but also it showed that I cared, you know, about her treatment.

So those are my ethical situations in clinic. I just wanna know, what would you have done?

[00:29:29] Purvis: That's incredible. I mean, that brings up such important aspects of what we deal with all the time.

And the resounding theme throughout that is autonomy. Autonomy of the patient and making their own decisions. And then also people within the treatment arena speaking up, whether it be the patient speaking up or a provider speaking up. Or in the first instance, so sounds like he was assisting a faculty member speaking up during that instance when something might not have been going right.

It is really interesting. I have a lot of friends that fly airplanes, a lot of friends that are pilots. And my dad's best friend, I call him my Uncle Fred, he was a pilot and growing up we used to always talk about pilot stories. And even to this day, he'll come over to our house and we'll sit around and we watch these National Geographic documentaries of planes that crashed, and he'll armchair quarterback the whole thing and think of ways that, you know, maybe it could have been prevented.

But he brings up a very good point, and it's this; you know, unless an airplane has just an absolute catastrophic failure of equipment, planes just don't fall out of the sky. Generally, there is a series of improper decisions made by the crew where if in one instance, one right decision had been made instead of one wrong one, that plane would probably still be in the air.

And historically, the captain had the final word. You know, you had the gentleman or the lady sitting on the left hand side of the plane, they operated that thing. And if things were going south or if an improper decision was being made, nobody spoke up all the way to the ground. This thing could be crashing and nobody spoke up. The captain's word was the final word.

In the last few decades the term crew resource management or CRM as they call it, has popped up. And basically it's, if you see something, say something, if you see where there is a decision being made that imperils the lives of those on board or the airplane itself, you speak up. And it made itself evident.

There were, I don't know if you remember the, the DC 10 that had the hydraulic failure and ended up crash landing in Sioux City, Iowa. But it was basically they, when things started going wrong, they opened up the cockpit and asked for help. And a passenger turned out to be a DC 10 mechanic who's sitting in first class. And he opted the cockpit, and lives were lost that day, but a lot more were saved because they executed a fairly good landing in a situation where that plane shouldn't be in the sky.

And so in a dental treatment situation, you're kind of in the cockpit of the plane. You've got a pilot, you've got a first officer, and you may have an engineer. Or then really you really have the patient, and everybody has got to be able to speak up to preserve the autonomy of the patient, to preserve where we're going with the procedure and to make sure things are going well.

My team is empowered if I'm about to do something wrong. My dental assistants are absolutely empowered to speak up and say something, and they have saved me before. There have been times when I have been going down a road in the procedure that maybe was not the best idea. I'm looking at something I shouldn't be looking at, or I'm not looking at something I need to be looking at. This is just me being humble here and my dental assisting team is absolutely empowered to speak up. So in his first example, he preserved patient autonomy and advocated for a patient that was not being advocated for otherwise.

And the second situation, he had the courage to be honest with a patient, and to stand up for the sake of what he really knew needed to be done in the face of adversity. And it created a relationship that was solidified long term. So this is a hundred percent patient autonomy. And I love the way he framed these situations and how he talked about 'em.

[00:33:16] Ioannidou: I agree this, this was very, they're very, very important and useful examples and the, what you brought up, related to the empowerment of staff and, assistance in this case. Then the students to be able to feel comfortable to phrase their concern and advocate for the patients. It's great, but it's also a thin line that, you know, the tone and the way that, one expresses this statement. Could be in some cases, and depending on the faculty personality, be perceived as disrespectful. So it's a thin line, how to walk it. And I think, Jaylon here, at Tufts presented it really nicely, and framed it very wisely and, and kudos to him.

[00:34:09] Wright: Yeah, I was always taught it is never what you do, it's always how you do it. So, those are some good examples that we just heard.

[00:34:18] Ioannidou: I think we have one more. Yes. It's a very interesting one. Our next guest, Dr. Akeadra Bell, is sharing a story about an uncomfortable and quite weird encounter with a patient. So let's hear what happened. I think it'll be very interesting.

[00:34:31] Wright: Yeah.

[00:34:33] Bell: Good afternoon. Thanks so much for having me on the show. I'm so glad to be here. My name is Dr. Akeadra Bell, and I'm a general dentist in Raleigh, North Carolina. I have a sticky situation to share with you that happened at the office. So my hygienist had just introduced me to the patient and said, Dr. Bell is going to come in now to do your exam.

I walk in and the patient looks at me and says, is it Miss or Mrs. So I paused. I said, it's doctor, and we'll get started with your exam. So we went through the exam. The patient apologized a couple times. Thankfully he had no concerns. And then I go off to my office, my assistant comes back a couple minutes later and says, Dr. Bell, guess what I have for you? It's a piece of paper from the patient and it says, just wanted to apologize again, with his phone number.

I completely just threw it in the trash. I act like it never happened. Not sure if that was the best thing to do, but I love to hear what you would do in that situation. Talk about awkward.

[00:35:33] Wright: It's definitely awkward.

[00:35:35] Ioannidou: Oh God, I've been there.

[00:35:37] Purvis: So, I said earlier that, you know, that dentistry is not procedural, it's relational. Well, maybe not that relational. We have to draw a line somewhere. Now, this is, first of all, I admire your courage for sharing that story.

This happens all the time. It has happened to me, It has happened to my team members, It has happened. Patients making comments to my assistant and me that are inappropriate. This is very common. And so, I think you handled the situation beautifully. You got down to business in the exam. Ultimately, you are there to provide a service to that patient and provide healthcare. And as a provider, you do have to establish some degree of relationship with that patient, but it could be a clinical and a professional relationship, and it can stop there.

Now, obviously, if we have patients that are pushing the boundaries and they continue to be disrespectful, providers are well within their rights to set the boundaries and remind the patients of those boundaries. Look, I'm your professional clinical provider, that's what I'm here to do. If that's a boundary we can't be comfortable with, perhaps I'm not a dentist that you should be having treat you. And we see that, but I think with good, honest conversations, we can address those things and we can move past them.

But ArNelle, I've seen it, I'm sure you have too; It's very common. This is something that we see often, I've seen this in dental schools that I'll speak to dental students a little bit. This was actually, I think in every dental student environment I've ever spoken. And this has come up in one way, shape, or form where there's been a sticky relational boundary or sort of flirting, crossing the line.

And it's very common and it's something that we deal with, but it's something that can be very easily managed with the appropriate language, and then simply moving on.

[00:37:29] Wright: Yeah. I think you did a great job. Yeah.

[00:37:31] Ioannidou: Yeah, for sure. And you're absolutely right. It's very common in dental schools, very common in medical schools.

We tend to speak about the patient's rights, but then, you know, I don't think we were, I mean now we are, nowadays we do what we are, but it took us quite some time and few decades to develop, a code of ethics that really protects the students vulnerability and exposure to patients. Many times just, you know, innocent flirting, but it can certainly turn to spiral harassment, right?

Yeah. So, it, I think it's really important that we do this and we protect, and when the students graduate from this environment, and this type of protection, they are very familiar with the guide and the principle that should frame their relationships with the patients in their practice. Because the practice, is Private practice is a completely different dynamic. It's very different to have to be in an institution practicing under the structure of an institution, and, you know, security that is available for you 24 7. And then you graduate, you go to your four walls, and it's you, your staff and your patients. Different exposure and different danger sometimes.

[00:38:57] Wright: Yeah. I was gonna say, one of the things that Dr. Bell talked about was the staff and I had a similar situation like this. And one thing that we should always know is that the staff is always watching how we navigate these situations. So we wanna always make sure that what we do, is what they want to emulate and mirror.

And so I love how she kind of just took it, tossed in the trash, moved on, that demonstrates professionalism. Character and a line in the sand and a boundary in front of the staff. Because I had a patient come in and you know, the staff, they're just like, Ooh, Dr. Wright, this patient likes you. You know, sometimes they can get a little like, Dr. Wright.

And so if you handle it and you squash it, that lets them know that that is not something that you are about. You have a boundary and it's a professional setting, and then they are going to, you know, mirror that same behavior the next time, should it? Happen again. So I really loved how she handled that.

[00:39:57] Purvis: Yes.

[00:39:58] Wright: This is such a good show. So I do wanna bring it back to you, James. We've been hearing from our colleagues about, you know, the situations that they have found themselves in. You've heard some of Effie’s and I sticky situations, but I imagine that you too have faced some of your own. So, if you would, please, can you share a sticky situation that's, you know, you've encountered and how you handled it?

[00:40:22] Purvis: Sure. Things aren't always what they seem in dentistry, and there is an instance that very recently happened that reminded me of that, and I shared this with a group of students at East Carolina maybe a month or two ago, and it is probably one of the most interesting things I've ever dealt with, and it turned out very well. But it, at first, I didn't know where this was going. Probably, I don't know.

Seven or eight years ago, I had a patient that came in and I'll call her Mrs. Jones, I'll change her name. She needed a lower denture maid, and her lower ridge was incredibly deficient. We've all had that patient that comes in thinking that a hundred dentists before have tried to make a lower denture that just doesn't work, and somehow you're gonna be the one to do it.

And I told her at the outset, I said, Ms. Jones, look, I love removable prosthodontics. I feel like I can make pretty good dentures. But, doggone the best removable prosthodontist in the world is not gonna be able to give you a result that I think you're happy with. She wasn't a candidate for implants. Ridge was incredibly deficient, and so I said, we're gonna give it the best shot we have.

So, I made her a dentured and doggone it, y'all. I thought it was a good one. I really did it. It was as good a denture as I was conceivably going to make this woman. And during the process my dentures, I take my time.

I'm kinda old school. I go through a lot of steps to make 'em, and we, I really gotten to know this patient and she was incredibly sweet. The most wonderful patient I've ever dealt with. And she gotta know me and my assistants and we loved her. And ultimately I delivered the denture, and I could tell she's a little sad almost when she stepped out the operatory to leave. But she loved it. She was happy with it, and she left.

Well, a couple days later, my administrative team came to me and they said, oh my gosh, Ms. Jones has called us on the phone and she is irate. She said, she hates this thing. It's just awful. It's the most ill-fitting denture she's ever had. I said, well, bring her in. Let's take a look at it.

And so we got her back and she was pretty nice to me. She was very kind, wonder how my family was doing. And I made a few very minor adjustments and she was thrilled. She was so happy and she left and I said, well, I guess that'll be it. And about a week later, my front desk came back and said, y'all, she's back on the phone.

She's irate, she's ill. She's just not happy at all. I said, really? Okay, well bring her back. And I got her back and she was so nice. We talked and we cut up and laughed and she hung out with my assistant. And we just, y'all, this went on for probably two or three months. And finally my administrative team effectively staged a muti that they said, we can't deal with this woman anymore.

She calls us on then phone. She is irate. She's borderline, verbally abusive on the phone. I said, okay, okay. I can't have anybody doing this. I got her back and I said, Ms. Jones, look, I've done the very best I can for you. I've made you the most wonderful denture I can possibly make. But I said, this is just not a relationship that can continue.

You're driving my front desk crazy. You're borderline abusive. I said, I'm sorry, but I think you're gonna need to find dental care elsewhere. I'm gonna dismiss you from my practice. I'm gonna refund your money entirely. I'll provide emergency care for a month if you need it, but it's time to find somebody else. And her eyes just kinda welled up. And her, she looked at me and she said, well, does this mean I won't be able to see you anymore? I said, yes, ma'am. That's traditionally what this means.

And as it turns out, we got to the bottom of the story. She was lonely and she didn't have anybody to talk to. Her family was gone. She didn't really have anybody in that community. And bless her heart and her dentist and his assistant were about the only two friends she had. And I told her. I said, Ms. Jones, you don't have to call my front desk angry in order to be seen. If you wanna come have a conversation with me and my dental assistant, you can come in anytime you want.

Just call us, give us some notice. I'll carve out some time and we can talk. And for probably the next five or six years, maybe every month or two, she'd come in, we'd catch up on the wife, we'd carry on. I never even adjusted the denture anymore and, she passed away about four or five months ago.

And to date, she is my favorite patient I have ever treated. I will never forget her, but it's the biggest reminder and I carry it with me to this day. Things are not always what they seem, and patients are carrying things with them that are deeper than the clinical conditions they walk in with. And I'll never forgive Ms. Jones. I will always admire and love and respect her memory, and I will carry that with me forever.

[00:45:02] Ioannidou: Oh, this is so sweet.

[00:45:03] Wright: So sweet. Right. Oh my gosh.

[00:45:07] Ioannidou: And then it teaches us also exactly what you said. It teaches us how much and how deep we have to listen to our patients, and how to explore to find the truth to go under and figure it out.

[00:45:18] Purvis: It is, there's always something. There's always something more. There's always something below the surface.

[00:45:23] Ioannidou: Yeah, that's so humane and so sweet. I really enjoyed the story. That was good.

[00:45:30] Announcer: On the next Dental Sound Bites.

[00:45:32] Wright: We are talking about dollars and decisions. From the latest information on student loans to setting yourself up for success as a first-time practice owner. If you're thinking about your financial future, you gotta tune in.

Before we wrap the show, we also wanna ask, is there anything else that you want to add that you haven't covered or that you think our listeners may benefit from?

[00:45:59] Purvis: Well, I would encourage any of your listeners to look up the ADA code of ethics. Even if you're not an ADA member yet, I'm gonna say yet, 'cause we want you to be a member.

Look up the code of ethics. It's freely available on the internet. You can download it in the PDF, you can digitally download it to your phone, your tablet, whatever, and just pour over it and ask yourself, how could understanding these different facets of the code make me a better provider and more importantly, a better human being.

And certainly, anybody is welcome to reach out to me. I'm still a part of the New Dentist's Committee. My contact information is accessible through the ADA and I would be honored to talk to anybody, at any time and help in any way.

[00:46:42] Ioannidou: Thank you so much, James. Thank you. It was really wonderful having you on Dental Sound Bites today.

[00:46:47] Wright: Yes, thank you.

[00:46:48] Ioannidou: And you already shared your, contact information with our listeners, which is great. Is there anything, do you have any social media presence. How is your social media life?

[00:47:01] Purvis: My social media life. I mean, I had a flip phone up until pretty recently, so,

[00:47:06] Ioannidou: Oh dear God.

[00:47:07] Purvis: So, I have Instagram and it's mostly pictures of me taking trips and pictures of my cat, so that's not very exciting. But certainly I'm on the board of trustees for the North Carolina Dental Society. Anyone can look me up via my local component. Even my cell phone number probably is on that site and I welcome any contact from anybody, email, cell.

There's probably a way to even contact me directly.

[00:47:29] Wright: I love that.

[00:47:29] Purvis: It would be my pleasure to help anybody in anyway. I do love dental students. That's my passion. I love speaking at our local dental schools and be a chapter, so, anybody who wants me, I'm happy to come do it. But outta clear, being on here with ArNelle and Effie, I don't even know what to do with myself.

Y'all are amazing. I love what you're doing. You're doing so much for dentistry and making it so fun and so accessible to so many people. The fact that I gotta hang out with y'all for an hour just made my day.

[00:47:56] Wright: The girlies.

[00:47:58] Ioannidou: Aw, us too. We had a blast. I love the episode and I really liked the discussion.

[00:48:03] Wright: Yeah. I think our listeners are really gonna enjoy it. For sure. Well, thank you so much once again, Dr. Purvis. We also want to give a good thank you to all of our guests who also came and shared their sticky situations, Dr. Wang, student Dr. Jaylon Johnson, and Dr. Bell for sharing with us as well.

[00:48:22] Ioannidou: It was amazing. Thank you all.

[00:48:23] Wright: To our listeners, all of the information that was shared here in the episode today, we're gonna link all of those resources mentioned on our show notes section, which is ada.org/podcast.

[00:48:35] Ioannidou: And if you liked this episode or you found it interesting, please share it with your friend or share it with your team.

[00:48:44] Wright: Everybody. Share, share, share.

[00:48:45] Ioannidou: And everybody share it. Then be sure to subscribe wherever you're listening so you can get all the latest episodes. And don't forget.

[00:48:54] Wright: Yep. One last thing. Make sure you rate it, write a review, and follow us on social media.

[00:48:59] Ioannidou: Bye, bye everybody.

[00:49:02] Wright: Bye for now.

[00:49:04] Purvis: Bye guys. It’s been a pleasure.

[00:49:06] Announcer: Thank you for joining us. Dental Sound Bites is an American Dental Association podcast. You can also find this show resources and more on the ADA Member app and online at ada.org/podcast.