Scenario: Fractured Instrument

This is a basic outline of areas to cover when discussing the scenario with the patient:

• Introduce yourself and check the patient’s details – this is commonly forgotten!
• Take a pain history – take a standard pain history from the patient following the acronym SOCRATES. Don’t forget to take medical and social histories as well. Listen to the patient’s concerns
• Apologise to the patient and explain the clinical situation as best as possible – advise the patient that an instrument has broken and, though not common, this is a risk of a root canal treatment. This needs to be explained a jargon-free manner. Ensure you apologise for the problems they are experiencing but you want to rectify this as best as possible. You have a Duty of Candour so cannot hide the fact there is a fractured instrument.
• Use diagrams/radiographs to demonstrate what you mean and where the instrument is – if you don’t have one in the interview, pretend you’re showing one – the actors will play along!
• Explain how you are going to manage their immediate problems – this re-focuses the patient on their current pain. Managing their pain is the primary concern for this appointment followed by future planning. Offer appropriate methods to manage the acute problem including drainage, antibiotics if indicated and extraction. 
• Discuss options for long-term management – re-treatment (most likely with a specialist referral) or extraction. Explain implications for the patient, especially in terms of cost. You may need to discuss the implications of referring to a specialist. 
• Carry out shared decision-making and a patient-centred treatment plan.
• The patient may be unhappy about the separated instrument and may want to complain – apologise that they feel this way but be diplomatic with answers, state facts and do not place blame anywhere. Try to shift the importance to managing their acute problems now and that you can remedy their concerns in a future appointment. If the patient DOES want to complain, try to stress the importance of their dental treatment and things going from this point so it helps show you are considering the patient’s problems first.
• End on an agreed plan going forwards to ensure the patient is happy.

You short-term management is about patient safety and mediating the initial situation:

• Be clear and jargon-free with explanations – use terms like ‘broken instrument’
• Use diagrams or hand motions to help illustrate your points.
• Show empathy – empathetic noises and gestures will go a long way – particularly when the patient is sharing their concerns and history.
• Demonstrate good non-verbal skills – body language and posture need to friendly. Ensure you carry out attentive listening.
• Let the patient speak and don’t interrupt them – allow them to explain their concerns and ask questions.
• Use open and closed questions as necessary
• Chunk and check your information – give a small amount and then check the patient understands as well as allowing them to ask questions. 
• Repeat and summarise important information – for example, once you’ve discussed all aspects of long-term treatment, finish by stating ‘so we will do …. for you today and plan …. for next time’.