Ethical Dilemmas in Dentistry, Third Series

Learning Objectives

After completing the course, participants will be able to:

  • Understand the issues surrounding the ethical dilemma of a patient that asks a dentist to misrepresent treatment in order to maximize dental insurance benefits
  • Understand the issues surrounding the ethical dilemma of an obnoxious/noncompliant patient who also may make unreasonable demands on the dentist
  • Understand the issues surrounding the ethical dilemma of potentially conflicting obligations of generalists and specialists to patients and to each other.
  • Understand the ethical reasoning behind the evaluation of these ethical dilemmas
  • Understand the decision making used to approach these ethical dilemmas
  • Understand options when confronted with an ethical dilemma

Please Review the Following Material:

“The Patient’s Fraudulent Request”

Edited by Thomas K. Hasegawa, Jr., DDS
Reprinted with permission from the Texas Dental Journal
(Dilemma #10)

What Would You Do?

Ms. Gladys Marker is a new patient in your office with a chief complaint that she “hates her partial denture” and she wants a “porcelain bridge, just like the one you just did for my best friend.” She is a 39-year-old computer analyst working for the same company for the past 15 years and has had a fee-for-service dental insurance contract with her company since she was hired.

Ms. Marker is in excellent general and dental health and has had yearly dental examinations for the past 15 years. Twenty years ago, she had a serious auto accident and lost her mandibular central and lateral incisors, mandibular molars on the right side, along with her maxillary right first and second molars. She initially wore a temporary acrylic partial denture for three years that was replaced by her current removable partial denture that she has worn for ten years. The fit and appearance of the partial denture is poor. Her excellent periodontal health, tooth position, size, and occlusion would tolerate either a fixed or removable partial denture.

You have explained to Ms. Marker that she will not have occlusion on tooth 3 if a #22×27 porcelain fixed partial denture is made, but she doesn’t care. You agree to submit a preestimate for a fixed partial denture along with radiographs to her dental insurance company. Her dental insurance has a $250 deductible with a co-pay of 50% for prosthodontics, for a maximum annual benefit of $1,000.

Five weeks later, you receive a reply and a rejection of the treatment plan with an explanation that a removable partial denture would be allowable. Ms. Marker is upset and insists that you complete the fixed partial denture, submit it as a removable partial denture, and she will pay the balance. You explain to her that this is illegal, but she again insists that you follow her decision.

You are now faced with an ethical dilemma. Check the course of action you would follow.

  1. Send a letter or call the insurance company explaining that the patient does not want a removable partial denture.
  2. Have the patient contact the company representative for dental insurance.
  3. Contact the insurance consultant for your local component of the TDA [or your dental society].
  4. Follow the patient’s request and submit the bridge as a removable partial denture.
  5. Other alternative (please explain)
Response

Ms. Gladys Marker is a healthy, 39-year-old new patient with a chief complaint that she “hates her partial denture” and wants a “porcelain bridge, just like the one you just did for my best friend.” Her ten-year-old removable partial denture that replaced her four mandibular incisors and molars on the right side has a poor fit and appearance. She is also missing maxillary molars on the right side (correction—the case should have stated her maxillary second and third molars were also avulsed in the accident.) Her excellent periodontal health, tooth position, size, and occlusion would tolerate either a mandibular fixed or removable partial denture.

She has had a fee-for-service dental insurance contract with her company since she was hired 15 years ago. Her current contract has a $250 deductible with a co-pay of 50% for prosthodontics, for a maximum annual benefit of $1,000.

You explained to her that she will not have occlusion on tooth #3 if a #22×27 porcelain fixed partial denture is made, but she doesn’t care. You agreed to submit a preestimate for a fixed partial denture, and five weeks later you receive a rejection with an explanation that a removable partial denture would be allowable. Ms. Marker is upset and insists that you complete the fixed partial denture, submit it as a removable partial denture, and she will pay the balance. You explain to her that this is illegal, but she again insists that you follow her decision.

The dentists that responded to the dilemma agreed that insurance companies would usually agree to pay the alternative benefit based on the removable partial denture fee if the dentist proceeded with the fixed partial denture. Respondents chose either to send a letter or call the insurance company (option #1), or have the patient contact the company representative for dental insurance (option #2). None of the respondents chose to contact the insurance consultant of the local component of the TDA (option #3), or to follow the patient’s request and submit the bridge as a removable partial denture (option #4).

Although the case did not seem to be a dilemma for the respondents, the case illustrates that seemingly simple requests by patients may have serious ethical and legal implications. This case presents potential ethical problems related to: (1) multiple treatment alternatives and informed consent: (2) submitting dental claims; and (3) problematic requests by patients.

Multiple Treatment Alternatives

Ms. Marker’s case proposed two viable alternatives for treatment: fixed or removable partial denture therapy. In other cases, informed consent for dentists may involve a myriad of treatment options, materials and techniques, compounded by the patients’ preferences and the dentists’ preferred materials.

For example, although a three-surface restoration could be provided in amalgam, resin, porcelain or gold, the dentist may not provide (or even recommend) the specific material and technique the patient requests. In order to provide “quality care in a competent and timely manner,” and “involve the patient in treatment decisions.” The dentist first must learn to deal with multiple treatment alternatives. The author, Donald Sadowsky, referred to this as “moral dilemmas of the multiple prescription,” as in the three-surface restoration example with each material having risks, benefits, and varied costs. The dentist may perceive role conflicts such as between doctoring and salesmanship as he or she discusses treatment options with the patient.

Dental Insurance

Ms. Marker’s case provides the opportunity to discuss the effect that third-party payers may have on dental practice because of the possibility of multiple treatment alternatives and the unique character of fee-for-service dental insurance.

The patient may question the judgment of the dentist if a treatment recommendation is rejected by the insurance company even though it is the benefit plan that is the issue. Some patients don’t understand the coverage limits of their dental plans. Another potential conflict in Ms. Marker’s case is why the patient must pay the more expensive co-payment for a fixed partial denture than its removable counterpart. In comparison, less expensive treatment such as preventive and restorative services have a proportionally higher co-payment, which makes the fee-for-service plan more like a prepayment plan than medical insurance. Out-of-pocket expenses to patients may be higher for dental than medical claims, even if the medical costs may be significantly higher because of the proportionally higher dental co-payment.

One respondent replied that as in Ms. Marker’s case, he had “lost count of the times” this situation had happened, and that in every case, when a “complete narrative” was sent to the dental insurance consultant, the co-payment of the alternative treatment, the removable partial, was approved. Another wrote, “in my opinion, the patient is entitled to the best dentistry regardless of what her insurance company says,” and finally, “insurance companies don’t dictate dental treatment, just the benefits allowed.”

The Patient’s (Fraudulent) Request

Patients, like Ms. Marker, may ask their dentists to misrepresent treatment in order to maximize dental insurance benefits, a request that challenges the honesty of the dentist.

The TDA Principles of Ethics describes these questions of reimbursement as: “(public and private entities) and the dentist are in an important relationship which demands mutual fidelity, and requires each to recognize their obligations to patients and to society.” Fidelity refers to keeping implicit promises such as being truthful when submitting procedure codes and treatment dates. Those who break these implicit promises. according to the ADA Principles of Ethics, are making an “unethical, false, or misleading representation to such a third party.” The misuse of insurance codes may be “fraudulent and misleading when funds are requested for a procedure that has been “miscoded” and may result in the suspension of the dentist’s license to practice dentistry.

The TDA Department of Economics recommends that dentists call the insurance company to review any questions about a claim or policy benefits.

Conclusion

Dentists must routinely manage the complex areas of informed consent and third-party payers in practice. Ms. Marker’s request focused our attention on the dentist’s obligation to maintain implicit promises, such as being truthful, in the process.

References
  1. ADA Principles of ethics and code of professional responsibility. Revised, January, 1994.
  2. Sadowsky, D. Moral dilemmas of the multiple prescription in dentistry. J Am Coll Dent 46(4): 245-248.
  3. Rule IT & Veatch RM. Ethical Questions in Dentistry. Chicago: Quintessence Pub. 1993: 181-182.
  4. Texas Dental Association. Articles of incorporation constitution and bylaws and principles of ethics and code of professional conduct. May, 1985:18.
  5. Ross WD. The Right and the Good. The Clarendon Press. Oxford, 1930:235.
  6. Limoli TM & Limoli JP. Insurance reimbursement mattersa consultation. Compend Contin Educ Dent 13(10):1992:830.
  7. Jerrold L. Insurance fraud. Jour Law & Ethics in Dent. 1990:3:83-4.

Editor’s Comment: Carl D. Ellis, DDS, Assistant Professor in the Department of General Dentistry, Baylor College of Dentistry, is a consultant for this ethical dilemma. Responses to the ethical dilemmas are views of the contributors and consultants and not Baylor College of Dentistry, the National Center for Policy Analysis or the Texas Dental Association.


“Skip the Gum Work and Start the Bridges”

Edited by Thomas K. Hasegawa, Jr., DDS
Reprinted with permission from the Texas Dental Journal
(Dilemma #11)

What Would You Do?

Arthur Green, Ph.D., is a forty-eight-year-old Professor in the mathematics department at the nearby university who joined your practice four months ago and has been a source of continual irritation due to his obnoxious attitude.

Although his general health is good, his oral health, in the words of your hygienist “is horrible…the worst!” He has halitosis and obviously doesn’t brush because you cannot see the gingival one third of his crowns because they are covered with food debris. His chief complaint is that he wants to have the “gaps filled in with bridges” since he recently acquired dental insurance.

Dr. Green feels that his teeth are a “nuisance” and that he lets the dentist take care of them. He has generalized chronic periodontitis with 4-6mm pockets with bleeding in all four quadrants.

As part of your preventive program you have scheduled three appointments with your dental hygienist. After the second appointment, he gets up from the chair and says, “Look—I don’t have time to brush and floss…that’s why I pay you! Let’s skip the gum work and get on with the bridges!” As you intercede he again says, “I’ll sign a waiver that says I know about the gum disease but choose to have the bridges made. I know the consequences.” You again try to explain the need for periodontal treatment but he insists “Let’s skip the gum work and start the bridges!”

You are now faced with an ethical dilemma. Check the course of action you would follow:

  1. Have Dr. Green sign a letter acknowledging that he has gum disease but wants the bridges anyway even though he knows they may fail in a few years. Proceed with the fixed-partial dentures.
  2. Discuss with Or. Green that you will only treat his periodontal disease and active caries now and that you will not proceed with prosthodontics until his disease is under control.
  3. Tell Dr. Green that his attitude makes it impossible for your office to effectively treat his oral health problems. Offer to refer him to another office.
  4. Dismiss Dr. Green from your practice.
  5. Other alternative (please explain).
Response

Arthur Green, Ph.D. is a healthy, 48-year-old professor in the mathematics department at a nearby university who joined your practice four months ago and has been a source of continual irritation due to his obnoxious attitude.

His chief complaint is that he wants to have the “gaps filled in with bridges” since he recently acquired dental insurance. His oral hygiene according to your dental hygienist is “horrible…the worst!” and he has halitosis and generalized chronic periodontitis with 4-6 mm pockets and bleeding in all four quadrants

After his second appointment with your dental hygienist, Dr. Green gets up from the chair and says, “Look—I don’t have time to brush and floss…that’s why I’m paying you!” As you intercede he again says, “I’ll sign a waiver that says I know about the gum disease but choose to have the bridges made. I know the consequences.” You again try to explain the need for periodontal treatment but he insists, “Let’s skip the gum work and start the bridges!”

All four options were selected by the respondents, with the fewest preferring so “have Dr. Green sign a letter acknowledging that he has gum disease but wants you to proceed with the bridges anyway, even though he knows they may fail in a few years. (#1) Most chose from the remaining three options, which included proceeding with the prosthodontics only when his periodontal disease and active caries are under control (#2), offering to refer him to another dentist because his attitude makes it impossible for you to treat him (#3), or just dismissing him from your practice (#4).

Of the ethical issues in this case, one is immediately drawn to the obnoxious behavior of the patient: Is the dentist obligated to treat this patient? There are also associated questions: Is the dentist’s sole obligation to do what the patient requests?; and finally, is Dr. Green making a reasonable request?

The Obnoxious/Noncompliant Patient

Dr, Green in this case is a new patient who has been both noncompliant regarding his own oral health and “obnoxious” in his relationships with those in the office. Is the dentist obligated to treat these patients?

Philosopher Ruth Purtilo has described the noncompliant patient as one who engages in self-destructive behavior, thereby frustrating health professionals by rejecting their advice and are uncooperative by doing things to their bodies which effectively prevent a health professional from curing them. (1) She also cites the chronically ill patient, terminally ill patient and the hypochondriac as frustrating the health professional because they don’t get well. When Dr. Green exhorts. “Look — I don’t have time to brush and floss…that’s why I’m paying you!”, his obnoxious behavior may be stressful for the dental hygienist and staff. Ruth Purtilo has written about how treating the noncompliant patient is emotionally stressful for professionals and has offered five guidelines for taking better care of undesirable patients. They include: 1) avoiding derogatory labels; 2) remembering that the caring function is as important as the cure; 3) avoiding unrealistic expectations of one’s own power as a health professional 4) avoiding blaming the victim; and 5) taking care of one’s own emotional well-being. (1)

Most dentists have known patients like Dr. Green who elicit an audible groan by the staff when his or her name appears on the list of the day’s appointments. This could be the patient who is rude or discourteous, overly demanding or critical, impatient or curt, or simply refuses to take responsibility for his or her own oral health. The ADA Code is clear in its statement that the “dentist’s primary professional obligation shall be service to the public,” but the Code also advises that dentists “may exercise reasonable discretion in selecting patients for their practices” (2) and, according to the TDA Code, that they “may choose whom to serve.” (3) Those responding to the case selected options ranging from the dentist who stated, “I don’t need that headache…this is a no-brainer…get him out,” to another who would attempt to educate the patient by using an intraoral camera so that the patient could view the extent of his disease. Another wrote that by informing the patient that you will only treat his periodontal disease and active caries now and proceed with prosthodontics when the disease is under control would leave the decision with Dr. Green and “this will result in patient’s attitude change on his own, or he will voluntarily leave on his own without us being too judgmental or confrontational.”

Although dentists have a general obligation to treat patients, this obligation is not absolute. Dentists may, for example, have patients that are obnoxious but follow professional recommendations. More likely, the difficult patients are those who are personable but ineffective in maintaining their oral health. In a case like Dr. Green’s, although the dentist and his staff may be obligated to care for Dr. Green, it would be unrealistic to expect the staff in the dental office to change his personality. How far should a dentist go when dealing with these patients? It would seem reasonable for the dentist to counsel Dr. Green and, if he continues to be obnoxious and noncompliant to the extent that his behavior becomes disruptive, the dentist is justified in dismissing the patient. To avoid abandoning the patient, dentists in Texas may discontinue treatment after reasonable notice has been given to the patient by the dentist of his intention to discontinue treatment and that the patient has had a reasonable time to secure the services of another dentist or all other dental services actually begun have been completed. (4) The ADA recommends that: (1) the dentist be careful to assure that the health of the patient is not compromised; (2) the notification for termination be by registered or certified mail, providing at least 30 days as the termination date after the receipt of the letter; (3) the letter should indicate what treatment the dentist will complete during the prescribed days; and (4) emergency care will be provided until the patient finds another office. (5)

Separating the patient’s obnoxious/noncompliant behavior still leaves the central question: Is the dentist obligated to address the patient’s chief complaint to have the “gaps filled in with bridges” and to furthermore, “skip the gum work and start the bridges”?

Dentist as the Patient’s Agent?

Is the sole responsibility of the dentist to fulfill the patient’s needs and desires? Dentists are advised to identify and manage the patient’s chief complaint. (6) Does this mean that “the patient is always right”?

Although the ADA Code establishes that the “dentist’s primary professional obligation shall be service to the public,” this does not imply that there is an absolute obligation to follow the patient’s needs and desires if it includes dentists setting aside his or her professional judgment and values. Dr. Green’s request to “skip the gum work and start the bridges” is an uninformed and unreasonable request.

Philosopher David Ozar has recently described a fourth model of the dentist-patient relationship called the Agent Model that has relevance to this case. (7) The dentist in the Agent Model may perceive his or her primary task as “only to give effect to the patient’s choices regarding his or her needs or desires. The dentist is to act, in other words, only as an agent for the patient.” (8) The patient makes demands that the dentist must fulfill in this model. This seriously flawed model disregards our ordinary understanding of a profession’s values. It separates the core values of professional judgment and replaces it with a sole commitment to following the patient’s desires. Ozar constructs an extreme example of a dentist who, following the Agent Model, agrees to write a prescription for a patient requesting controlled substances to support an addiction in order to respond to the patient’s choices more completely. According to Ozar, the Agent Model “severely misrepresents our ordinary understanding of a health professional’s ethical commitments.”(8)

An Unreasonable Request?

The ADA Code specifies that “the dentist should inform the patient of the proposed treatment, and any reasonable alternatives, in a manner that allows the patient to become involved in treatment decisions.” (2) Is Dr. Green’s request that the dentist “skip the gum work and start the bridges” a reasonable request?

The patient, in this case, is not asking to choose between shades for denture teeth, alternatives such as fixed or removable partial denture prosthodontics, or extraction versus root canal therapy. The patient is asking the dentist to set aside an accepted standard of care by ignoring periodontal disease and providing fixed partial dentures. Standard regimens for dental treatment planning include implementing an initial therapy (9) or disease control phase (6) that includes for example root planing and scaling, selective restorations, and assessing the patient’s ability to adopt proper dietary habits and plaque control techniques. When the initial or disease control phase is successfully completed, then the corrective (9) or restoration phase (6) (periodontal surgery and then fixed partial dentures) is initiated. Providing fixed partial dentures is precluded by establishing a healthy periodontium.

One of the difficult roles for the ADA Code is to provide substantive guidance to dentists in specific instances. The “reasonable alternative” statement is necessarily vague and therefore provides little guidance. There are no “Advisory Opinions” to further define the meaning of the term “reasonable,” thus leaving a wide discretion to dentists. The ADA Code does emphasize both the “benefit of the patient” as the primary goal for dentistry and the duty to provide “quality ca in a competent and timely manner.” On both accounts, skipping the gum work and starting the bridges would have limited long-term benefit for the patient and would be in conflict with standard competencies for dental therapy. One respondent wrote in this regard, “a patient cannot consent to malpractice under any conditions, signed or verbal!!”

Conclusion

Dr. Green’s case has brought together the distinctive elements of the obnoxious/noncompliant patient who also may make unreasonable demands on the dentist. Dealing with the obnoxious/noncompliant patient is stressful for dentists, but is not an unusual burden for health professionals. However, the dentist’s professional judgment is not overridden by patients who request treatment that is clearly inconsistent with established standards or central values of a profession. The dentist cannot be forced to set aside his or her standards of competent treatment simply because the patient requests to “skip the gum work and start the bridges.” The dentist is ethically justified in this case to inform Dr. Green of his disruptive behavior, to attempt to educate him regarding his oral health and plan for periodontal therapy prior to fired partial dentures, and, if he continues to be obnoxious and noncompliant, to dismiss Dr. Green after taking steps to assure that he is not abandoned.

References
  1. Purtilo RB, Cassel CK. Ethical Dimensions in the Health Professions. Philadelphia, Pa: WB Saunders Co;1981:90-91.
  2. ADA Principles of Ethics and Code of Professional Conduct. January 1994.
  3. Texas Dental Association Articles of Incorporation Constitution and Bylaws, and Principles of Ethics and Code of Professional Conduct, September 1985.
  4. 109.121 Abandonment of Patient Prohibited. Rules of the Texas State Board of Dental Examiners – Rev 12-93:39.
  5. Berry RM Dentistry & law: Ending the relationship. Amer Dent Assoc News August 4, 1986: 11.
  6. Langlais RP, Bricker SL, Cottone JA, Baker BR. Oral Diagnosis. Oral Medicine and Treatment Planning. Philadelphia, Pa: WB Saunders Co: 1984:108-109.
  7. Ozar DT. Three models of professionalism and professional obligation in dentistry. Amer Dent Assoc 1985: 110(2):173-177.
  8. Ozar DT. Sokol DJ. Dental Ethics at Chairside: Professional Principles and Practical Applications. St Louis: CV Mosby: 1994:37-41.
  9. Lindhe J, Nyman S. Treatment planning. In: Lindhe J. ed. Textbook of Clinical Periodontology. 2nd ed. Copenhagen: Munksgaard: 1989:326-328.

Editor’s Comment: Responses to the ethical dilemmas are views of the contributors and consultants and not Baylor College of Dentistry. the National Center for Policy Analysis or the Texas Dental Association.


“Conflict, Collusion or Collaboration: Who Benefits From a Referral?”

Edited by Thomas K. Hasegawa, Jr., DDS
Reprinted with permission from the Texas Dental Journal
(Dilemma #12)

What Would You Do?

Dr. John Wilkins is a periodontist who recently joined a large group specialty practice including endodontists, prosthodontists and other periodontists. The group practice has a strong referral base and enjoys an excellent reputation.

Dr. Ed Biggs, a general dentist with a large practice in the area referred a patient, Mr. Randy Crane, for an evaluation. Dr. Biggs sent a note “evaluate perio and call me.” When Dr. Wilkins asked others in the practice about Dr. Biggs, they said he was a “great guy but his dentistry isn’t the best.” Dr. Biggs has referred patients to the group practice for several years.

Mr. Crane had been in Dr. Biggs, practice for 10 years and was pleased with his overall care. Mr. Crane, at 40 years-old, was in excellent health and had regular dental examinations, but was worried that he had an offensive mouth odor and that his gums were bleeding frequently, especially when he flossed. Recently, food would get lodged causing soreness between the mandibular molars that were crowned five years ago.

Mr. Crane had four porcelain crowns on his mandibular molars that were esthetic but had bulky margins that made it difficult to floss. The interproximal contacts were loose but not open between the molars. There was a generalized, chronic gingivitis with localized areas of mild periodontitis (3-5mm pockets with bleeding) in the molar areas around the crowns.

As the examination continued, Mr. Crane asked, “are these crowns causing a problem for my gums? I don’t want to lose my teeth like my father.”

Dr. Wilkins is faced with an ethical dilemma. Check the course of action that he should follow.

Dr. Wilkins in this case should:

  1. defer the question from Mr. Crane and call Dr. Biggs and inform him of the findings including the possibility of replacing some of the crowns due to the bulky margins and loose contacts
  2. inform Mr. Crane that he has a mild form of periodontal disease and that some of his crowns may need to be replaced
  3. defer the question from Mr. Crane and not inform Dr. Biggs of the concerns about the crowns. Dr. Wilkins should attempt to provide periodontal care first without recommending the removal of crowns
  4. defer the question from Mr. Crane and without being specific, tell Dr. Biggs that he will be unable to treat Mr. Crane.
  5. Other alternative (please explain)
Response

Dr. John Wilkins is a periodontist who recently joined a large-group specialty practice, including endodontists, prosthodontists and other periodontists. The group practice has a strong referral base and enjoys an excellent reputation.

Dr. Ed Biggs, a general dentist with a large practice in the area referred a patient, Mr. Randy Crane, for an evaluation. Dr. Biggs sent a note “evaluate perio and call me.” When Dr. Wilkins asked others in the practice about Dr. Biggs, they said he was a “great guy but his dentistry isn’t the best.” Dr. Biggs has referred patients to the group practice for several years.

Mr. Crane had been in Dr. Biggs’ practice for ten years and was pleased with his overall care. Mr. Crane at 40 years old was in excellent health and had regular dental examinations, but was worried that he had an offensive mouth odor and that his gums were bleeding frequently, especially when he flossed. Recently, food would get lodged, causing soreness between the mandibular molars that were crowned five years ago.

Mr. Crane had four porcelain crowns on his mandibular molars that were esthetic but had bulky margins that made it difficult to floss. The interproximal contacts were loose but not open between the molars. There was a generalized, chronic gingivitis with localized areas of mild periodontitis (3-5mm pockets with bleeding) in the molar areas around the crowns.

As the examination continued. Mr. Crane asked. “Are these crowns causing a problem for my gums? I don’t want to lose my teeth like my father.”

Did Dr. Biggs adequately advise Dr. Wilkins whether Mr. Crane was referred for periodontal treatment or for a second opinion? Is etiquette our primary concern when patients are referred? Should specialists share sensitive information with patients without conferring first with the referring dentist? How are the constituent obligations of Dr. Biggs to his patient affected by Dr. Wilkins’ obligations to both parties?

Respondents to the case chose two of the four alternatives with almost all having the periodontist inform Mr. Crane that he has a mild form of periodontal disease and that some of his crowns may need to be replaced (option #2). The remainder chose to defer the question from Mr. Crane and call Dr. Biggs and inform him of the findings, including the possibility of replacing some of the crowns due to the bulky margins and loose contacts (option #1). None of the respondents chose to have the periodontist defer the question from Mr. Crane and not inform Dr. Biggs of the concerns about the crowns and to attempt to provide periodontal care first without recommending crown replacement (option #3). None of respondents chose to have the periodontist defer the question from Mr. Crane and without being specific, tell Dr. Biggs that he will be unable to treat Mr. Crane (option #4).

The case of Dr. Biggs’ referral allows us to examine the constituent obligations of the generalist and specialist to the patient and to each other. We will first profile key aspects of specialty practice and then examine the potential for conflict, collusion or collaboration in referrals.

Specialty Practice

Specialists share their “special skills, knowledge, and experience” (1) to supplement those of the generalist in providing competent care for patients. Specialists also serve as expert witnesses to evaluate competency and establish standards of care in dental litigation cases. They may be privy to instances of gross or faulty treatment in their private referral patients and may experience role conflicts between not harming either their patients or the referring dentists.

The ADA Code of Ethics offers guidelines for consultation and referrals that include returning the patient to the referring dentist after the specialty is completed. In cases of a consultation for a second opinion, the Code also specifically states that “the dentist rendering the second opinion should not have a vested interest in the ensuing recommendation.” (1) It is unclear whether Dr. Biggs has asked Dr. Wilkins to treat Mr. Crane or offer a second opinion.

Mr. Crane has asked the periodontist, “Are these crowns causing a problem for my gums?” Since the crowns were provided by the referring dentist, how should the specialist respond to the patient? The periodontist is a new practitioner in an established specialty practice, and revealing unfavorable information to the patient may be poorly received by both Mr. Crane and Dr. Biggs. Specialists as well as generalists prosper by building and nurturing their referral network, although in this case, communication is scant between Drs. Wilkins and Biggs. Should Dr. Wilkins answer Mr. Crane’s question?

Conflict, Collusion, or Collaboration

Most dentists chose to inform Mr. Crane that some of his crowns need replacement, risking conflict among the generalist, specialist and patient. A periodontist wrote that either the crowns should be replaced or, if the crown margins were not open, apical positioning of the soft tissue next to the crowns be performed. “The responsibility is to the patient first,” wrote another dentist.

The case could also be managed through collusion, defined as a “secret agreement between two or more persons for a deceitful or fraudulent purpose.” (2) It is possible that a generalist and specialist could agree to minimize the issue of faulty treatment if pursued by the patient, although none of the respondents recommended this arrangement.

Consider a similar situation that radiologists face when asked by a distressed patient, “Is it malignant?” One view in the medical literature recommends that “the primary physician should be the spokesman for all physicians involved in a particular case,” (3) while another view limits that restriction to only those cases involving a malignancy or a poor prognosis. (4) One recommendation is that “when malignancy is diagnosed or strongly suspected, radiologists should indicate that they will discuss the result with the clinician, and when talking to patients use euphemisms such as bowel obstruction or large ulcer.” (4) A radiologist faced with the decision to tell an obstetrics patient the “bad news” from an ultrasound, wrote: “I had to be straight with her and give an honest answer. It’s what any physician would do.” (5) Disagreeing with this view, a pair of physicians reasoned that “delaying immediate transmission of diagnostic information to the patient does not constitute a lie or falsehood,” and that “the one general rule of Hippocrates, ‘The Father of Medicine,’ was not to ‘tell no lies’ but instead to ‘do no harm.'” (6) The argument is that since the primary physician is more familiar with the case and the patient, he or she may be more capable of protecting the patient from harm while disclosing “bad news.” Critics of medical paternalism respond that physicians may “link arms against the patient,” (7) and that there is a history of silence between physicians and their patients. (8)

Central to the case is the possibility for collaboration, instead of conflict or collusion, between generalist and the specialist. There is no easy formula for improving how generalists and specialists communicate. However, if the fundamental purpose of referring patients begins with a commitment to competence and the realization that certain cases or circumstances require individuals with specialized training, then collaboration is indispensable. Philosopher D.T. Ozar proposes that “collaborative practice is the ideal relationship that dentists are professionally committed to work for, and is so because of what it contributes to dental care for the profession’s patients,” and that the commitment to practicing competently and to collaboration are “equally fundamental to the proper practice of dentistry.” (9)

Conclusion

What is your relationship with specialists or the dentists that refer patients? How do you communicate about patient care? We propose that Mr. Crane may have benefited by Drs. Biggs and Wilkins practicing in collaboration instead of sending notes to “evaluate perio and call me.”

References
  1. ADA Principles of Ethics and Code of Professional Conduct. January 1994:4.
  2. Second College Edition The American Heritage Dictionary, Boston, Mass: Houghton Mifflin Co: 1982; 292.
  3. Siegler M. Medical consultations in the context or the physician-patient relationship. Agich GJ (ed) Responsibility in health care. In: Engelhardt HT. Spicker SF, eds. Philosophy and Medicine. Boston, MA: D. Reidel Pub Co.:1982; 12:152.
  4. Vallely SR, Manton Mills JO. Should radiologists talk to patients? Br Med J 1990; 300:305-6.
  5. Brown DL. A piece of my mind. No pretending not to know. J Amer Med Assoc 1988; 260(18):2720.
  6. Rokey R. Rolak LA. Letter to the editor (reply). No pretending not to know. J Amer Med Assoc 1989; 260(9):1276-1277.
  7. Purtilo RB, Cassel CK. Blowing the whistle on incompetent or unethical colleagues. In: Ethical Dimensions in the Health Professions. Philadelphia, PA: WB Saunders, Co; 1981:152.
  8. Katz J. The Silent World of Doctor and Patient. New York, NY: The Free Press; 1984:1.
  9. Ozar DT, Sokol DJ. Working together. In: Dental Ethics at Chairside: Professional Principles and Practical Applications. St. Louis, MO: CV Mosby; 1994:172-3.

Editor’s Comment: Responses to the ethical dilemmas are views of the contributors and consultants and not Baylor College of Dentistry. the National Center for Policy Analysis or the Texas Dental Association.

Reference

The ethical dilemmas presented in Course 4 were originally published in the Texas Dental Journal in 1994, various pp., and are reprinted with the permission of the Texas Dental Journal. The dilemmas were originally edited by Thomas K. Hasegawa, Jr., DDS, MA, Associate Dean for Clinical Services, Baylor College of Dentistry. Sincere appreciation is extended to both the Texas Dental Journal and Dr. Thomas K. Hasegawa, Jr.

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