Tell it like it is

Your setup for Lauren looks great. She has a severe Class II dentoskeletal malocclusion with a convex profile; therefore, double-jaw surgery is the solution to her functional and esthetic concerns. The past 10 months of orthodontic decompensation render her ready for the orthognathic surgery she will receive at a nearby teaching hospital. You meet with her attending surgeon, accompanied by one of his residents, for final treatment planning. You then see Lauren once more to place her surgical archwires and bid her well in this next phase of her rehabilitation.

A few days after her procedure, you receive a call from the surgical resident who tells you that all went well with Lauren’s mandibular advancement procedure. As he confirms that your patient is beginning to feel well again, you pause in contemplation and state that your recollection of her treatment plan called for a LeFort I osteotomy in conjunction with the mandibular advancement. Silence ensues from the other end of the line. You repeat your question about the need for maxillary surgery, because you are sure that the treatment result will be unstable without it. The resident nervously responds that he’ll return your call shortly.

Later that day, the attending surgeon calls you and apologizes for the oversight. He agrees that a LeFort I osteotomy should have been accomplished but concedes that it was not. He tells you that he’ll “keep a close eye” on Lauren’s progress as she heals during the next few weeks. You politely thank him for his return communication.

Your observation of Lauren once the intermaxillary fixation is removed confirms your fears about her treatment: the vertical dimension is opening, despite Lauren’s diligent cooperation with elastics. Now what do you tell her?

Concerns abound. You do not want to be accusatory of the oral surgery service given the inadvertent change of the treatment plan, but your patient’s welfare is your first priority. A patient has the right to know when miscommunication between cotherapists occurs—especially if there is a potential consequence to the patient. Concealment of such a miscommunication is a violation of the principle of veracity and could lead to both physical consequences and mistrust of the providers.

The fact that the oral surgeon did not discuss the procedural omission with the patient complicates the issue. Whether he realized the error or not is irrelevant. Although his resident admitted the oversight to you once he was questioned, the patient might have remained uninformed until the negative sequelae developed.

The disparity of knowledge between the orthodontist and the patient places Lauren in a position of unique vulnerability. She simply does not know what she does not know—and thus cannot be aware of what to ask. She relies on the doctor not only for delivery of safe, effective care, but also for protection of her overall well-being in matters related to her orthodontic treatment. The formal doctor-patient relationship implies that the patient trusts the doctor to disclose any facts that are pertinent to the success or outcome of her care. But how much need the surgeon disclose? Ethics authorities assert that which a reasonable person would want to know is essential to sufficient disclosure. Although that might remain vague and subject to personal interpretation, certainly a patient should be informed that a treatment outcome might be highly unstable.

If the surgeon will not directly approach Lauren to discuss the incident, you should contact him to verify his intent to remediate the shortcoming should the treatment result continue to deteriorate. Lauren should be informed that both you and her surgeon have established an agreement to stand behind your work. If Lauren declines future remediation, your obligation to provide her with sufficient autonomy is fulfilled.

Patients need to be apprised of misadventures that affect their future well-being. This is essential for their peace of mind as well as ours. As a veteran professor once told me: “Physicians have a distinct psychological advantage over us as orthodontists. They bury their mistakes. Ours follow us forever.”

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Apr 4, 2017 | Posted by in Orthodontics | Comments Off on Tell it like it is
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