Whistle Blowing in Dentistry

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Whistle Blowing in Dentistry

• When Does the Dentist Have the Obligation To
  Blow the Whistle On A Colleague Who Is Treating
  A Patient Unjustly?

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Definition of Whistle Blowing

• The disclosing to an authority of a wrongdoing of
  another reporting a wrongdoing to call attention
  to a practice of another one considers to be
  harmful, unjust or illegal, including such
  matters as incompetence and impairment.
• More broadly, whistle blowing is the sounding of
  an alarm to highlight potential harm, when all
  other avenues for change have been exhausted.
• The metaphor whistle blowing derives from the
  blowing of the whistle by a referee of a
  sporting event to indicate a rule has been
  violated and a penalty must be imposed.

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Case Scenario

• Hygienist Troubled By Employers Attitude and
  Behavior

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• Ms Bigelow, a dental hygienist, identifies
  progressive periodontal disease in a patient at a
  periodic recall visit. Despite Mr. Chafin's (the
  patient) best efforts the periodontal condition
  is progressing with notably deeper pocket depth
  this appointment than 6 months ago. She has
  documented in the dental record the deepening
  pockets, the exudate and bleeding on probing, and
  the radiographically observable bone loss among
  all the posterior teeth.  Ms. Bigelow thinks Mr.
  Chafin should be referred the local periodontist,
  as her employer, Dr. Johnson, a general
  practitioner, only treats mild periodontal
  problems requiring root planing and curettage.
• When she informs Dr. Johnson of her findings
  and recommendation, he dismisses her with a wave
  of his hand, and enters the operatory where Mr.
  Chafin is seated. He  probes among a few anterior
  teeth, and dismisses Mr. Johnson in a cordial
  manner, reconfirming to him the importance of
  returning again in 6 months for another
  "cleaning."
• Ms. Bigelow is distressed by her employer's
  cavalier attitude regarding Mr. Chafin's serious
  periodontal disease. She is confident that it is
  imperative that he receive substantive and
  definitive periodontal treatment or he will lose
  his teeth to the condition.
• What should she do?
•  

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Conflicts for the Hygienist

• Hygienists are not permitted by state practice
  acts to diagnose oral diseases however, they are
  educated to recognize them.
• ADHA Code of Ethics states that the hygienist
  must provide oral health care utilizing the
  highest professional knowledge, judgment and
  ability. But, it is silent on duty to follow
  dentists instructions, or on the duty to report
  poor dental care.
• Hygienists practice under a state granted
  license. The hygienist must justify her or her
  own negligence in choosing not to inform the
  patient about potential harm.

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Hygienists Versus Nurses

• In contrast to the ADHA Code of Ethics, the
  American Nurses Associations Code states that
  the nurse acts to safeguard the client and
  public when health care and safety are affected
  by incompetent, unethical or illegal practice of
  any person.
• Should the hygienists obligation be any less
  than that of a nurse?

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Scenario

• Periodontist Frustrated With Referring Dentists
  Treatment

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• Dr. Omer is the only  periodontist in a
  community of 30,000 people. He has a good
  relationship with the community's 12 general
  dentists, all of whom refer their patients with
  periodontal disease to him. One general dentist,
  Dr. Deringer, regularly sends patients, who he
  has treated, with treatment so poor as to
  compromise what Dr. Omer can do to resolve their
  periodontal problems. Typically the patients will
  have overhanging amalgam and composite
  restorations, and crowns with open or
  overextended margins. Fixed prosthetic appliances
  are rarely in proper occlusion.   Often, Dr. Omer
  has done what he can within the constraints of
  his periodontics practice to fix these problems,
  but there is only so much he can do. He has
  spoken to his colleague, Dr. Deringer, on several
  occasions, suggesting ways in which he might
  improve the outcomes in this treatment. But this
  has not seemed to help.
• Today he has had another one of Dr.
  Deringer's patients and has had to trim a large
  excess from the gingival margin of a temporary
  bridge. The patient asked why such was necessary,
  as Dr. Deringer had just placed the temporary a
  week ago. This is the third time in less than a
  week that one of Dr. Deringer's patient's has
  asked Dr. Omer potentially embarrassing questions
  about Dr. Deringer's treatment.
• What should Dr. Omer do?

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ADA Principles of Ethics and Code of Professional
Conduct

• Patients should be informed of their present
  oral health status without disparaging comments
  about prior services.
• How is it possible to tell a patient that his or
  her oral health is poor without explaining some
  of the causative factors?

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ADA Code (continued)

• Specialists or consulting dentists, upon
  completion of their care, shall return the
  patient to the referring dentist.
• If the periodontist tells the patient about the
  problem and refers him/her to another dentist,
  s/he seems to be violating this section of the
  Code.
• Yet, the principle of beneficence obligates the
  dentist to work for the patients best interests.

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ADA Code(continued)

• Whenever the patients interests conflict with
  the professionals, the Code states that benefit
  the patient is the primary goal.
• And, the Code specifies that all dentists are
  obligated to report gross or continual faulty
  treatment by other dentists to the appropriate
  reviewing agency. (Association peer review in a
  specific case, or to the state board of
  dentistry.)

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Scenario

• UK Graduate Launches Practice As Associate

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• Diane Campbell graduated from the
  University of Kentucky in May, and is now the
  associate of Dr. Gutz in Northern Kentucky. Dr.
  Gutz is in his early 60s, and plans to retire
  within a couple of years. The plan is for Dr.
  Campbell to purchase his practice at that time. 
  Shortly after arriving in the practice Dr.
  Campbell notes that the quality of Dr. Gutz's
  work is not what she anticipated it would be, and
  certainly is not in keeping with the standard of
  care that she was taught while at the
  University.  Dr. Gutz never uses a rubber dam. He
  does not perform endodontic procedures, nor does
  he refer them to the local endodontist, regularly
  telling patients that such teeth cannot be saved,
  and routinely extracting them. He  does not do
  patient consultations and does not know about the
  issues associated with informed consent. (Once
  when Dr. Campbell asked him about it, he replied
  that such was nonsense that he knew what was
  best for the patient, and that he had never been
  sued.)  Dr. Gutz does not restore primary teeth,
  but routinely extracts them, without placing 
  space maintainers. Just recently Dr. Campbell
  entered Dr. Gutz's operatory and noted that he
  was condensing a large mesio-occlusal restoration
  on a mandibular first permanent molar without a
  matrix band in place.  Dr. Campbell is distressed
  concerning the welfare of patients under Dr.
  Gutz's care she believes it just isn't fair that
  they receive less than adequate dental care. She
  is also very concerned about the type of practice
  with which she is associated, and her plan to
  purchase the practice in the near future.
• What should Dr. Campbell do?

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ADA Principles of Ethics and Code of Professional
Conduct

• The Code warns that criticizing comments must be
  justifiable and a difference of opinion as to
  preferred treatment should not be communicated to
  the patient in a manner which would imply
  mistreatment.
• Does this preclude comments about or reporting of
  care that is clearly outside the standard of
  care, and is harmful to the patient?

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Three Common Elements in Whistle Blowing

• Dissent the whistle blower disagrees with
  another.
• Loyalty typically the whistle blower sounds the
  alarm about a member of his/her team, in
  dentistry a member of the profession, By so doing
  raising the specter of lack of loyalty.
• Accusation the whistle blower identifies an
  individual to an authority who is acting
  incompetently, immorally, and/or illegally, thus
  causing harm to another.

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Dissent

• Should the incident or person be reported to the
  peer review committee or the state board of
  dentistry?
• Questions to ask
• Who will be harmed and how badly?
• Who will benefit and how much?
• How accurate and well-documented are my facts?
• What is the standard of care?

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Loyalty

• Loyalty to the profession does require that an
  attempt be made to work things out with the
  offending individual before going public and
  blowing the whistle.
• Have all the existing and less drastic avenues
  for change been exhausted?

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Loyalty (continued)

• Is excessive loyalty being displayed? Rarely do
  dentists come before peer review bodies, and
  rarely do dentists have their licenses sanctioned
  for incompetence or treating patients unfairly
  yet many dentists will affirm privately that they
  witness examples of incompetent care regularly.
• William May suggests, in The Physicians
  Covenant, that duty to colleagues frequently is
  more persuasive in the practitioners mind than
  duty to patients and suggests this is highly
  problematic ethically.

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Accusation

• What are ones motives in blowing the whistle?
• Careful attention must be given to separating an
  urge of self-aggrandizement, gaining a patient,
  or revenge for perceived wrong-doing by the
  other, from a genuine desire to serve the
  patients and societys best interest.

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Self Regulation in Kentucky

• The Kentucky Board of Dentistry receives 5 or 6
  complaints by dentists of other dentists
  annually.
• Typically these relate to advertising, quality of
  dental care, and impairment.
• Though all not necessarily whistle blowing,
  the Kentucky Dental Association receives
  approximately 20 cases for peer review annually.