Leaving
Leaving one dental practice and starting afresh is an exciting time, especially when you have a long career in front of you that is full of opportunities. It may therefore seem odd to be thinking about how you are going to leave a practice when some of you are only just beginning to settle in, but there are some important considerations to keep in mind for the future.
It is well worth getting the details right from the very start so that things are as straightforward as possible when you do eventually decide that it's time to leave and move on.
Foundation training
This is a perfect start to a dental career. It offers you an 'umbrella' of protection whilst you are finding your feet in the world of clinical dentistry that exists outside your university. There is plenty of social contact and useful training within your peer group, whilst at the same time you are employed under a twelve-month contract which ensures that your finances are looked after for you.
The national contract allows you to leave the practice after completing your twelve month training period. Should you wish to stay on at the practice under a conventional agreement that may also be an option for you to discuss with the practice owner.
One of the clauses to be aware of in your contract of employment is the clause which states that you cannot treat 'patients of the practice' for 12 months after you have left.
Associate/performer agreements
Leaving these jobs has some legal implications, as, in most situations, you will no longer be considered as employed, but classed as self-employed. There are many dentists practising without a contract at all. This is a dangerous position to be in. Quite simply, if you don't have a contract, you may find it very difficult to defend your position should a dispute arise. Hopefully that situation will not arise, but it is always wise to be prepared.
Negotiating contracts
It is really important that you pay attention to the 'small print' of the proposed contract. Often, practice owners will use the Dental Board or Association models as a basis for their contract, however sometimes they will draw up their own. It is widely accepted and indeed expected that you will give a reasonable notice period (usually three months) to the practice when you leave, which should allow time to complete any outstanding treatments. It also allows the practice time to find a dentist to replace you and take over the care of your patients. This period is not set in stone and if both parties are agreeable the notice period can be much shorter.
It is important that you follow the ethical guidance by putting the patient's best interests first. If you leave before the end of your notice period without mutual agreement, it could be seen as abandonment of your patients, so it is worth ensuring that appropriate arrangements are made for your patients' future care.
Restrictive clauses
Contracts will often contain restrictions on where you can work. In order to protect the goodwill of the practice, the owner may state that you cannot work within a certain radius of the surgery for a specified amount of time. This will vary depending upon the type of practice you are leaving. In a densely populated city centre the radius may be less than in a quieter rural area.
Before signing the contract take the appropriate advice and make sure that this clause is reasonable, otherwise you may find yourself working a long way from where you actually want to! Some contracts will also state that you have to work for a certain length of time before you can even hand in your notice, which may not suit every associate, so worth remembering.
Withholding fees
It is a commonly heard complaint that a practice principal has withheld a sum of money from the performer or associate's final month's pay. This arrangement is not always written into the contract. However, it is worth trying to come to a mutual agreement between yourself and the practice owner at an early stage. They will want to ensure that any treatment which needs to be rectified once you have left can be done without anyone else being out of pocket.
Often, an arrangement can be made where the principal holds a sum of money, and can account to the departed dentist with the relevant document regarding any necessary treatments that have been needed so it can be seen that the money is being used fairly. For obvious reasons arrangements need to be in place so that the relevant information can be shared between the practice and the departed dentist so that they are in a position to agree (or not!) to the fees being used in this way. It is not intended to be an open chequebook!
If there is any element of the sum withheld remaining after a certain period, usually 12 months, this can then be returned. Whilst it is tempting to argue this point, it can sometimes be advisable to leave the practice on good terms whenever possible, and to consider that this arrangement which allows for any failed treatment to be replaced quickly will benefit you by the simple expedient of removing the need for the patient to make any complaint about the original treatment that was provided.
Staff relationships
It is always advisable to leave a practice on good terms with your colleagues. Bad feeling can often lead to problems once you have left. It has been known for members of staff to indulge a personal grudge and incite complaints from patients which you will then have to defend. If somebody is feeling particularly aggrieved, they may want to raise conduct or behavioural issues which at worst could damage your reputation and at best result in a time-consuming wrangle.
Patient relationships
Once a patient gets to know you, they can put a huge amount of trust in you to carry out their treatments to a good standard. They may put you on a pedestal, which can be a difficult obstacle to overcome by the new dentist. It is important to communicate effectively with your patients to let them know that you are leaving. It can also be extremely helpful if you can tell them who will be taking over their treatment. It is always better to keep people informed, as nobody likes the shock of seeing a new face when they weren't expecting it.
If the new dentist then disagrees with your treatment plan, or perhaps handles the conversation insensitively, that shock can quickly turn to anger. This is why it is so important to keep full, contemporaneous records of the symptoms and diagnosis, and the treatment options discussed and decided upon.
Remember the mantra:
Good records = Good defence
Some records = Some defence
Poor records = Poor defence
No records = No defence'.
We know that there will always be variation between the treatment plans developed by different dentists. As the old saying goes 'there are lots of different ways to skin a cat!' Ask ten dentists for their opinion and you will often get ten different answers, which may all be correct in their own way, but it is the ability to justify those plans that is the all important factor.
Wherever possible, a course of treatment should be completed by the clinician who embarked upon it. Taking over a treatment plan midway through is fraught with difficulties. Any change in direction from the agreed plan would need the consent process to be revisited.
These differences between individual treatment plans can lead to complaints once you have left if they are poorly communicated to the patient. It is therefore important to ensure that you are contactable to respond to these complaints if they should arise. Make sure that the old practice is updated with any new contact details.
The apportionment of any fees payable for the work can also become overly complicated. In the event of a formal complaint arising from the treatment it can be difficult to determine where the liability rests if more than one operator has been involved in its provision
Financial considerations
The biggest problem financially in these early days is not putting enough money aside every month for paying the tax man. The chances are that your income will increase, and you won't need to pay the tax on it for quite a while. It is very tempting to spend the money and to tell yourself that you will catch up, but in reality this means a mad scramble to raise the cash which can be very stressful. An account can help by advising what sums you should put aside for future tax liabilities.
You also need to consider that when you leave one self employed position and start another, it can be financially difficult for a few months, as your productivity drops whilst you are finishing treatments at the old practice, and it can take a while to start an income flow from the new practice. It is worth planning for this if you can.
It may be that you won't be taking over existing patients, but will be seeing mostly new patients. Although clinically this may be easier than taking over existing treatment plans, financially it can be difficult initially as you may be spending a lot of appointments simply to complete one course of treatment which can have a knock-on effect on what you can earn in those first few months.
Having moved practices four times in the last 12 years, I have first-hand experience of the pitfalls this can present, although I have been lucky to have relatively few problems. Perhaps it was not so much about being lucky, as being prepared.
Change is part and parcel of life, no matter how unwelcome or inconvenient it may be. However the effects on a patient's care can be minimised by all parties attempting to act in a sensible and accommodating manner.
Caroline Chapman is a part-time dento-legal adviser for Dental Protection.
www.dentalprotection.org