Expertise with integrity

In the Court of Dionysius

Toby Talbot shares his personal experience facing a General Dental Council PCC…

It isn’t with any pride that I write this article, but with humility. After enjoying 40 years caring for thousands of patients with few complaints, I have just spent eight days listening to appalling negative accounts about myself. I have had to face the very real threat of censure, conditions, sanctions and the possible loss of my license to practice. My future, and my reputation, lay in the hands of just three people sitting in front of me.

Having found oneself up before the Headmaster, it’s intuitive to put one’s tail between one’s legs and hide in shame. But rather than scuttling away and ‘putting it all behind me’, I am embracing the openness and transparency that is de rigeur these days, and feel compelled to share my experience with others. Almost every one of us will face our governing body at least once in our professional lives, so whether you’re a doctor or a dentist, I hope this account will prove useful.

I have had the misfortune to face two professional committee hearings in my working life which in the short term, literally shorted my life, but actually in the long term have had a positive and profound effect upon my practice protocols.

In both cases, I didn’t see them coming. Neither patient gave an inkling of what they intended. Neither patient had verbalized their discontent to me in any way. The only indication that I NOTED was that the patients had decided to go elsewhere for treatment and never returned. In one occasion they stated monetary restraints prevented them continuing to attend my clinic, and one patient just failed to return for follow-up.

The first I knew anything was amiss was courtesy of a letter from the General Dental Council (GDC) requesting original clinical records to be sent to their offices due to a complaint having been received. This letter was signed by a case worker who is effectively an experienced clerk whose job is to collect the necessary documentation for presentation to a committee.

As you read a letter like this your heart will sink and your stomach will drop with it. My advice? Never read any letter with the stamp of your governing body on the envelope first thing in the morning. I promise you – your day will not go well, despite your own superhuman effort to put on a brave face with your patients.

And do not allow your receptionist or practice manager to open such letters either. You don’t want to get the message from a staff member. Any letter bearing a governing body stamp should wait until the end of the day when your crew have left. I personally find a G&T before opening very helpful. If you’re lucky, it’s just a renewal notification and you can enjoy your second G&T. Instinctively, after you’ve read the letter, you will grab the patient’s records and remind yourself of the details. Whatever you do – do not start writing additional notes, consider re-writing those records or conveniently ‘losing them’ or part of them that you may feel will prove incriminating. The authorities WILL find out and you will then find yourself facing the ultimate charge possible – dishonesty.

Found guilty of that charge and you lose your license as it’s wholly indefensible. Whatever you do, don’t ignore it. A very senior advisor of my own indemnity insurers revealed that after 40 years in the business he had only once come across a set of clinical records that could not be criticised by a committee, but sadly, it transpired that the practitioner had rewritten the entire records over several days, referring to references and standard texts, only to find himself with erasure.

Once you’ve read the patient’s notes, you must contact your indemnity insurers immediately. Transcribe the clinical records exactly if hand-written, and write your own account of events. This will add to the paucity of anyone’s clinical records that are made out in a hurry, contemporaneously and are invariably short on detail. If the GDC then say that they are proceeding, make sure your indemnity provider has also been informed.

A meeting will then be set up with your indemnity team to discuss the specific complaints of the patient and your formal response to each and every one of those complaints. Do remember that the clinical advisor will be a seasoned former clinician with a wealth of experience. They will be supportive, but at the same time will point out the chinks in your armour that leave you open to criticism. A draft of your response to those complaints will be sent for your approval. Don’t make stuff up because it fits. Be thorough when reviewing this letter as it’s your testimony and is difficult to change.

The complaints of the patient and your formal response will now be passed to a review committee and a decision made as to what action is appropriate. They may decide there is no action to take and the case is closed. They may decide that advice is given and no further action is to be taken. They may decide a formal warning is indicated and this will be posted on your entry on the GDC website for a period of 6-12 months. Alternatively, they may decide to refer the matter to the Professional Conduct Committee (PCC) for a formal hearing to be set at a later date.

This becomes the Sword of Damocles that will hang over your head until conclusion of the case. You will find this spot a lonely place. Support from colleagues and family should be regarded as peripheral. What you really need is proper, practical, professional guidance from a someone who is an absolute authority on the processes involved, and ideally has complete insight into the mindset of the GDC. My mentor became Liz Gibb at lizgibb@psychmetrix.co.uk.

While awaiting a PCC hearing, don’t be surprised if the number of charges increases enormously. Ultimately, I found myself facing 85 charges related to two patients, after treating two teeth. Once the charges have been levelled, you will require a further meeting with your dental advisor, and with legal counsel including a solicitor and barrister to prepare your own witness statement.

In the meantime, you must look carefully at each and every one of the charges and list them on the left hand side of a document that only you can produce. This is the ‘reflective document’. I include sections of mine below as APPENDIX ONE. You will treat this document with enormous seriousness and conviction. In essence this document clearly sets out each of the individual charges, what you’ve learnt, and what action you’ve taken to address the issues. Don’t hold back with this. Put your heart and soul into it. The indemnity team will not write this for you.

For example: A charge of poor record keeping may be levied. Show clarity of insight into the actual ‘failings’ and then document precisely what you have done to remedy this. Name the courses you have attended, and list the amendments in your record keeping, to ensure this is not repeated. I’m a seasoned clinician. I have always regarded my own record keeping as my ‘scribblings’, always carried out in a hurry as the patient is just about to leave the surgery. I still depend on my own handwritten notes, which is far more vulnerable to omissions when compared with the computerised proformas that are used by younger clinicians with IT systems well-established.

What’s most important is that you do your homework. Read the latest edition of Standards for the Dental Team cover to cover. It is the most boring document you’ll ever read in your life, but possibly the most important. It’s through this reference, and the help of Liz Gibb, that I gained most insight into myself, as well as into the issues that underpinned the charges.

In my particular case, I had no difficulty accepting charges of poor record keeping, but I had enormous concerns about the charge of dishonesty and misleading the patients. It was not only hurtful, but was also the most serious, because if found to be true, it would invariably lead to immediate erasure from the Dental Register.

Engagement with Liz Gibb of Psychmetrix is a unique experience. She is based in the depths of the Scottish countryside so everything is carried out on Skype – quite an experience for an old codger like me.Liz will need to have sight of the charges and a copy of your own reflective document. My own reflective document amounted to 130 pages and took months to compile. In an initial interview with Liz I gave the salient details of the charges against me, what caused me the most concern, and what I expected from her.

Although she has an in-depth understanding of the language and culture of the GDC, she also has personal experience of attending their hearings in her capacity as an expert witness in occupational psychology. If you’re a bad’un, after a 30-minute interview, she will sniff you out like a dead rat in a soil pipe. I found my first interview with her stressful. I have always regarded shrinks as professional mind readers.

The most useful advice Liz gave was to use GDC language in my reflective document, referring directly to ‘standards’. Thereafter, she asked me to complete a number of psychometric tests – 120+ questions, all to be answered intuitively. If you dwell on any question too long it often reflects that you are trying to second guess the right answer, and you can bet your bottom dollar she’ll find out.

In my case, because my main concerns hinged around the subject of dishonesty, she asked me to write about the subject, beginning with my own definition of what constitutes dishonesty, and how the GDC may have arrived at their conclusions (See APPENDIX TWO below). In my case, it all came down to my own view of consent as a continuum of what is verbalised and written down. I didn’t record everything said to a patient in writing, and I should have.

It took me about 4-5 weeks before I really grasped the salient points, viewing the issue from the Committee’s perspective, and acknowledging that it was entirely understandable. Then I turned to the presentation of my own view. I began by assuming the GDC charges might be correct. Why would they think that? Now I was in a better position to respond. Do remember, if the Committee are right, don’t be afraid to admit it.

It shows openness, transparency and integrity. I readily acknowledge that other practitioners will have different needs when working with Liz Gibb, related to their own coping skills when faced with this experience. Some time ago I myself spent an evening talking to a senior colleague who had decided he would take his own life and leave his family bereft rather than face the music. As it turned out, he didn’t and ended up with barely a slap on the wrist for poor record keeping. Another colleague hit the bottle, lost his job when he fell out with his colleagues, and lost his family when he fell out with his wife. He is now living under the care of social services, a totally broken man.

Let me be quite clear here – family, friends and colleagues will all be well meaning, but they are amateurs. You will require professional help to provide you with the emotional tools to get your mind in the best place to manage yourself, whoever you are and however robust you may be. You won’t find this support with your indemnity insurance company, you will with Liz Gibb.

To return to the reflective document – I assumed the Committee were right in their charges, so I began my reflections by acknowledging how they might have come to their conclusions, but then following up with rebuttal’s or solutions for avoiding a repeat of the misdemeanour.

Let me give you an example. I was carrying out some treatment on a tooth and discovered something unexpected. As I constantly give a running commentary to all my patients as I work, I proceeded with the modified treatment as indicated. However, although I documented the adverse events, I didn’t document the specific fact that I had TOLD the patient about it. In other words, I should have merely added the words ‘patient informed’ and that would have been the end of the matter. Although I distinctly recall that I did TELL the patient, the clinical records did not provide the EVIDENCE and the Committee found the patient’s complaint proven.

In my reflective document I declared that we now have a clearly defined policy – every adverse event, however minor, is clearly recorded with the addition of the comment ‘patient informed’. My reflective document still allows me to defend myself with respect to my recall, but emphasises to the committee my insight and action taken. A hard lesson learnt. A PCC hearing begins with the charges read out by opposing Counsel. This is then followed by the patients in the witness box being led by their Counsel and then cross- examined by your own. To this point you have only heard dreadful things about yourself, so during the break, take a brisk walk outside to get some air.It is then that you have your turn in the Witness box. Your Counsel kick off by confirming your CV and your working practice. Then specific questions about your treatment of the patients follow. Thereafter their Counsel begins cross-examination.

Throughout the process ensure that your chair and body stay facing directly towards the Chair, to engage eye contact when giving your answers. Ensure you have to turn awkwardly towards Counsel so that you instinctively return to face the Committee. Answer all the questions given and always answer truthfully. Don’t try to weave an answer you think they want to hear. If you remember something, even if it’s not documented in the records, say so. If you don’t, say so.

One of my cases was related to events nine years earlier. Of course I didn’t remember. If I had said I did, I would have had no credibility at all. If you contradict the patient with conviction, remember that the patient is only ever recalling events themselves, as they rarely make any notes at the time. They are not police officers with notebooks in their top pockets. It may just come down to who the Committee find the more convincing. And like all committees they can contradict themselves. At my own hearing, they concluded I was a reliable, believable and credible witness and so too, the patient. They still concluded that her account was proven.

So much for the balance of probability. As I’m sure my reader is aware, Civil Law departs from Criminal Law in this respect. Under the former one may find in favour of 51%, under the latter one should be 99% certain of guilt, or ‘beyond reasonable doubt’. As the Committee reported that I was a credible witness and the patient was equally a credible witness that amounts to a 50/50 split in old money. That should have led to an open verdict, surely? However, it is my opinion that PCC committees are institutionally biased, and favour whatever the patient has to say in ‘evidence’. Despite the noble principle to the contrary, it seems that a defendant is guilty until they prove their innocence. I believe recent criticisms of the GDC have led to this cultural bias.

If a question is asked of you out of context, answer yes or no, but ask the Chair if you can put the matter in context so that they have a complete picture. My style of engagement with patients is considered highly informal, and I was often criticised by Hospital colleagues in my earlier career and by my own legal Counsel in camera. But that’s me. I don’t need to make excuses for that style, but I may have to explain it to a committee of members that are highly institutionalised and politically over correct. I am quite happy to be regarded as a contrarian in my postgraduate capacity, but that does not make me a rebel. I can take criticism from my peers and I make it clear to the committee that I can display insight when rebuked and accept that criticism with grace and humility. Humility is important, because arrogant stubbornness wins no friends.

Remember, the Expert advising the GDC will only have access to your records. They never carry out a clinical examination of the patient. Also remember that the Committee may include only 2 registrants (usually only one dentist), so considerable time is spent explaining quite detailed clinical events to a non-dental audience. Be patient, and never lose your temper in the Witness box. Don’t become frustrated when opposing Counsel have asked you the same question repeatedly in different ways. They’re just trying to get you to contradict yourself and lose your professional integrity.

Ensure that your Indemnity Insurers engage your own Expert, as lay members of the committee do not always appreciate that there are wide variations in opinion within the profession, and relying on a single Expert is inevitably going to present a skewed interpretation of the literature.In one of my PCC hearings the Expert advising on behalf of the GDC was wholly discredited by our own Expert and was not asked any further questions. In another,  a patient was shown to be wholly unreliable in the wake of numerous contradictions. The Chair stepped in, thanking the witness for their contribution and indicating that the questioning had ended.

As part of my preparation I carried out a specific patient survey before the hearing and presented the results to the Committee. I focused on the specific charges levelled at me, and garnered direct feedback which I referred to as ‘the patient voice’. This provided very persuasive support. I include this questionnaire below as APPENDIX THREE for the benefit of readers. Note my use of the language of ‘standards’ in order to strike a chord with the Committee. The bold type in the questions reflect the same words used in the charges directed against me.

Patient and Colleague testimonials are only referred to by the Committee after they have reached their conclusions having considered all of the facts. These testimonials are read by the Committee before they decide upon their final decision of what action is to be taken. Remember, you will have successfully cared for many patients over the years. They will be your best Ambassadors for you and your qualities. I felt that my patients’ letters and testimonials, along with the patient survey, influenced the Committee’s decision with respect to whether my current practice protocols were adequate to prevent a recurrence of the issues. ‘Current fitness to practice not impaired’ were the Committee’s concluding words.

Ultimately, the only upshot is that I now have less time to actually treat my patients due to additional paperwork. But, by way of an epilogue, I’d like to conclude with some reflections on what I’ve learnt.It is a deeply stressful experience and professional support is advised. In my opinion, the language used by the GDC in all their correspondence to me was unnecessarily brutal, and implied my guilt from the outset. This is wholly contrary to the statement of the Chair of the Committee in which the emphasis was placed on fairness. It was exceedingly distressing. My stress levels were enormously increased for the entire 30 months that passed from the arrival of the first letter from the GDC, to the final outcome.

There were times when I found myself in a very dark place.Finally, as if to rub salt into the wounds, when the Committee concluded that my current fitness to practice was not impaired, they nevertheless keep a record of the entire proceedings on the GDC website for one month after their decision is made. Again, this departs from the stringency of criminal law whereby once a not guilty verdict is reached, the Judge asks for the person in the dock to be released immediately.

When I combine the brutal nature of correspondence received from the GDC offices throughout the process, with the bias I perceived at the hearing, and the continued inclusion of my case on their web site after judgement, it appears that the culture of the GDC is one of complete disdain, especially amongst clerical staff, for members of the profession, and reminds me of the Spanish Inquisition and McCarthyism. I don’t believe it’s a level playing field – the dice are loaded and the cards are marked, despite any gesture to fairness. Be prepared, and beware.

I also wish to add that my Indemnity Insurers advised me not to publish this account, as it could affect a blemish on my reputation. However, I believe it is well measured and demonstrates complete transparency on my part – surely honesty and openness fall short of slurs on my character?

All the views and opinions expressed by the author are personal but I would welcome public debate on all the issues included.

Appendix 1 ” My reflective Document”

Appendix 2 ” My reflections on honesty and the meaning of misleading”

Appendix 3 ” The Talbot Clinic Patient Survey”