Peer-to-Peer Conduct

Dentists who responded to this dilemma chose these options: 1) Margaret should talk to the staff in the office and plan an intervention for Dr. Sanders; or 2) Margaret should contact the Professional Recovery Network (PRN), an outsourced program of the Texas State Board of Dental Examiners. None of the respondents chose these options: 1) Margaret should not get involved – it is not her concern; or 2) Margaret should just continue to observe his behavior – maybe it is something else like a midlife crisis and even document the events to track changes over time. Dentists and staff members offered their own views on Margaret’s responsibilities and actions.

Margaret is faced with a true dilemma in this case. She has known Dr. Sanders for 18 years and the concerns are serious for the patients, the staff, the practice, and her doctor. Is her intuition accurate in this case? Is she willing to risk breaking the trust with Dr. Sanders and even losing her job if he retaliates from her accusations? Will she help anyone if she loses her job and his problem persists? These questions and others lead us to reflect on the ethics of: 1) the scope of chemical dependency; 2) intervention and confidentiality; and 3) protecting patients from harm and confidentiality.

Scope of Chemical Dependency

Margaret’s situation is not unique. According to recent surveys, 9.1 percent of the overall population is chemically dependent or abuses alcohol or other drugs.¹ The literature on chemical dependency and professionals indicates that approximately 15 percent of professionals are chemically dependent.² Dentists are not immune to the disease; it is estimated that the percentage may be higher for them than those they treat.³ Stress, isolation of solo practice, career dissatisfaction, access to drugs, and a genetic predisposition are factors which may play a role in the clinician’s vulnerability.⁴ Dentists may also feel a false sense of immunity because of their education and high intelligence. The perception of the professional dentist defies all stereotypes of an addict.³

Margaret understands that there may be consequences whether she acts or not. Her loyalty to Dr. Sanders over the last 18 years is weighed against other possible harms to patients, the practice, staff, and even herself.

Margaret is not alone in her concern for patients, however. The mission of the Texas State Board of Dental Examiners (TSBDE), a self-regulating body appointed by the governor is to “safeguard the dental health of Texans by developing and maintaining programs to: 1) ensure that only qualified persons are licensed to provide dental care; and 2) ensure that violators of rules and regulating dentistry are sanctioned as appropriate.”⁵

To ensure that safety, in 1985, the legislature established a peer assistance program for chemically and mentally impaired dental professionals. The program is approved by the TSBDE and is currently operated by the PRN which is part of a non-profit corporation. Funds are received through a surcharge added to license and license renewal fees. PRN works through confidentiality and trust to educate, prevent, intervene, refer, support, and monitor professionals experiencing problems that threaten their well-being and the quality of their practice. PRN stresses a proactive approach, a concentration on early identification and treatment, and advocacy for its participants.

The actions of the TSBDE demonstrate that there is a concern for impaired dental professionals. A review of all of the cases filed with the TSBDE from 1977 through 1984 revealed that about 55 percent were related to the diversion of drugs for self-use or other “non-dental” purposes.⁶ A Michigan study reported that 48 percent of participant respondents knew a fellow dental colleague who was experiencing untreated chemical dependency.⁷

Are there advantages for involving PRN rather than have Margaret plan an intervention for Dr. Sanders?

Intervention and Confidentiality

Margaret is in a tenuous position in this case because she understands that there may be consequences whether she acts or not. Those who responded to the case provided additional advice on whether Margaret should talk to the staff and plan an intervention or contact the PRN.

While some respondents chose to have Margaret involve the staff in an intervention, others did not. A practice administrator based her decision not to involve the staff out of mutual respect and loyalty to her employer. Suspicions were just that, suspicions, and she felt that she would be more effective due to the mutual trust and her concern for his well-being to perform the intervention herself. Another dentist agreed that Margaret should intervene after hours when the rest of the staff was gone, a right she earned after 18 years as a loyal employee.

The challenge for Margaret is that while she may be acting out of loyalty to her doctor, staff, and patients, she is not trained as an interventionist. She is not prepared to deal with the denial and possible retribution if Dr. Sanders views her intervention as a misguided threat to the practice. If she does choose to intervene in this case, she does so at some risk to herself.

Some respondents chose to have Margaret contact the PRN although there was some confusion about how confidentiality is managed. One respondent wrote that Margaret should contact the PRN because the potential consequences of not blowing the whistle were more dire than losing a job. One reason for colleagues not choosing to intervene is fear of negative repercussions that might ensue from notifying programs like PRN. They fear being found out by their friends or being mistaken in their suspicions.

Peer assistance programs such as PRN keep all concerned individuals’ contacts confidential. A breech in confidentiality could damage friend­ships, professional communities, and the credibility and trust in these programs. Confidentiality is a central component of professional responsibility for dental professionals and counselors.

Ms. Holly Johnston, a counselor for PRN explains that, “there is never a time that PRN counselors would disclose the relationship of the caller to the potentially impaired dentist or the name of the concerned caller. Furthermore, it is not the belief of PRN staff that everyone reported has a problem. However, members of the PRN staff do feel it is their responsibility to help the possibly impaired professional investigate the concern of impairment by obtaining an unbiased evaluation. The benefit of utilizing PRN is that it allows the impaired professional to seek help and obtain recovery while remaining anonymous to the TSBDE.”

Colleagues often feel that they “owe it” to the dentist to intervene themselves rather than contacting PRN. Many times, they believe by not contacting PRN, they are maintaining the impaired professional’s confidentiality thereby reducing the perceived harm of reporting the believed chemically dependent dentist. In Ms. Johnston’s professional experience this is not a good choice because it often is not effective. There is a great deal of training and skill required to complete a successful intervention. Additionally, many times the nature of the reported problem may not be related to substance abuse disorders but rather mental health conditions. Members of the PRN staff are licensed and trained to make these distinctions as well as break down the denial if a problem does exist. In addition, PRN staff members know which treatment centres specialize in treating healthcare professionals and which local evaluators are skilled in detecting problems with professionals.

Even with the expertise of the PRN counselors and this shield of confidentiality, why should anyone intercede on the life of a dentist due to a concern for chemical dependency?

Ethical Responsibilities

The ethical themes emerging in this case include protecting patients from harm, protecting the confidentiality of those who report their concerns, and protecting the confidentiality for those in treatment for chemical dependency.

The ADA has identified five fundamental principles of ethics that form the basis for the Code. One of the principles that apply to this case is nonmaleficence, or “do no harm.”⁸ In this principle the dentist has a duty to refrain from harming the patient. The ADA Code regarding a chemically impaired colleague states:

“It is unethical for a dentist to practice while abusing controlled substances, alcohol, or other chemical agents which impair the ability to practice. All dentists have an ethical obligation to urge chemically impaired colleagues to seek treatment. Dentists with first-hand knowledge that a colleague is practicing dentistry when impaired have an ethical responsibility to report such evidence to the professional assistance committee of a dental society.”⁸

Patients expect to be treated competently, and an impaired professional jeopardizes this standard. The Texas Dental Association’s Principles of Professional Conduct explains this as, “Professional competence is the just expectation of each patient.”⁹ An impaired professional jeopardizes this standard.

Another ethical theme involves the rights of the dentist as it relates to the responsibility to report an impaired dentist as it relates to confidentiality. Whether reporting or in treatment, health care professionals have a right to confidentiality, just as the patients they treat. They are expected to protect the patient’s confidentiality and may only breech this responsibility in specific circumstances such that a failure to disclose would be a threat to public safety. Counselors like those at the PRN are held to the same standard. The obligation of confidentiality stems from a second principle cited in the ADA Code and healthcare ethics as respect for patient autonomy.^8,10 Counselors must protect the confidentiality of their referrals on these serious matters in order to respect their autonomy. Counselors in programs like the PRN are obligated to protect the confidentiality of their clients from the TSBDE unless their impairment threatens public safety.⁵ Confidentiality, then, is maintained for those who make the report and set aside for those practitioners who are or may be a threat to public safety.

Conclusion

Margaret is in a dilemma in this case because she understands there may be consequences whether she chooses to intervene with Dr. Sander’s possible chemical dependency or not. But if she decides that the situation warrants an intervention – and the circumstances do lead to that conclusion – she should realize that she is not trained to undertake the intervention herself. It is a serious consideration for Margaret or anyone else, not specifically trained, to have an intervention with Dr. Sanders. This is serious business with lives, jobs, and patients’ health all at stake. Margaret is ethically justified in contacting a counselor at the PRN to request a professional assessment and intervention if needed.

References

1. Substance Abuse and Mental Health Services Administration. Overview of Findings from the 2003 National Survey on Drug Use and Health (Office of Applied Studies, NSDUH Series H- 24, DHHS Publication No. SMA 04-3963). Rockville MD; 2004.
2. Crosby LR, Bissell L. To care enough. Intervention with chemically dependent colleagues. Minneapolis, MN: A Johnson Institute Book 1989.
3. Combs RH. Drug impaired professionals. Cambridge, Mass: Harvard University Press 1997.
4. American Dental Association Council on Dental Practice. Dentist Well-Being Programs Handbook. Chicago, IL: American Dental Association; 2004.
5. Texas State Board of Dental Examiners, Mission Statement. 2004. [WWW document]. URL http://www.tsbde.tx.us/aboutsbde
6. Sandoval VA, Hendrickson WO, Dale RA. A survey of substance abuse education in North American dental schools. J Dent Educ 1988; 52(3):167-9.
7. Peterson RL, Avery JK. The alcohol-impaired dentist: an educational challenge. J Am Dent Assoc 1988; 117(6):743-748.
8. ADA Principles of ethics and code of professional conduct. American Dental Association. 1995-2004. [WWW document]. URL http://www.ada.org/prof/prac/law/code/preamble
9. The 12 fundamental principles of professional conduct. Texas Dental Association. 2004. [WWW document]. URL http://www.tda.org/site/pp.asp?c=grKQL2NSE&b=67660
10. Beauchamp TL, Childress JF. Princip les of biomedical ethics (4th ed.) New York: Oxford Univ Press 1994:125-8.

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 on 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 in dispensable. 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 of 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 I 988; 260(18):2720.
6. Rokey R, Rolak LA. Letter to the editor (reply). No pretending not to know. J Amer Med Assoc 1 9 89; 260(9):1276-1277.
7. Purtilo RB, Cassel CK. Blowing the whistle on incompetent or unethical colleague s. 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; l.
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.

How should Dr. Boley respond to Ms. Wentworth?

Dr. Boley’s dilemma was no stranger to our readers as they related similar experiences and reflected on the per­plexing nature of the problem. One reader “felt horrible” about the way he had handled a case, another felt “re­miss for not dealing effectively” with another dentist, and a third wrote that reporting a colleague resulted in “hard feelings from this dentist’s buddies.” It was a “soul searching” experience for the readers. Dr. Boley’s dilemma is one of the most difficult for dentists be­cause they must weigh the dual re­sponsibilities of preventing harm to patients while preserving their own personal and professional integrity. Is Dr. Leeds’ work unsatisfactory? If so, what are Dr. Boley’s ethical obligations to report continually faulty work and what actions are available to her?

Levels of Adverse Outcomes

Dentists routinely assess the appropriateness and the quality of care provided by other dentists. When this assessment includes an adverse patient outcome, it is worthwhile to begin by defining issues of competency. The philosopher, Morreim¹, identified five levels of adverse outcomes in order to separate ordinary mishaps from real mistakes indicating incompetence.

The first level of adverse outcome is the accident, an event totally out of the control of the dentist as what may result from an equipment failure. At the second level the dentist makes a well-­justified decision that turns out badly, as in the case of a patient requiring antibiotic coverage, who has no known allergies to antibiotics, but suffers an anaphylactic reaction. The third level occurs when there are disagreements about treatment options, a common problem for dentistry.² What are the options for the TMD patient, the patient with a malocclusion, or the patient who needs a three surface posterior restoration?³ There is as much uncertainty in dentistry as in medicine. The adage “ask three dentists for their advice on a case and you’ll get four opinions” applies. Simply because dentists disagree about treatment choices does not signify incompetence or mistreatment. The ADA Principles of Ethics recognizes this common occurrence when it states “a difference in opinion as to preferred treatment should not be communicated to the patient in a manner which would imply mistreatment.”⁴ At the fourth level, the dentist exercises poor, though not outrageously bad, judgment or skill. The general dentist may cement a full gold crown with a deep distal margin and determine that the margin is faulty at the next recall. The concern at this level is not the single error, but rather a pattern of errors as observed by Dr. Boley – a circumstance the ADA Principles of Ethics could describe as “continual” faulty treatment. At the fifth level are the outrageous violations such as the dentist who performs unnecessary treatment, performs surgery on the wrong site, or threatens the lives of patients⁵ – situations the ADA Principles of Ethics could describe as “gross” faulty treatment by another dentist.

Obligations to Report

The obligation to report a colleague suspected as being incompetent may be derived from several origins. When people are faced with ethical dilemmas they naturally fall in two primary categories⁶; those who guide their decisions by their principles (principlists) and focus on what is right; and those who set their principles aside and guide their decisions by stressing the consequences of their actions (consequentialists). The consequentialist focuses on that which produces the most good. For the principlist, principles such as “do no harm”, keeping promises, and the authority of codes of ethics may be the source of their obligation.

Physicians and dentists are instructed by the Hippocratic Oath to “above all or, at least, do no harm”, or simply phrased, “if you can’t help, at least don’t harm.” Dentists must routinely decide if a new product or technique is thoroughly researched, safe and effective, and when it is necessary to refer a patient who needs the skills of the specialist. Preventing the unnecessary harm of our patients is a key principle in health care ethics.

Keeping promises is another leading principle. The dentist enters the profession prepared to provide beneficial care and by staying contemporary in knowledge and proficiency, fulfills the promise to work in the patients’ best interest. We don’t expect this same treatment from a used car salesman where “buyer beware” may be the rule.

Official codes are another source of our obligations if we use their authority as our guide. The ADA Principles of Ethics⁴ states: “Dentists shall be obliged to report to the appropriate reviewing agency as determined by the local component or constituent society instances of gross or continual faulty treatment by other dentists.” The TDA Principles of Ethics⁷ goes further by stating: “Dentists should observe all laws, uphold the dignity and honor of the profession and accept its self-imposed discipline. They should report dentists deficient in character or competence or who engage in fraud or deception.”

For the consequentialist, the obligation to report depends on whether the individual is seeking the action that produces the greatest good for the greatest number or the greatest good for the individual. Dr. Boley is faced with alternatives that have overwhelming consequences. Although it could be argued that the greatest good would be served by reporting incompetent practitioners, thus preventing harm to patients, it is the decision of the individual to determine what is good for whom.

Actions for Dr. Boley

The action for Dr. Boley begins with a thorough review of the accuracy and fairness of her assessment of Dr. Leeds’ work. Were her concerns primarily a disagreement about therapy (level three), or a pattern of faulty treatment (level four)? We are not aware of the circumstances of the other five cases or if she is biased about his “old-timer” status. Emergency patients pose a special problem as our challenge is to manage the crisis – a situation that thwarts a thorough examination. Dr. Boley’ s obligation to her colleague is to be fair and unbiased and to prevent an unnecessary harmful action. Her obligation demands that she perform a careful, thorough, investigation.

If Dr. Boley is now certain of the facts and circumstances surrounding the six cases she may decide to discuss the case, without mentioning Dr. Leeds, with a trusted colleague, a member of the local peer review committee, or an Examiner with the Texas State Board of Dental Examiners. These were choices selected by our readers. If after her discussions she decides further action is necessary, several options are available.

One reader recommended that Dr. Boley discuss the situation directly with Dr. Leeds, a reasonable action considering that patients sometimes misunderstand our explanations. Dr. Leeds may have informed Ms. Went­worth of the difficulty of the extraction and the need for periodontal and restorative care. This discussion may decide the need for further action by Dr. Boley.

Reporting Dr. Leeds to the local peer review committee was another option that readers selected in this case although it was presented in error, as “the current peer review system is not intended to handle a complaint initiated by one dentist against another.“⁸ Peer review was established to manage dentist to patient, and dentist to third party disagreements and was established by the ADA in 1970. As one reader stated, Ms. Wentworth “urgently needs to know the truth about her dental problems – it is morally and ethically imperative” and that Dr. Boley can communicate this and not “disparage”⁴ Dr. Leeds. In Texas, Dr. Boley could inform Ms. Wentworth that if she has a concern about the quality or appropriateness of her care she could call the local dental peer review committee. Peer review is available to both TDA members and nonmember dentists in Texas and in the calendar year 1991, Texas reported 534, or 13%, of the total of 4,030 peer review cases initiated nationally. Of the Texas cases, 60% were quality of care issues and 29% involved appropriateness of care issues.^9,10

If Dr. Boley decides to file a complaint against Dr. Leeds she would contact the chairman of her local dental society committee on ethics and judicial affairs. If both dentists are members of the TDA the local committee would review the case. If one or both dentists are not members of the TDA the local committee would forward the complaint to the TDA’s Council on Ethics and Judicial Affairs who would then forward the complaint to the Texas State Board of Dental Examiners for review.

There are several actions available to Dr. Boley and they are predicated on her careful and thorough investigation. None of the dentists responding to the case selected the option to say or do nothing, or to recommend that the patient review her case with a lawyer.

Conclusion

Dr. Boley’s ethical dilemma asks us to consider how we value our personal and professional responsibility to protect the health of the public and the integrity of our profession. A decision to report a colleague is one of the most agonizing dilemmas that dentists encounter and requires an extraordinary measure of wisdom, courage, and integrity. However, whether the dentist derives his or her decisions by principles or by consequences, since our duty first is to the patients’ welfare rather than our colleague’s career, evidence of manifest incompetence demands that we take steps to address it.

References

1. Morrheim, EH. Am I my brother’s war­den? Hastings Center Report, 23(3);19-27, May-June 1993.
2. Bader, JD & Shugars, DA. Agreement among dentists’ recommendations for restorative treatment. J Dent Res 72(5):891-896, May 1993.
3. Sadowsky, D. Moral dilemmas of the multiple prescription in dentistry. J Am CoU Dent 46(4):245-248.
4. ADA Principles of Ethics and Code of Professional Conduct. May 1992.
5. McCarthy, FM. The Protopappas anes­thesia deaths. JADA 110(1):26, Jan 1985.
6. Matthews, M. Ethical reasoning: making ethical decisions in the context of den­tistry. Texas Dent J. 32-37, Sept. 1992.
7. Texas Dental Association Articles of In­corporation Constitution and Bylaws and Principles of Ethics and Code of Profes­sional Conduct, p.18, Sept 1985.
8. ADA Peer review in focus. Dentistry’s dispute resolution program, p.3 & 9, 1993.
9. American Dental Association, Council on Dental Care Programs. National Peer Review Reporting System, 1992 Survey Results.
10. American Dental Association, Council on Dental Care Programs. 1992 National Peer Review Reporting Calendar Year 1991 Data (Texas)