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Whistle Blowing in Dentistry


More broadly, whistle blowing is the sounding of an alarm to highlight potential ... not be communicated to the patient in a manner which would imply mistreatment. ... – PowerPoint PPT presentation

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Title: Whistle Blowing in Dentistry

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

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.

Case Scenario
  • Hygienist Troubled By Employers Attitude and

  • 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
  • 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?

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.

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?

  • Periodontist Frustrated With Referring Dentists

  • 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?

ADA Principles of Ethics and Code of Professional
  • 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?

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
  • Yet, the principle of beneficence obligates the
    dentist to work for the patients best interests.

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

  • UK Graduate Launches Practice As Associate

  • 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?

ADA Principles of Ethics and Code of Professional
  • 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
  • Does this preclude comments about or reporting of
    care that is clearly outside the standard of
    care, and is harmful to the patient?

Three Common Elements in Whistle Blowing
  • Dissent the whistle blower disagrees with
  • 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.

  • Should the incident or person be reported to the
    peer review committee or the state board of
  • 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?

  • 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?

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.

  • 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.

Self Regulation in Kentucky
  • The Kentucky Board of Dentistry receives 5 or 6
    complaints by dentists of other dentists
  • 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.
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