Smart Strategies for Malpractice Prevention

So usually in a malpractice claim, the GP failed to observe the pockets were getting deeper, didn't do any treatment, and neglected the situation where he didn't make the referral to the periodontist. Welcome to Austin, Texas, and welcome to the Phil Klein Dental Podcast. Did you know that over the course of your career, statistically, most dentists will face at least one malpractice claim? While the annual risk is low, even a single claim can be stressful, costly, and time-consuming, and it highlights why strong documentation and risk management are essential. In today's episode, we're focusing on what every dental practice can do to reduce the risk of being sued and the daily steps you can take to stay prepared, strengthen your documentation, and give yourself the best chance to defend your practice if a claim arises. Our guest today is Dr. Marc Goldman, a board-licensed periodontist with leadership in periodontal and implant therapy. He is the founder and long-term owner of a premier periodontal practice in Milburn, New Jersey. He's also a teacher in a general practice residency program at Beth Israel Hospital in Newark, New Jersey. Before we bring in our guest, I do want to say that if you're enjoying these episodes and want to support the show, please follow us on Apple Podcasts or Spotify. You'll be the first to know about our new releases and our entire production team will really appreciate it. Dr. Goldman, it's a pleasure to have you on the show. Thanks, Phil. Thanks for inviting me. Yeah, we're very happy to have you. It's always great to have a periodontist on the show. We don't have a lot of periodontists on our podcast show. I'm not really sure why, but it's always great to have one, especially someone that's practiced as many years as you have. So in this episode, we're going to be talking about malpractice prevention, which you speak a lot about. From a malpractice prevention standpoint, why is a truly comprehensive medical history so critical for every new patient? And what are some of the most commonly overlooked red flags you see in referrals from the GP and, in your case, to the periodontist? When new patients come in, and even your recall patients, very important to review the medical history. Make sure there's not any medical problems. What I find often is that patients will check that they have heart problems, but they don't list the medication they're taking. So it's really incumbent upon us to go through that medical history, see what they check off. For example, a patient with a heart valve replacement or a history of subacute endocarditis has to be pre-medicated before any dental visit. That's important we pick that up on that medical history before we do anything. Anything happens, they get an infection, then you're open to malpractice. I once reviewed a similar case and the dentist had it marked red ink on the chart pre-med necessary. So he was taking every precautions. And even when I reviewed the case, he wrote the patient came in for emergency and patient did not pre-medicate, clinical exam only. So once I reviewed that case, he was not guilty of any malpractice. He was following everything. So there's no question a thorough, comprehensive medical history is so critical. And also we need to understand the drugs that patients are taking, the medications that patients are taking, what the side effects are. We talked offline briefly about a case that I asked you to share with us about a dentist who prescribed an antibiotic. I think it was an endo case. Tell us about that, where the dentist was not fully aware of the side effects and ended up getting quite a bit of trouble. There's a case where a general dentist did a root canal on a patient and put them on ciprofloxin. The patient was an avid runner and asked, can I work out? Well, apparently one of the side effects of cipro is that it can cause tendon ruptures. So, of course, the patient went out. That week, ruptured two Achilles tendons, needed surgery, rehab, calls the doctor and says, well, sorry, no offense, but I have to sue you. And he won. And the court ruling is that dentists have to advise the patient about the side effect of these drugs. So we have to know our pharmacology. So let me ask you this. Can you give us an example of a case that is clearly part and parcel of a red flag? So when that patient comes into the office, that... dentist should be alert and realizing that this could be trouble. Give us an example. For example, implants. Everybody's doing implants now. So in the medical history, the patient writes they're in a drug rehab program. They still admit to taking drugs. They have bipolar disease, schizophrenia. So right away in my mind, this is a red flag. Patients coming in, they want to do implants. and appreciate that these drugs that they're taking for mental illness are selective serotonin reuptake inhibitors that have an effect on bone healing. And then they're on this buprenorphine for drug addiction can also affect on bone healing. So the red flag, as soon as they check these off, is this patient is probably not a candidate for implants. So you mentioned SSRIs. Right. Now, they obviously have a negative effect on bone healing. and so does buprenorphine as well, which the patient was on for drug addiction. So I assume it's important to talk about this with the patient and say, listen, we could proceed with implants, but you're a high-risk patient or a higher-risk patient because of the medication you're on, and we may not get good implant integration and so forth, and document that all on the chart. I'm sure that in some ways protects the dentist. Well, no, that goes like with informed consent. And but I think there's some clinical judgment here. Another red flag is smokers and diabetics. And I reviewed a case where the dentist told the patient, oh, I've had success in those cases. But still, you need some clinical judgment whether you want to proceed with these cases, because unfortunately, there's other professions out there that are called lawyers and they can jump and spin anything. And so that's why I say just be careful. And sometimes it's better to not do these cases or to punt on these cases when the medical history has so many risk factors. Well, let me ask you this. What if the GP refers to a specialist and says, listen, I don't feel comfortable treating this because of the risk factors. I'm going to refer you to a specialist. And then the specialist goes ahead and does it. And then the case fails because of the side effects of these drugs. Is the GP still? involved with that lawsuit? No, no. The GP did the right thing. He referred to the specialist. He said, I don't feel comfortable doing this case. And the specialist went ahead and did it. So no, the GP is not responsible. Okay. So once that GP refers the patient out of the office for treatment, regardless of the result of that treatment, the general dentist is no longer involved with a potential lawsuit. I wasn't expecting them to be the... primary defendant, but maybe a secondary or tertiary defendant in the case. But you're saying that they're off the hook. That's correct. Okay. What's your experience, by the way, in malpractice? You were a consultant for the defendant? Most of the cases, and this is a question they always ask you in deposition, is do you do mostly defense work or mostly plaintiff work? And I'm pretty much open to both sides, which sometimes I'll get cases for both. But it seems that a lot of cases have been pretty much working with the plaintiff. Yeah. I don't know if our audience wanted to hear that answer exactly that way. At least we're getting, it's actually a benefit to our audience to hear what you have to say based on that. ask, and I quote, any changes to your medical history? Now, that's a typical question. You hear that going from the GP to the patient all the time. And then they move on after that question. Now, we talked about this, Dr. Goldman. Why is that approach risky? And how should clinicians properly review and document medical history updates at each visit? It's a funny question, Phil, because I'll tell you the number of times that the hygienist will come rushing into my office, or I could be working on a patient, and she'll say, Mr. Cohen just told me he had his knee replaced a month ago, and he didn't take his pre-med. They said, well, you asked if there was any change in his medical history, and the patient said no. So I'll walk in, and I have a pretty laissez-faire attitude, and I'll say, you know, we asked if there was any change in your medical history, and you said no. And he said, well, what does my knee have to do with my teeth? When I go to the physician, they'll sit down and they'll review each line item. Okay, you had a stent place. You had this surgery done. You had knee surgery. Is there been any other surgeries you have done in that time? Also, I have you down as you're taking a high blood pressure medicine. You're taking aspirin once a day. You're taking vitamin C. a thousand milligrams a day, and he changes to that. And sometimes they'll have something on there that we stopped, that it was only intermittent, and they'll remove it from the record. You have patients who are taking natural over-the-counter things like fish oils, vitamin E, ginkgo biloba. Yeah, those are blood thinners. Yeah, those are blood thinners. So let me ask you this. The physicians do this. In your opinion, most dentists do not do this. So by not going line by line, And I guess what's the reason for, I guess, whether they don't think they have the time to do it or they're overbooked or whatever the reason is, what's the risk of not actually documenting precisely what the changes are in their medical history? You gave an example. One was with the hip or was it a knee replacement? Yeah, knee replacement. I mean, the good news is there is that very rarely, if any, does a prosthetic joint break down because of a dental procedure. But that practice got lucky. So what is, give me an idea of what the risk is of not precisely going line by line on the changes. The risk, like my biggest one is like a valve replacement or surgeries or some type of procedure that they have to be premedicated for or that the doctor recommends and they be. premedicated for. That's one example. If they've changed, for example, like in perio, my biggest thing is calcium channel blockers and gingival hyperplasia. So if I'm not aware that they've switched to medications, I may not be concerned. I may be unaware of what's going on with their gingival condition. Before we continue, I've got to give a shout out to our sponsor, NSK. These folks are the real deal. Their air and electric handpieces are not only top tier, they're the highest rated in the industry, peer-reviewed by Dental Product Shopper. Their Timex Z99L electric handpiece actually scored the first ever perfect rating. And the Timex Z990L is the most powerful handpiece on the market. So do yourself a favor. Check out everything they offer at nskdental.com and take advantage of their free trial by reaching out to your local NSK rep. I've heard this many times from many dentists. Once you start using NSK handpieces, you'll never look back. So the number one malpractice claim in dentistry, and correct me if I'm wrong because this is what you consult on quite often, Dr. Goldman, is failure to diagnose periodontal disease. I mean, it's as simple as that. It's an actual missed diagnosis of an infectious disease, right? Periodontal disease is an infectious disease. From your perspective as a periodontist, what should proper perio charting look like for new patients and recalls for that matter? And where do GPs most often fall short? For each new patient, you should be doing the six-point pocket charting. Early on in my career, I tried to debate with the insurance companies, what's the difference if it's a two or three? When you go to submit for insurance, and here's the practice management part of it, they want six-point pocket probing. They want to look at the perio charting, and they want to see all the pocket depths. So that's the important thing. Not only is it good for patient management to know where you're starting, but also if you're sending in to the insurance companies. As a routine procedure, You can do a scanning, pretty much pick up the probe. If you're probing five, six millimeters, you know the patient's going to need replaning and scaling. If I'm probing seven, eight millimeters in a quadrant, I know that area is going to need surgery. So that's why it's important to have those initial numbers. When I'm reviewing a malpractice claim, the pocket charting is really key because if I see five millimeter pockets or greater, I go to the chart entries to see, is there a perio diagnosis? For example, is it generalized or localized, moderate or severe perio? Number two, what perio treatment was done? If I see four or five millimeter pockets, seven millimeter pockets, and I see the patient was in for a prophy and it says next visit, six month recall. then I wonder, you know, I guess they missed the period diagnosis. The question is always, doctor, you were probing five, six millimeters and you just did a prophy on this patient. You never got him back. You didn't do any period treatment. I don't see any recommendation for root planing or scaling. And then if they do the root planing and scaling, is there a follow-up to see if the pockets are reduced? And if they weren't, was a referral to a periodontist? So usually in a malpractice claim, the GP failed. to observe the pockets were getting deeper, didn't do any treatment, and neglected the situation. Or he didn't make the referral to the periodontist. Yeah. So you teach in a GP residency program at Beth Israel Hospital in Newark, New Jersey. And you were on the resident selection committee for many years. And many of these residents were in the top 10% of their class, of their graduating dental school class. And you found that they did not have a really keen understanding. of periodontal diagnosis, understanding the whole process of periodontal disease and treatment. And you felt they weren't well prepared for the real world. And of course, we're talking about malpractice. And so this is concerning. And speaking as a graduate of a dental school, Penn, which was very focused on periodontal disease and periodontal therapy, obviously the dean was D. Walter Cohn, who wrote the book on it. I proceeded to go into grad endo and become an endodontist, but my perio background really helped me a tremendous amount with my diagnosis and treatment of patients that were referred to me because I understood the attachment apparatus and I understood periodontal disease so well because of the training that I got from the school I came from. Now, these students, you told me, they're just ill-prepared. Talk to us about that. We do the interview and then I'll say, what's your perio experience? And most of them had no perio experience in root planing, in flap surgery. And most of them have never even picked up a Barb Parker blade, which always amazes me that how you can go through four years of dental school and not know how to make a flap. So my favorite question is always like, so what was your perio? And it was always, well, we do root planing and scaling. What do you do? after replaning and scaling? And the stock answer, it's always like it's rehearsed. They all spit out the same thing. Wait six to eight weeks and then reevaluate. And I asked, what magically happens after six to eight weeks? And to which I get that deer in the headlights stare, like, what do you mean? I said, if you started with seven, eight millimeter pockets, you did one visit of replaning and scaling, you think it's magically... to shrink up to three millimeters. And they look at me like, well, then we usually refer it to PG perio. So they have no experience. I mean, did they get to observe any grad perio flap surgery when they were dentists, when they were dental students? What most of them will say is I assisted in two surgeries. Well, come on, we know assisting in two surgeries is not. doing two surgeries yeah but what's more concerning is to me based on the feedback you're talking about dr goldman is that they assumed even with pocket depth of uh and i think you were talking about seven to eight millimeters is that what you're right yeah right scaling and root planing is the first step to get the tissue a little bit healthier but without having some sort of surgical intervention or maybe some possible laser therapy and, you know, LENAP or something like that. But I don't know enough about the research to show that. But based on your experience, you're pretty much set on that patient needs surgical intervention to reduce the pocket depth so they can clean at home. They can maintenance these pockets. Is that correct? Yes. My whole philosophy is to get access to make a flap and... I work with them and we do the first surgery with them and we make a flap and they see the calculus that's left, usually it's at the CEJ, which I'll point out to them, but they're amazed that, wow, they thought they did such a good job doing the root planing and scaling. So making a flap, getting access to that area, spending the time doing root planing and scaling is really... the key to trying to reduce those problems. Yeah, so those residents were lucky they had you as their mentor in their general practice residency. So let's talk about radiographs for a second, because again, we're talking about malpractice in this episode. Radiographs are a frequent point of confusion because of insurance limitations. And I got to tell you, I'm so against having insurance companies dictate what we should do as clinicians. that's where it's gone. I mean, we've kind of let them do that to some extent. Can you explain why full mouth radiographs for new patients are still essential and why the proverbial insurance didn't cover it response is never a legal defense? It's a good question, Phil. And it's a question I get a lot when I'm doing some other seminars, when they say, patient says, well, it's not covered by the insurance. Number one, today with digital radiographs, it doesn't really cost us anything to do x-rays on patients. And I can't do a diagnosis. If I'm trying to defend your case and you have bite wings from 2021 and a couple PAs, there's no defense. You can't see everything. Even with full mouth x-rays, we know sometimes it's difficult to get the apex of certain teeth and how certain patients can't open wide enough. But the important part to malpractice is that you have recent x-rays. Somehow we said every three years was good. Then the insurance companies dictate, oh, every five years. You can't really do full mouth x-rays every five years. Anybody who's out there knows that things happen. So the question really is, so what do you do here? I would say, tell the patient that it's not covered and see if they pay. Other times I could say, okay, it's not covered. They only cover every five years. I'm going to reduce the fee for you. I would say. You got to forget about the money in these cases. It's crazy. You're arguing over $150 for x-rays when you have a $2,000 or $3,000 treatment plan. So when it comes to avoiding malpractice claims, how important is it to document a comprehensive diagnosis and discuss all reasonable treatment options? And that includes implants, fixed, removable, or even no treatment at all, like actually putting down and recording. no treatment at this time for whatever reason. Tell us about the importance of that, that kind of documentation to avoid malpractice claims. Anytime you have a conversation with a patient, and I emphasize this in my lectures and when I talk to residents, write it down. I spoke to Phil, told him I suspected a fracture number 30. He says, it doesn't bother him, I'm going to leave it alone. So something happens and then you come back and you say, You never told me the tooth was fractured. Phil, remember you were in, you were complaining of pain here. I said, let's adjust the bite. It could be a fracture. And then you show it to them in the chart. Patients are more likely to back down after this. Also, most state boards even say that you're supposed to document all the treatment plans. Working with my residents, even though it's a teaching situation. We'll go over the treatment plan. I'll say, okay, what happens if the patient only wants to do what the insurance pays? What happens if they don't have insurance? What's the ideal treatment plan? I said, here at the hospital, gee, we have a lot of options. We could do two, three implants for these patients where if they went out into private practice, they'd never be able to afford it. So write down all the possibilities. Sometimes we have to send it in to the insurance to get a pre-estimate. Yeah, so in other words, if you think that a patient, you're assuming the patient will not financially go for something, you don't not suggest it to them just because you think they're not going to, based on the history of that patient, they're not going to pay for it or they don't have the resources. By you not presenting it to them, you're saying that they are opening themselves up to a lawsuit because that patient can come back to the GP and say, you know, you never even gave me the opportunity to say, that I may want that treatment. Maybe I fell into some inheritance or my cousin hit the lotto and he's ready to pay for my dental work. So is that what you're saying, that that could be opening yourself up to a lawsuit? That's a liability. And it's happened. I've prejudged people. They want implants. So right away you think, I'm just wasting my time with this patient. But then I'll go through the treatment plan and I've had people come up to the front desk and they'll... out a check. And I'll hear my office manager say, no, you don't have to do it next week when we do the implants. So do not prejudge. Well, you know about the millionaire next door type, you know, the millionaire next door drives a Subaru. He lives in a, you know, a 2,600 square foot house, nice, comfortable area, but not extravagant, but he's worth, you know, $50 million because he lives a very simple life. very unassuming, and you can't prejudge these patients. And again, the most important thing is that you tell them what their options are so that it doesn't come back later to haunt you. Right. Yeah. So let's talk about financial misunderstandings because they often fuel lawsuits. Talk about using the terms warranty and guarantee when presenting a case to the patient. What's the difference between the two? Should we be using these terms? And also, can clear written financial arrangements, especially around insurance limitations, protect both the dentist against a lawsuit and the patient as far as what their expectations are. We'll be getting right back to our guest in a second. But first, for the optimal bond between zirconia and your resin cement, check out Bisco's Z Prime Plus. Rated best in class by thousands of top clinicians, Z-Prime Plus, featuring MDP, creates a strong, reliable bond to zirconia, metal, and alumina substrates. And nothing could be simpler. It comes in a single bottle, and it's 100% compatible with both light-cured and dual-cured resin-luting cements. It's time you get the most out of your zirconia restorations. To learn more about Z-Prime Plus and the entire Bisco adhesive product line, visit bisco.com. I mean, for the purpose of this conversation, we'll use the terms like warranty, guarantee, interchangeably. You know, a denture may not be warrantied, but if it breaks in two or three years or a tooth comes out within that time, my philosophy, practice management, and I preach all this time, is you probably just do the repair for the patient. We're always taught there's no guarantees in dentistry. My favorite is always, I hate to go against endodontist, but the endodontist will do the root canal and beautiful root canal and the patient never goes back to the dentist and six months later bites down on an olive pit and breaks the tooth. Well, no, the root canal is fine. I did my job. There's no guarantees as far as that. What I do say is, For example, a couple weeks ago, I did a root amp on a tooth. Well, we know that the success of root amps is not that great. But it was a mesial buccal root of number three. The tooth looked good. And I tell the patient, listen, we're going to try this. I know they're not in a hurry to take out the tooth. They don't want an implant and a sinus graft, especially in a maxillary molar area. They said, we're going to do this. I give you a guarantee. And I write it down. I write it down because I have a good memory, but it's short. But I write it down. And if something happens, and I always tell them, if it fails within the next couple of years, I'll just credit it towards the extraction and the implant. But you got to be careful when you guarantee or warranty anything. Well, let me ask you this. When someone gets a veneer and they say to their cosmetic dentist, you know, I want to do this veneer. It's $1,500. I want it to last 10 years. And he says, he or she says, it should last 10 years. It should. Anything could happen, but it should. By making that statement, are you opening yourself up to a situation where your risk is higher for that patient to sue you down the road if the veneer doesn't perform as hoped for? When you say it should last 10 years, it's like with implants. Oh, how long should implants last? I've had implants last forever, and I've lost implants after 12 years. So that's what I try to explain. There's no guarantee. But in your case where you say, oh, it should last 10 years, you really have to be careful how you word things as far as how long it should last. What I would say is... anything happens, if it breaks within the next couple of years, I'm happy to replace it maybe just at the lab fee. When it comes to insurance policies and written financial agreements, you're one that you want to make sure that the doctor has a copy and gives the patient a copy, correct? Correct. Okay. And you recommend also giving the patient a pre -estimate from the insurance company. And also not all plans go from January 1st to December 31st. So we can't assume that it's the calendar year. So there's a lot of things we got to make sure we're aware of and that our staff is aware of because these little things can be gotchas that could turn into something more substantial when it comes to lawyers suing your practice. Right. You know, people say, well, can you get a pre-estimate? I don't really like to do pre-estimates because it could take six to eight weeks to get back from the company. What we always did in the office was my office manager would call up. She'd find out what the maximums are per year. Is it a calendar year? Is it a PPO? Can they go to any dentist? Do they have out-of-network benefits? So having all that information up front when you go to present your case. is much easier. And then there's no questions later where after you went ahead and you did the crown and you told the patient it's covered at 50 percent and then the insurance comes back and says, well, they're over their maximum or they had a crown done three years ago. We only pay every five years. So that's always good. What happens is, is then, you know, you're you're out the money. The patient doesn't want to pay. You wind up suing the patient and then. The knee-jerk reaction with most patients is, well, I'm going to sue you, and then the dentist will back down. You're a proponent of GPs getting their lab costs up front and possibly even using third-party credit organizations like Care Credit, and there's others out there. Tell us about that, and how does that help the practice? Most GPs, we're a little laissez-faire when it comes to financial. We don't want to charge the patient up front. But my referring dentist, when I walk into their office and we walk into the lab and there's cases sitting up there, I always feel bad. I say, listen, you paid the lab cost. So just presenting to patients up front that when I take the impression, I need to get at least X amount up front. And a lot of patients are going to say, well, can I pay you after the insurance? What is the insurance going to cover? So that's why those financial arrangements are important. And just to be upfront with the patients, well, I have to pay the lab for it. So if you could just put two or $300 down, I would like that. Now, the dentist shouldn't be saying this to the patient, right? No, no, no. The office staff. Yeah, right. So when the treatment plan is presented to the patient and they accept it, what typically happened to me, my dental, when I went to the dentist was they came in, the office manager came in or somebody came in, financial person. And it was all printed out. It said, this is what you're going to get done. This is what your insurance covers. And here's your responsibility. And here's what you need to pay today. And I had to sign that. Is that something you recommend? Yes. Yes. I never like to discuss money with the patients. So that's why I always had my office manager would do that. I would do the treatment plan and then she would go. And she'd say, okay, you're going to need four quadrants of root planing and scaling, four quadrants of surgery. We're going to make you a night guard. Here's the total cost. Here's what your insurance covers. But to let them know, ballpark what it's going to be. If it's a $3,000 case and they get $1,000 from their insurance, then we'll make the financial arrangements based on the $2,000. As long as it's paid for by time, we're done. But we were talking about like this third party, like care credit. It's really great. Sometimes they take a little hit, but they, if you have a big case, a four or $5,000 case, you put in for the whole case first. Within a week, you're going to get a check for that. And then the financial arrangements are between care credit and your patient. You don't have to send out statements. You don't have to go chasing them for the money. What percentage do they usually take? if you do a year i think they charge almost 10 okay so four thousand dollar case they take four hundred dollars Right. But you get paid. You get paid up front. You don't have to chase the patient. I would take that in a heartbeat. Yeah, I would take that in a heartbeat. So let's pivot over to dentures for a second. A dentist fabricates a denture for the patient, upper and lower. There's a balance. And the dentist has his staff or a collection agency go after the balance. And the patient says the denture doesn't fit. And you're saying is any denture that's not paid for doesn't fit. So elaborate on that for us. Any denture that's not paid for doesn't fit. That's when you call the patient, you have a balance. We've been trying to collect the balance. And they say, oh, well, the denture doesn't fit. But they never called you to come in for the adjustments. So it's always when these things go to the state board, they try to sue you over it. They're going to say the denture didn't fit. But if you never came back for an adjustment. Or never complained to the dentist saying that. Right, never complained. Never complained. And then as soon as we call you and we threaten to send you to a collection agency. All of a sudden the denture didn't fit. Right. So does the dentist have a case there or is it even worth pursuing in small claims court? My experience with small claims court. is I have a stack of, same thing with collection agencies. Rarely do you get paid. You send somebody to small claims court, you wind up losing almost a day out of the practice. And even if you do get a judgment, it becomes hard to collect. What I do find is you put a lien. So when they go to sell their house, and I've had this happen where I'll get a check. 15 years later, I said, what is this from? Oh, well, he went to sell his house and he had a lien on his house. Yeah, and anybody can put a lien on anybody's house. You don't even need to go to court. I think it's pretty easy to put a lien on someone's house. But usually the title company clears that up because they tell the person who's trying to sell their house, if you owe this person money, just pay it because we can't clear the title. So the moral of the story there is you should at least cover your lab costs on that denture. And if they don't pay the balance. Now, should you deliver the denture before that balance is fully paid? It's always nice to say up front. Again, this becomes a very difficult situation where if the denture patient comes in and you're supposed to deliver the denture that day or insert the crown that day and they say, oh, I didn't. I didn't bring the copayment or I, you know, I'll send it to you next week. It's always difficult to not put it in. I think legally, you probably have to put the crown in or you have to give them the denture. Good financial arrangements, even from the beginning. Your office manager, your financial person should say, listen, it's going to be three visits. We're going to take an impression. We're going to do a trial fit. We're going to do this. So we're breaking it up in three visits, and it must be paid for before it's inserted. Everything up front. So as we get to the bottom of this podcast, I do want to ask you about depositions. It's important for doctors to take CE throughout their career. professional development so they learn about new techniques and procedures, obviously to stay up to date so they can best service their patients. In addition, the states, many states, if not all, require CE to get your license. But another reason is if you are involved with a malpractice lawsuit, we talked about this, Dr. Goldman, that the plaintiff's lawyer will ask you questions about procedures that you may not even do in your office. And there's a strategy behind that. And that's why it's really important to know about things, even if you don't do them in your practice, to at least be familiar with them. And this obviously is a reflection on you as far as making the right clinical judgment with your patients. So the lawyers can get you on this. So address that, if you will, Dr. Goldman, how important CE is as it relates to being deposed in a malpractice lawsuit. Yes, that's a good point. You know, the continuing education, most state boards have like 40 hours continuing education every two years. And I said, even me as a periodontist, I love to do these webinars on restorative dentistry. There was one on silver diamine fluoride. And when I bring this up in lectures and I talk to other... General dentists, they're not even aware what silver diamine fluoride is, you know, to help to arrest caries. So I said, I take these courses. And I think it's really, again, incumbent upon us to be up to date with everything. That was one of the questions before, should be up to date. In one of the depositions, the plaintiff's lawyer, pretty astute, knows a lot about dentistry. And he asked the defendant, you said that the patient. didn't want periosurgery. And she said, that's true. Never wrote it in the chart. She was trying to defend why she never sent a patient to a periodontist. And the lawyer said, well, did you tell her about the LENAP laser procedure? And the defendant said, what is that? At that point, her lawyer just put his head in his hands and the defendant had submitted with pocket charting and everything else. She didn't even know the difference between pocket depth and attachment loss. So essentially, she lost the case right there. She had to settle, I assume, based on the fact that she didn't know what LENAP was, because that's something that should be presented to the patient, especially for someone who's afraid of surgery. It gives them another option. So that's a liability right there, no question. So while we have you on the show, I have to ask you this. We often hear the phrase, if you didn't write it down, it didn't happen. What are the most critical documentation habits dentists should adopt, especially with informed consent, refusals, referrals, oral surgery, dental implant planning, all that stuff? What are we talking about here? Yes. I'm going to emphasize that again, the documentation part with the medical history, the pocket charting, your treatment plans. You mentioned like if a patient refuses x-rays or refuses perio treatment. A question that comes up a lot of times is, what do you do? And unfortunately, this is a point where you may have to end the relationship with the patient. And you got to be aware of abandonment and ADA ethics codes. But I had patients and I just had to say, listen, I'm presenting these cases to you. I think you need to have the work done. If you want, you can go for a second opinion. But I just don't feel comfortable treating you here. If you're going to keep refusing x-rays, you're going to refuse. keep refusing to do the periosurgery that I think is necessary. So that's the conversation. But to document it in the chart that I had the conversation with the patient, discuss the options. Again, you don't have to write a whole novella. Some people write a whole book here. Just say, spoke to patient, recommended getting a second opinion or offering to refer her to somebody else. So we can't make everybody happy. I'm telling you that over the years, These are the cases that come back to bite you. You know, you think you're doing a favor for a patient. You know, you're telling them, OK, we're going to try to hold on to this tooth. And then, of course, the week you're away, they go to somebody who says, oh, my God, you have advanced periodontal disease. And hadn't anybody ever told you about this? Or now that if we take this out, now you're going to need two implants and the patient's head is spinning. They walk out of the office and right away they lost that trust in you and they're ready to. I mean, the good news is, is that these kinds of malpractice lawsuits are few and far between. That doesn't mean we shouldn't take them seriously, because when they do come up, it's a pain. But there are things we could do, as talked about in this podcast, to reduce the risk of being sued. And if we are sued, we have a much better chance of defending ourselves. Very, very good discussion. Thank you, Dr. Goldman. I appreciate your input and hope to have you on future podcasts. Have a very nice evening. Thanks, Phil. Thanks for inviting me.