is to provide important iniormation not only on patient protection' but also on malpractice litigation protection' When I finishecl orthodontic specialty training' a while back, the word "malpractice" was not even itr our vocabr.rlary. Today it is a different story' lt has been a hobby of mine to testify in some of these cases; I finditexcitinganclchallengingbecausetheplaying field is not level, Ihe Unitecl States is fertile for litiga- tion. However, other countries are not necessarily inrnrune.ln the leacl article of the March 2001 issLre of the World Jottrnal of Orlhoclontic's' Dorrald Woodside' eminent Arnerican Association of Orthodorrtics (AAO) leaclerfrom-[oront0,reportsonalocal$4.4rnillion case awarcl in litigatiorl involving an orthtxlorrtist and nn orul surg,eon.r Malpractice litigatir:rr has becorne a worlclwide phenomenon and continues to Erow' Recently, a Chlcago I)r:nhr/ Revietr''rrlicle crltitled "[)clctor, You Arr'' []t'ing Strt'rlr" 11'Jlrrrlrrl thnl tht' tyt)i- cal malpractice suit in Chicago lasts z ot more \(-'ars ,trrd is trstrally strttlt'rl aftor sigrrificarrt trial pr('l)'lra- tion.2 Since this article 'rppeared' 'he risk management cluicksand has become ntore treacherous' Elizabeth Franklin, claims rnanager for tl^;e AAO lnsurance Company (AAOIC), says that atrout half of the cases filed are settled, ancl the other half go to court' You have about a 50% chance of lefending yourself in such a suit because the jury is syrnpatlretic to the poor patient, not the wealthy doctor and the successful insurance company' Because of poterrtial jury bias' attorney David Tltomas tells us elsewlrere in this sec- iion, tf,. iob of clefencling someone is rnore difficult because the jLrry panel knows tlrat the insurance com- pony i, goin5', to take care of the cost' Mr Thornas has been hig,hly successful irr defencling his clients' but nothing can rePay you for the psyt-hologic trauma that ,o, ,rif., before, cluring, ancl after such an experience' l(ule rrumber 1 abor'rt choosing your malpractice insurance compalry: These companies have become rlore cost consciclus as zr result of some astronomical awarcls, so rnake sure yoLl lrave the ultimate decision to clefencl or settle yoLlr case' lt is ofterr much cheaper 185 ;i+:t:"'.;ti.; .:l!;.-;l;tl for the insurance company to settle the suit than to fight it, but your name then appears on tlre National Practitioner Data Bank, which should be avoided if at all possible. Until 30 years ago, lawsuits were a last resort' but not anymore. We've seen one danrage ceiling after another shatterecl' A iecetrt Nevy Ytrrk Tlmes editorial on silicone breast implants ("Trial by Science") ancl the class-action lawsuit by Marsha Angell, former edi- tor of the venerable Nerv Englan d Jottrnal of Medicine, provided a wake-up c;,11.3 Tl-re eclitorial states, ""fhere is no scientific evidence that silicone implants cause any diseases at all in women." Nonetheless, the man- ufacturer pairl out $2.5 billion dollars despite the fact that there was no evidence! The spurious clainl of causing cancer cculd not be valiclated, but the jury still awarded $2.5 billionl The New York Tintes commentecl that this decision was a combination of greecl, rnedia sensatiorralism, iudicial gullibility, and the cleverness of lawyers. The fact that the contingency- fee lawyers wort is a kind of legal confisc;ttion ancl obfuscation ol several billion dollars, errgineerecl by zl gullible media, and a relection of science. For those of us in orthodontics, what we clo may not be malpractice, but that does not mean a suit brought against us is going to come out in our favor. This sec- tion was written to let you know that there are ways to defend yourself. By the time you reaclr this part of the book, you should lrave a good idea of the poten- tial iatrogenic sequelae in orthodontics. lf you keep good records, follow the laws, and uphold the stan- dard of care, your chances of being sued are infinitely reduced. As the Boy Scout motto says, "Be prepared!" lf, after serving as a defense expert irr some 'l 50 cases, I seem a bit biased, it's because l've seen so many things happen in which the dominant factor is a 5-letter word: money. (Others would sLrbstitute the word greed.) An extreme example is a recent tobacco case in Wisconsin. The plaintiff lawyers billed for 24,733 hours, most of it done by paralegals, at a rate of $3,782 per hour plus expensesla The irony is that even the defense attorneys who lost the case were amply paid, adding ttr the financial burden on the insurance comPanies. ln some of the cases in which I have been involved, the massive files, records, and depositions are a foot and a half thick, Too often, the records from many orthoclontists are not even half an inch thick' are inconrplete, and/or are harcl to decipher' Such prob- lems are a ntagnet for contingency-fee lawyers' No doubt you've heard or seen their ads: "Sign right here' It won't cost you a penny' But if you win, you get two- thircls." Of course, by the time you pay the legal costs' it is far less. But it is still a lottery awarcl for some patients. t There are many examples of this legal cancer, but I will cite only a couple' A Long lsland hospital in New York was orclerecl to pay $40 million to a 39-year-old wonr.rn who lost a hancl because of an lV needle that was inrproperly inserted during lung srrrgery' Sad for all roncerni:d, except the lawyers. ln Highland Park, lllinois, $21 million was awarded to a fanrily because tlre cloctor was late getting to the hospital when the chilcl was being born and the child was later judged nTentally retardecl. The attorneys for the plaintiff blarred the late birth as the cause' Was it tlre cause? lnflation for a sirnilar problem resulted in a payout of $35 rnillion by Northrvestern Memorial Flospit'rl in e.rrly 2004.'r Ihc potlr patient, the rich cloctor, the rir:h hospital! Tragically, the public ultinrately pavs the cloctor, who passes on the huge nralpractice insurance premium.s Like doctors, orthodontists ltave an affluent image, one that is likely to invite litigation' The public psy- chology is against us,6 so you must protect yourself' The popular press has exposed this legal obfuscation lvith frequent articles, such as one that appeared in a recent issue of the U.S. News and World Report' The front cover showed the Statue ,rf Liberty, the torch helcl high, with rats nibbling away.at the statue base. As the legend below the figure stated, "The rats are no longer nibbling. They are devouring our very founda- tions!"7 I have qr-rite a collection of cartoons saying rnuch the same thing. As a result, malpractice premiums have skyrocker ecl, and insurance companies are suffering huge loss- cs. ln 2002, ttine major companies stopped writing malJ:ractice insurance because of their prodigious costs. St Paul Federal alone lost $1 billion, and some suits are still pending.s Ask any obstetrics/gynecology specialist how many medics have quit the specialty, not only because of the incredibly high insurance premiums trut because of the psychologic trauma they suffer from frequent suits. There was a bill before e )- o ). -1 I I Cong,ress, supported by President Bush, 'to put a $250,000 cap on awards for pain and suffering, but it was opposed by the trial lawyers lobby, the ntr:st powerful and well healed of all lobbies, ancl blocked in the Senate after passing in the Flouse, Ilre bill was defeated in late 2003. lt will be re-introduced in 2004, but don't hold your breath. Ask your orthognarhic surgery colleagues what their annual malpractice pre- miums are-at least $ 1 25,000 and clirnbirrg. No w,on- der so many are no longer doing orthognathic sLlrgery. When I started in orthodontics, our malltractice fees were $72 annually. Now that is multiplied nrany times. We must all take a proactive position to warcl off the increasing financial burden that is being placed on our shoulders. lt is no mere coincidence that the US has 5% of the world's populatiorr but 70oh of the world's lawyers. The prclblent, as I see it, is that the lawyers make the laws, enforce the laws, ancl acl.iucli- cate the laws in all three branches of government. Among our representatives in Washington, how many are not lawyers? Your chancr.s of lteing sur'rl are mtrch lletter if you live in a lriq rilr th,rrr if \ou i.r,irr a srr.,rll town, since the greatest conr.cntrltion of l,rrvyr:rs ls rn the big cities. The risk-managernent section of this hrok provirics some of the basic ways to defend yourself in the fare of the exponential increase in the number of suits and the amounts paid out. ln .1980, in lllinois, the total medical indemnitl, was $11 million; by 1995, it rvas $349 million; in 2000, it was g4B5 million! The nunr- ber of annual claims has risen frorn 620 k> 14,8261 Dentistry has seen similar increases. The insurarrce companies are all very busy, though they are usually making less, not more, profit. Many have either gone out of business or stopped writing malpractice insur- ance altogether. Another problem is that when one health service gets sued, it can have a machine-gun cffect on all providers: Everyone is sued even if they have no direct involvement in the case. For example, it is highly like- ly for you to get sued in an orthognathic surgery case even if the problem is surgery-related. l'he only way to protect yourself is to keep com;:lete, comprehen- sive written records of exactly what you have told all parties and to get records fronr other providers. Communication is the name of the game, as you'll read in this sectiorr again ancl again. lil?,[ntlar,,,r*?i]ik!.Hptwr+:i!i,]] Contingency-fee lawyers have no rnonopoly on un- ethical behavior, so we have to keep our own house in order. 1bo nrany of our collr:ail,ues are ready tr_l serve the ego-inflating role of "e\pert" in these cases. Sorne of them will take eitlrer sic1e. Justice rnay not be the deterr:rining factor; the pecLrniary reward is what is important to the self-styled expert, sometimes criti- cally referreci to in the press as "haclcs for hire." These so-callecl ex[)erts are listecl in a book organizecl by specialization. -lhe aclvertising for one of these books trunrpets, "This is the one book rhat defense lawyers do not want yctu to have!" I have faced one such "orthodontist" testifying on both sides of a question many times. We nrust protect .Jur own ethics, our integrity, and our public image. A recent Callup poll surveyed the public on the rel- ative honesty and integrity of various professions and trades.6 Druggists werer ranked highest at640/o, clergy at 56%, and college teachers and physicians both at 55%. Dentists were rated at 53'lo. Further down the list was lawyers al17ol-,, not far above used-car sales- men, at B"/o. The public has an image of ethical helravior, ancl ortlrr;clonlists rlo relatively well. BLrt on a scale clf I to 100, shouldn't our reputation be rated hrigher than 53%? l'm not trying to argue that there is no rnalpractice; of course there is malpractice. But sometimes we think we see it rnuch easier in a cornpeting orthodon- tist's patient who comes to us, though it is not mal- practice, We tend to be judgrnerrtal when we do not know all the facts. lt is vitally important to know what has transpired. Why is it that clentistry is the most crit- ical profession? I think maybe we sometimes have an inferiority complex, because we use the term doctor all the time, like podiatrists and chiropractors, in con- trast to the rnedical profession, which instead uses the MD degree. Regardless of the cause, we tend to be too critical of our colleagues. Before delivering an opinion, the very first rule is to look at the patient, look at all the facts, know what has happened, deter- mine the patient's level of cooperation. Review the records.lt is amazing how fevr orthodontists ask tbr the records from the prior treating orthodontist. ln any event, "Do unto others as you would have thern do unto'you." lf you have a patient who is unhappy for one reason or another, you should try to rnakr-, surc that paticnt is tal<en care of by taking the i j 'i .I l I i i l l I I l I I l l i :i .; I ^:i I I j ,l I .t fl 187 time to consult with a colleague. Try to see that all the records go with the patient. The AAO can provicle you with transfer or consultation fornrs. Call the sub- sequent orthodorrtist ancl clo all you can to expeclite the consLrltation ancl possible treatment. You and the patient will benefit fronr those actions. This is stanclard practice in medicine. Make sure yoLr do a compreherrsive nredical and dental history and functional and TMJ examinatiorr on every patient, preferably Lrsing one of the many excel- lent questionnaire sheets available. The AAO provicles case history forms for patierrts unr.ler 1 B anrJ for ac1ults (see Appendix). I have been involved in at least 24 TMD cases, and yet we don't even have any proof that TMD is a factor in orthociontics.s The 1996 National lnstitute of Health conierence stated this categorical- Iy.e,10 Nevertheless, the million-dollar Brimm case cJecision galvanized h,"rndreds of copycat suits. The record shows that Ms Brimm had two thircl molars removed by the oral surgeon after orthodontics. lt seems that her acute TMD synrptoms clevelopecl afterwards. 'fhe surgrron who renrovecl the third molars settled for $2,500, and the orthr:dontist got clobbered for $1 n'rillion. The orthodontist was a member of a university faculty and did the'righr thing. The so-called expert for the plaintiff was a general practitioner as well as a non-lroardecl specialist who I have faced a number of times in court. The expert supporting tlre orthodontist was a professor in a great university and a world-class orthodontist. None of us is inrmune. Moreover, the AAO appealed and lost on the appeal. Who says all decisions are fair?rr your records should reflect a functional exam, particularly of the TMJ and neuromusculature, before, during, and after treatnrent. Record nocturnal parafunctional activity, which is a leaciing cause of TMJ problems, lf present, consider incorporating an anti-bruxism, anti- clenching modification in the patient,s maxillary retainer, and instruct tl're patient about the probable need for indefinite wear at night. lf we get good records, it is harder for the plaintiff attorney and easier for your defense attorney. The AAOIC and other insurance companies work very harcl to make sure you get the very best legal atten- tion. ln tlre past, malpractice cases were assigned to the junior members or partners of the firm, but this has changed. Now that more money is involved, the top people in tlre firm are handling malpractice cases. Retain the right to make a decision on court action in your insurance policy. lf you are a nrale dentist, you have a 2.Bo/o chance oi lreirrg suecJ; fcnrale dentists get sued only 0.7'7o of the time. Oral surgeons are sued much more often,ll so you increasE your chances of being sued if you are the orthodontist working on the case with the surgeon. C-ommunication is the name of the game. You must havc infornrerl consent forms signed by the patient or parent of a rninor, Although the professional standard of c are is the lrasis for judgrnent in rnany jurisdictions, tlrere is a trend in this country to use what is known as lhe nraterial-risk standarcl or the reasonable patient standard, Courts are nrore and more protective of the patient's rights and nrore hesitant about formulating a conrprehensir e stanclarcl. The feeling is that the dental ancl nredical lrrofessions should not be allowed to dic- tate the stantlard for inforrned consent. The patient Lrltirrr.rtely ouns the right to deternrine what is to be ckin' rritlr I' ,rr ht,r ,uvrr ltorlr,. This doctrine pre- vailt,tl iri (,r, r(,rl)ur), rs SPrnce.r. We need to make slrre consent irirnrs arc. rea(i by the patient (or parent of a minor), cliscussed personally rvith the doctor, and signed ancl even witnessed. After the patient (or par- ent) has read the informecl consent document, ask him or her personally, "Have you any questions?" Then, have them sign and clate the signature at the bottom of the document.lr The AAO informed consent form (see Appendix) is available upon request, You need a proactive staff as well as a patient ombudsman. The warmth of one staff person can be critical. A friendly patient is less likely to sue you if somethlng goes awry, Of course, if you're going to be seeirrg B0 patients a day, it's more dilficult to establish an optinral office rapport. You need somebocly to rep- resent you and represent the patient. You need to cor- respond with a referral source. Again and again, I have seen cases in which there is no correspondence with the referring dentist. There is no report letter to the general dentist, sometimes no diagnosis or sum- mary of the patient's problems. I have seen malpractice cases with no models, no radiographs, no panoramic radiographs, no progress records, and no cliagnostic summary or treatment plan-often not even a report letter to the patient. lt's surprising how man;'cliniciarrs don't do what they should do. l'his makes it hard for all members of our specialty. ln this era of ntall;ractice ntani.-1, evt:rr tlte goorl Samaritan Sometimes suficrs. lf an orthorlor,rrst does ,r partial correction for an assistant, colleague, or rela- tive of a referring dentist, it is often gratis or for a nominal fee as an expression of appreciation. lf the treatment result doesn't meet the expectatiorts of thc patient, there is a distinct possibility that the ortho- dontist will face a malpractice suit. So often in such cases, full records are not taken, consent forms are missing, treatment notes are cryptic. This makes per- fect litigious fodder to present to a jury. The experience is traumatic to the orthodontist even if the case is ulti- mately won and takes much time and money for the defense. Very sirnply, treat all cascs with the same practice management details and goals, with no cont- promises at any level, Special "favors" can come back to haunt you.r4 We need to follow these rules. ln professional conr- munication, use written records rather than the tele- phone, and always keep copies. Maintain continuous written communication with the orthognathic surgeon and with the general practitioner, not .iust with the referring dentist. You are not an island unto yourself. lf you send something to an orthognathic surgeon or the pediatric dentist, stamp it on the records. lt's bet- ter to send copies rather than originals. When you send a bill to the patient, put "Please see your dentist" at whatever interval you want-3 months, 6 months, whatever you prefer. Then, have your staff check that the patient followed through. Use your trained auxiliary staff, but make sure they are qualified to perforrn the services you ask of thern. Sontetimes we have staff do things that are not legal. Ms Franklin refers to such a case, and the insurance company had to settle even though no',lrnlrg" *u, done. You do notface a friendly environment in court. I have been involved in a case where the auxiliarv personnel took off the bonded brackets, polishecl the teeth, and took the impressions for final study casts. ls this legal in your state? ln how many states is this legal? lf it is not, try to change the law. This was clone recently in lllinois, for example. Defensive practice is the name of the game for all health professions and surely applies to orthodontics. Consider referring. Referral is necessary when a patient's treatment needs are beyond the ability of the treating dentist's skill, knowledge, and experience. Dr Vanarsdall stresses this again and again in his chapter on periodontal ramifications. We know that there's nothing wrong with referring. Have the patient get second opinions before or during treatment. Why are we so worried about referring to another orthodontist, particularly when patients or parents question one- phase versus two-phase treatment, extraction versus nonextraction therapy, expansion versus nonexpan- sion? Always say, "lf this was rny child, this is what I would do, but I want you to be sure." Cet a second cpinion if there is ever any question. Failure to refer is a legal goldmine now. ln medicirre, if a patient has a cardiac problem and you're treating the liver or some other area, then you're in trouble. One of the most onerous problems is the cryptic, short-handed, inadequate, illegible written records that we keep to support each visit. l've gone over these records, and they look like hieroglyphics. Cet yourself a little recorder or sonlething that fits in your jacket breast pocket. When you've seen the patient, take the recorder out of your pocket and record sonre basic treatment notes: "Mary Jo Smith, 9-15-2003, retie archwire, torque incisors," etc. "Next tinre check mobility of incisors," etc. Have it typed into the record. Look ati'some medical records and then look at dental records. Ours are mediocre at best. ln 1996, the AAO councils developed an excellent statement of clinical practice. standards of care. Re- quest a copy of this document,r3 As orthodontists, our goal is well-aligned teeth, but that does not mean typodont perfection. Normal is not an ideal, it is a range based orr morphogenetic skeletal pattern, mus- cle pattern, age, etc. Be sure to say, "Does this look go-od to you?" Have patients initial their reply. Few lawyers are going to accept a case vrith such evidence against a likely success. Remenrber, the lawyer gets nothing unless he or she wins' -lhere are controversial treatmen'| objectives, such as canine-protected occlusion, that some clinicians try to attain. As the Creek aphorism says, "Everything in moderation." Lysle Johnston ccmments appropri- ately, "Cnathology is the science of how articulators chew!"rs The jury is still out orr this goal from a legal standpoint. Recording parafuncttonal habits is more 189 important and a proven cause of some TMJ conr- plaints. Much has been written by erninent authorities in the first part of this book to enrplrasize r,r,hat our bio- logic limitations are irr spite ot amazingly efficient orthodontic appliances. The infornreci consent nrust cover all potential iatrogenic sequelae ..is well as changes that may occrrr post-treatment. Do we cause-. damage? ls there something we can do? What price orthodontics? Missteps are potholes along the ortho- clontic highway, Ninety-nine percent of the cases that we treat have at least some nrinuscule degree of root resorption, according to a study from Ohio State Uni- versity, although you may not see it on the periapical films or the pan,tramrc radiogralth.i Moreover, we lose some crestal bone with every extraction. We also nrust monitor the pati:nt's periodontal response. References l. \Voociside t)C. lhe 94.4 rlillion case. World J Orthocl 1001;2:10--10. 2. []or-tor, You Are Being Suerdl [eclitorial]. Chir: Dent Soc tlulI Nlay'-lune 2002. |, ,\ngell rVl. Trial by Science leclitoriall. NY Tinres, Decem- lrt,r 9, l9(lB, p 29. .l ( lricaBo liilrunc, IebrLrary 15, 200-1. 5. ADA News, February 1'2,2004. 6. llonesty and ethics poll. Available at htrp://www.gallup. conr. Accessecl 1 4 January 2004. 7. [)ractice rVlanagenrent Fornrs. [Jpdated 200]. American Association of Orthodontists, St Louis, Missouri. fl. National lnstitute of Health. Technology Assessment Con- ference: Management of 'Iemporomanclibular Disorders, Nlll, Bethesda, April2g-May 1, 1996, 9. Kim N,tR, Craber TM, Viarra MA. Orthodontics and tem- poromanclihLrlar disorders. Am J Orthod Dentofacial Orthop )002;1 21 :4 38-446. 10. Egernrark l, Magnusson T, Carlsson C[. A 2O-year follow- u1; oi sigrrs ;rntl symptoms of tentporonranclibular disorrJers ,rnri ntaItr-r lrrsions in subjects with anrl rvithout ortho- tirrntir: treatrrrcnt in chilclhoocl. Angle Orthocl 2003;73: r 09- 1 I 5. Il . (lraber TN,1. Doctor, You Too Can Be Suedl American ,\:sociation of Orthociontics, Orlanclo, Nl,ry 4, 2004, l.r, ( ,rrrlr,rlrrrry v Spr,rrt r', ,1(t,l l. 2<l 77'2 D.(. Cir, l()7'1. 13, Anrerican Association of Orthodontists,40l N t-indbergh Ulvd, St Louis, Missouri 63141. Http://www.aaomembers. org. 1-1. Risk management review: Orthodontic ,,fayors,,can result irr rnalprat tir c t:laims. AAO Bullctin f antrary/Febru ary 2004; 22:1O-11 . 15. Johnston l-. Serninar. Department of Orthodontics, Univer- sity of lllinois, April 5, 2003.