Ethics Toolbox
Ethics Articles
Trust the Code
By: Dr. A. Garrett Gouldin; Member, Ethics and Judicial Affairs Committee
The first sentence in our American Dental Association’s Principles of Ethics and Code of Professional Conduct reads as follows: “The dental profession holds a special position of trust within society.” Dictionary.com defines a position of trust as the obligation or responsibility imposed on a person in whom confidence or authority is placed.
Then, in the second paragraph of our Code, we are reminded that “Members of the ADA voluntarily agree to abide by the ADA Code as a condition of membership in the Association. They recognize that continued public trust in the dental profession is based on the commitment of individual dentists to high ethical standards of conduct.” So, public trust of dentistry is inherently tied to our individual commitment to ethical behavior – makes sense - but is there any proof, and do patients really pay attention? We are dentists, we like data.
I was interested to read in the ADA News (July 15, 2015) an article that summarized the findings of a survey commissioned by the Association’s Council on Ethics, Bylaws and Judicial Affairs. The recent survey questioned 1,000 people to determine if patient’s awareness of our Code of Ethics, and whether or not a dentist was a member of the ADA, influenced their decision to become a patient of that dentist. Remarkably, 75% of those surveyed suggested that whether or not a dentist was a member of the ADA would influence their decision to choose the dentist, and furthermore, 69% are more inclined to select an ADA member dentist when they are aware that we follow a Code of Ethics. Surprisingly, 67% of those surveyed did know if their dentist was an ADA member.
The article concludes by suggesting that member dentists have the Code available and visible in their office, and that they post the Code on their website. What a novel idea, and given the results of this survey, who could argue? Every dentist I know publicizes that they are a member of the ADA, but I have never seen the Code, or even a link to it, on a colleague’s website. So, why not double down by making our Code readily available to our patients, a clear indication that we are aware of, and that we stand behind, the published ethical principles of our profession?
The Ethical Dilemma: To Refer or Not to Refer
By: Dr. Thomas J. DeMayo
Prium Non Nocere (“above all, do no harm”) is the principle precept of Medical Ethics and is also found within the ADA’s Principles of Ethics and Code of Professional Conduct under “Nonmaleficence”. The Principle of Nonmaleficence in brief states that the dentist has the obligation to provide the patient with proper diagnosis and treatment and to refer when necessary.
Today’s patients have a higher “dental IQ” than ever before and also have higher expectations regarding the treatment that they receive. There are many reasons which govern whether a procedure is performed by a general practitioner or if that procedure is referred to a specialty practice, but one’s personal economics should never enter into the equation. Likewise the patient’s trust in the general practitioner and fear of being referred to an unknown provider should not sway a dentist to perform a procedure that he or she otherwise would refer. The practitioner has an ethical and legal obligation to self-assess and decide if he or she has the expertise needed to manage a particular dental malady in a timely and predictable fashion. Every dental specialty association offers guidelines to the dental community concerning when it is prudent to treat or to refer a patient. And any local specialist would be happy to provide their general practitioners with lectures that review their specific specialty’s guidelines.
In general, reasons for a referral should be based on the level of difficulty associated with the treatment procedure for that specific case, the dentist’s personal level of expertise and confidence, the patient’s medical history, and/or the patient’s level of anxiety. Conditions specific to a patient such as a heightened gag reflex or limited opening, could make procedures, that otherwise would appear to be routine, very complicated. Proper diagnosis is paramount because only then can proper treatment follow. If the diagnosis was wrong, any treatment rendered, no matter how clinically excellent, is in reality a failure. This could lead to a patient’s loss of confidence in the dentist, the procedure, and in the dental profession. State of the art technology, instruments and the utilization of novel materials are no replacement for clinical skill and experience but are rather adjuncts that a practitioner can employ to reach a desired goal. It is imperative that a careful sequence of case selection and treatment planning be carried out based on the clinical presentation and the dentist’s own knowledge of his or her abilities and limitations1. The bottom line, as mandated by the ADA and VDA, is that the practicing dentist must be able to provide the patient with a level of care or competence that is consistent with the specialists who provide that same care in that same geographic area (this is The Standard of Practice). If a case exceeds one’s training or comfort zone or the general practitioner simply feels that it exceeds a personal level of competence, the patient should be referred. For a reasonable patient, who respects his or her dentist’s judgment and diagnostic skill, when time is taken to explain why a referral is necessary, the patient should be appreciative of the referral. The proper referral will actually allow the dentist more time for other procedures and will enhance the patient’s satisfaction and ultimately the doctor -patient relationship. The patient and the practice of dentistry will ultimately benefit from the ideal and proper treatment that is afforded to our patients.
In order for a referral to be a positive experience for the patient, general dentists need to have a good working relationship with each specialist to whom they refer. Most specialists will go the extra mile to treat an emergency patient in a timely manner. It should be understood however, that providers who regularly refer difficult cases will receive a scheduling priority and providers who only refer cases that had inadequate diagnosis or treatment, and want the specialist to “bail them out of trouble” generally will not receive top priority. A referring dentist should keep the specialist informed (verbally or in writing) of the suspected diagnosis, patient-specific nuances, treatment plan, what you anticipate as a treatment outcome, as well as what you have already discussed with the patient. Following any specialty treatment the general dentist should schedule a follow-up appointment with their patient. Of course the specialist should always provide a report following any treatment that includes appropriate information (as necessary) i.e. pre-op and post op images, histological diagnosis or the potential need for future procedures.
Advances made in dentistry have allowed our patients to maintain a functioning dentition for a lifetime, and any treatment alternatives that we offer our patients must have their wellbeing and health as our primary goal. We must always honestly assess our own level of expertise with regard to every patient’s unique treatment needs, and determine when to treat and when to refer.
1. Law A.S., Withrow J.C., ENDODONTICS Colleagues for Excellence Spring/Summer 2005
Dating Your Patient: Is It O.K.?
Many of you will not disagree with me: dentistry is an up-close and personal profession. But what happens when interactions between dental professionals and patients get a little too personal? Perhaps you’ve had a patient ask you out on a date. Maybe you’ve asked a patient to a romantic outing. The purpose of this article is to provide you with some guidance on what behavior is considered to be acceptable and ethical when choosing to date a patient.
The ADA Principles of Ethics and Professional Conduct states the following:
“Dentists should avoid interpersonal relationships that could impair their professional judgment or risk the possibility of exploiting the confidence placed in them by a patient.”
The Ethics Handbook for Dentists published by the American College of Dentists states:
“Dentists should not use their position of influence to solicit or develop romantic relationships with patients. Romantic interests with current patients may exploit patients’ vulnerability and detrimentally affect the objective judgment of the clinician. In such a case, the dentist should consider terminating the dentist-patient relationship in an arrangement mutually agreeable to the patient. Dentists should avoid creating perceptions of inappropriate behavior.”
So you’ve read the guidance quotes above and you still really want to date that patient? What do you do? What do you do if your hygienist or other team member wants to date a patient? What are the potential negative outcomes?
Any patient you or your team member desires to romantically pursue should be referred to another dental practitioner and his or her care should be well-established with the new practitioner before any romantic encounter occurs. You should have a written office policy outlining this procedure.
If you don’t terminate the professional relationship first and something goes wrong with the romantic relationship, you could face a variety of problems. Some states can seek professional disciplinary action against you if their code has a specific statement against dating patients. The patient may become litigious at a later date and/or may argue that you or your team member in question has unauthorized access to his or her private health information. In some cases, account balances may be forgiven or unauthorized credit given to the patient as a favor from the person they are dating. The public may also view these types of relationships as inappropriate.
It is your choice when choosing to enter into a more personal relationship with a patient.
Always remember to refer first and date second in order to protect your integrity and that of the profession!
References:
- Ethics Handbook for Dentists, American College of Dentists, p. 13 www.acd.org
- Chiodo GT, Toile SW. Sexual boundaries in dental practice: Part 1. Pub Med.
- ADA Principles of Ethics and Professional Conduct, Section 2.G., p.6. www.ada.org
Ethics: Understanding the Common Pitfalls of Patient Abandonment
By: Tonya A. Parris-Wilkins, DDS* and Joseph D. Wilkins, DPT, MSHA†
Often in practice, a dentist whether generalist or specialist is confronted with a complexity of legal, ethical and financial situations which can complicate everyday practice. Patient abandonment is one of these issues that will often cause practitioners to consult with their local dental societies, state dental boards or malpractice carriers and seek guidance on how to navigate this possible pitfall.
Patient abandonment is defined as “a form of malpractice that occurs when a dentist terminates the doctor-patient relationship without reasonable notice and fails to provide the patient with an opportunity to find a qualified replacement.”1 Often declining to treat a patient can result in a “negligent termination” of the relationship if the provider has failed to provide the necessary continuity of care required to complete the course of treatment.2
The ADA Principles of Ethics and Code of Professional Conduct states the following with respect to patient abandonment:
2.F. Patient Abandonment. Once a dentist has undertaken a course of treatment, the dentist should not discontinue that treatment without giving the patient adequate notice and the opportunity to obtain the services of another dentist. Care should be taken that the patient’s oral health is not jeopardized in the process.3
Examples of patient abandonment include the following:
Scenario #1
Doctor A is having financial difficulty and can no longer afford to operate his/her practice. Doctor A closes his/her practice but does not inform patients via letter, announcement in the newspaper, formal email notification, etc. In addition, Doctor A does not advise patients on how they can obtain their records and/or records of their dependents. Hence, patients must now pay for services that their insurance company will only cover every 3-5 years, i.e. extraoral film.
Scenario #2
Doctor B has dismissed a patient from his/her practice due to failure to show for appointments based on a signed policy that is in the patient’s chart. Doctor B does not inform the patient in writing that they are no longer eligible for care at Doctor B’s practice. In addition, Doctor B does not advise the patient that he/she is eligible for emergency care 30 days following the date of the dismissal letter. The patient contacts Doctor B’s practice because they have an abscess. Doctor B’s receptionist advises the patient that they are no longer eligible for care in the practice due to multiple failed appointments. The staff does not assist the patient in finding another provider.
Scenario #3
Doctor C declines to provide active treatment to a patient after discovering the patient is HIV positive.
Scenario #4
Doctor D, a general dentist has practiced for 15 years without taking an extensive vacation. Doctor D decides to close his/her practice for two weeks to take a second honeymoon. The office closed for a two week period and staff was not available to take calls. A routine patient contacted the office because a root canal was started but not completed on tooth #30. Over this two week period, the tooth became infected and caused facial swelling. The patient, unable to contact Doctor D, sought the care of an oral surgeon in the area for the extraction of tooth #30.
In order to avoid the above scenarios of patient abandonment, dental practitioners can take the following corrective actions:
Scenario #1: Corrective Action
According to the ADA’s Guide to Closing a Dental Practice, a provider should notify patients via a letter or an announcement in a local newspaper, roughly 30-60 days in advance. If a patient is undergoing active treatment, the practitioner must complete a minimum of the following four steps:
1) Identifying a skilled practitioner who will accept the unfinished case;
2) providing the accepting dentist with the necessary clinical information to continue or alter treatment, if necessary;
3) the patient agreeing to the referral; and
4) the patient actually submitting to the treatment in a cooperative fashion. Short of achieving all four, a dentist may unnecessarily be exposing himself to an allegation of patient abandonment, depending on applicable law.4
Scenario #2: Corrective Action
Dental practitioners must have clear office guidelines regarding failed appointments. These guidelines should be signed by the patient and kept on file prior to conducting the initial examination. If termination of the doctor/patient relationship is initiated due to multiple missed appointments, patients should be notified in writing of the termination and this notification should be sent via registered and certified mail. The patient should be provided a reasonable amount of time to seek the services of another provider. Typically the required notification is 30 days. The letter should include a brief explanation of why the relationship is being terminated although this is not required.5References
1 Chowdri, Prathyusha. What is Patient Abandonment? Nolo: Law for All. http://www.nolo.com/legal-encyclopedia/whatpatient-abandonment.html.
2 Segan’s Medical Dictionary. Definition—Abandonment. http://www.medicaldictionary.thefreedictionary.com/Abandonment.2012.
3 American Dental Association. ADA Principles of Ethics and Code of Professional Conduct. Last modified, 2012. http://www.ada.org/~/media/ADA/About%20the%20ADA/Files/code_of_ethics_2012.ashx.
4 American Dental Association. Guide to Closing a Dental Practice. Page 4.
2004/2008. http://www.ada.org/~/media/ADA/Member%20Center/FIles/topics_disability_closingpractice.ashx.
5 Passineau, Theodore. The Less-Than-Perfect Dentist-Patient Relationship: Case Studies and Tips. The Virginia Dental Meeting. Hot Springs, Virginia. September 18, 2014.
