Ethical Decision Making in Dentistry 9781607952565, 9781607951766

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Ethical Decision Making in Dentistry

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Ethical Decision Making in Dentistry Suzanne U. Stucki-McCormick, MS, DDS Private Practice Encinitas, California

2014 People’s Medical Publishing Company—USA Shelton, Connecticut

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People’s Medical Publishing House-USA 2 Enterprise Drive, Suite 509 Shelton, CT 06484 Tel: 203-402-0646 Fax: 203-402-0854 E-mail: [email protected] © 2014 PMPH-USA, LTD All rights reserved. Without limiting the rights under copyright reserved above, no part of this publication may be reproduced, stored in or introduced into a retrieval system, or transmitted, in any form or by any means ­(electronic, mechanical, photocopying, recording, or otherwise), without the prior written permission of the publisher. 14 15 16 17/KING/9 8 7 6 5 4 3 2 1 ISBN-13 ISBN-10 eISBN-13

978-1-60795-176-6 1-60795-176-2  978-1-60795-256-5

Printed in the United States of America by King Printing Company, Inc. Editor: Linda H. Mehta; Copyeditor/Typesetter: diacriTech; Cover designer: Allison Dibble Library of Congress Cataloging-in-Publication Data Ethical decision making in dentistry / [edited by] Suzanne U. Stucki-McCormick. p. ; cm. Includes bibliographical references and index. ISBN-13: 978-1-60795-176-6 ISBN-10: 1-60795-176-2 ISBN-13: 978-1-60795-256-5 (eISBN) I. Stucki-McCormick, Suzanne U., editor of compilation. [DNLM: 1. Ethics, Dental. 2. Dentist’s Practice Patterns—ethics. 3. Practice Management, Dental—ethics. WU 50] RK52.7 174.2’976—dc23 2013044644

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Notice: The authors and publisher have made every effort to ensure that the patient care recommended herein, including choice of drugs and drug dosages, is in accord with the accepted standard and practice at the time of publication. However, since research and regulation constantly change clinical standards, the reader is urged to check the product information sheet included in the package of each drug, which includes recommended doses, warnings, and contraindications. This is particularly important with new or infrequently used drugs. Any treatment regimen, particularly one involving medication, involves inherent risk that must be weighed on a case-by-case basis against the benefits anticipated. The reader is cautioned that the purpose of this book is to inform and enlighten; the information contained herein is not intended as, and should not be employed as, a substitute for individual diagnosis and treatment.

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Contents List of Contributors

vii

Foreword ix Preface xii

Chapters 1.  Ethical Dilemmas in the Education of Dentists Leon A. Assael, DMD

1

2.  Ethics in Dental School

13

3.  Licensure and Licensing E ­ xaminations

25

4.  The Joy of Solo Private Practice

39

5.  The Ethics of Referrals: Building Relationships to Build Your Practice

43

6.  Ethics of Professional Group Dental Practice

47

7.  Ethical Considerations in Dentistry

53

8.  Esthetic Dentistry: When Is Too Much Too Much and What Is Enough?

67

Michael C. Meru, DDS, MS Mark L. Christensen, DDS, MBA Lilia Larin, DDS

Suzanne U. McCormick, MS, DDS and Larry Stigall, DDS Bruce Whitcher, DDS

Jonathan Rudin, DDS, MS, MPH

Randy Mitchmore, DDS, MAGD

v

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9.  Patient’s Perspective on Medical Ethics Rocco Gemma

81

10.  Dental Board and Licensure: Where the Rubber Meets the Road of Ethical Decision Making

91

11.  Conscientious Billing P ­ ractices: ­Ethical Decision Making for ­ Patient Billing and Dental B ­ enefit Company Relations

95

Maxwell Finn, DDS, MD and Miro Pavelka, DDS, MSD

Sheri B. Doniger, DDS

12.  The Ethics of Career-Long Learning

103

13.  Office Management

109

14.  Ethics and Advertising

119

15.  Informed Consent

129

16.  The Itinerant Practice in Dentistry

137

17.  Ethics in Transition

143

James R. Hupp DMD, MD, JD

Sunny Stewart, MS, MBA, SD, PhD, Ric Salvati, OSA and Suzanne McCormick, MS, DDS Richard J. Simonsen, DDS, MS James Q. Swift, DDS

Roger P. Byrne, DDS, MS, MD Boyd Tomasetti, DMD

Epilogue 147 Steve Afriat

Index149

vi Contents

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List of Contributors Steven Afriat [Epilogue] President The Afriat Consulting Group, Inc. Burbank, California Leon A. Assael, DMD [1] Professor and Chairman, Department of Residency Program Director Medical Director Hospital Dentistry Oral and Maxillofacial Surgery Oregon Health & Science University School of Dentistry Professor of Surgery Oregon Health & Science University School of Medicine Portland, Oregon Roger P. Byrne, DDS, MS, MD [16] Chairman, American Association of Oral and Maxillofacial Surgeons Commission on Professional Conduct Private Practice Byrne Oral Surgery Houston, Texas Mark Christiansen, DDS, MBA [3] Private Practice, General Dentistry Salt Lake City, Utah Sheri B. Doniger, DDS [11] Private Practice of Dentistry Author, Clinician, Consultant, and Educator Lincolnwood, Illinois

Maxwell Finn, DDS, MD [10] Clinical Assistant Professor Baylor College of Dentistry Attending Physician Forest Park Medical Center Dallas, Texas Rocco Gemma [9] Patient Author of In The Midst Of Savage Darkness James R. Hupp, DMD, MD, JD [12] Professor, Oral-Maxillofacial Surgery School of Dental Medicine East Carolina University Greenville, North Carolina Lilia Larin, DDS [4] Private Practice South Coast Dental National City, California Suzanne Stucki-McCormick, MS, DDS [13] Private Practice Encinitas, CA Michael C. Meru, DDS, MS [2] Private Orthodontics Practice West Jordan, Utah

vii

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Randy Mitchmore, DDS, MAGD [8] Master, Academy of General Dentistry Master, American Dental Implant Association Private Practice Houston, Texas Miro Pavelka, DDS, MSD [10] Clinical Professor Department of Oral and Maxillofacial   Surgery College of Dentistry Texas A & M Health Science Center Dallas, Texas Jonathan Rudin, DDS, MS, MPH [7] Vice President, Training San Diego Healthcare Compliance San Diego, California Ric Salvati, OSA [13] Pacific Surgical Institute Encinitas, California Richard J. Simonsen, DDS, MS [14] Faculty of Dentistry Department of Restorative Sciences Kuwait University, Kuwait City, Kuwait

Larry E. Stigall, DDS [5] Private Practice Boone, North Carolina James Q. Swift, DDS [15] Professor and Director Division of Oral and Maxillofacial   Surgery Department of Developmental and   Surgical Sciences University of Minnesota Minneapolis, Minnesota Boyd Tomasetti, DMD [16] Clinical Associate Professor of Oral and   Maxillofacial Surgery University of Colorado School Of   Dentistry Denver, Colorado Private Practice Littleton, Colorado Bruce Witcher, DDS [6] Private Practice of Oral and   Maxillofacial Surgery Member, Dental Board of California San Luis Obispo, California

Sunny Stewart, MS, MBA, SD, PhD [13] Pacific Surgical Institute Encinitas, California

viii List of Contributors

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Foreword As members of society, we are raised with a sense of right and wrong. Making the right choice in difficult times is what determines your character, and character is what makes the difference. On November 30, 2009, Dr. Arthur A. Dugoni, DDS, MSD, Dean Emeritus and Professor of Orthodontics, University of the Pacific, Arthur A. Dugoni School of Dentistry gave a lecture to the Student Professionalism and Ethics Club entitled: “Road Signs on the Road of Life.” Excerpts for this lecture are presented here as his words highlight these ideals. Well over 100 years ago, a few super professionals with dreams, ambition, ideals, and aspirations of making dentistry a noble and learned profession organized and developed our ethical standards—our code of conduct—now our heritage—and molded a profession from a trade. You are aware of the ADA principles of ethics and code of professional conduct and the Hippocratic Oath of Medicine and Dentistry. However, our forefathers recognized human frailty and morality. They would have agreed with Mahatma Gandhi on those things that will weaken or destroy us as individuals or as a profession: “Politics without principles, wealth without work, pleasure without conscience, knowledge without character, business without morality, science without humanity.”

We in dentistry today are heirs to positions of respect, given to us by individuals who achieved that respect by adhering to principles, by going the extra mile, by giving of their time, talent, and treasury to create a profession. •  They looked upon their fellow dentists as colleagues and not competitors •  They believed we were a profession, not a trade. •  They believed we were providers of service, not commodities. •  They believed we have a commitment to serve mankind. Parents would say, with pride, “My son, the doctor,” “my daughter, the lawyer,” etc. Professions were referred to as “callings.” These callings were the conscience of America dedicated to noble things; moral things; and helpful, idealistic, and unselfish causes generated for the benefit of humanity. This commitment earned dentists and dentistry the stature of a learned profession (from a trade to a profession—It took us over 50 years!). We are called “doctor” and are filled with pride when we hear our names called as doctor ix

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or when that patient says to us, “Thank you, doctor, thank you for stopping my pain,” “thank you for my smile,” etc. What does the calling to be a doctor imply? In my mind, it implies: •  fairness (power corrupts; absolute power corrupts absolutely) •  integrity •  honesty •  service above self or self-interest •  respect for the human dignity of everyone •  a passion for quality and a commitment to excellence Today, we take so much for granted. If I were to give any advice, it would be: •  Hold on to something bigger than yourself. Work with others toward a common goal that benefits mankind—that improves your profession, your city, your state—yes, your country. Do more than your share. •  We are as good as we police ourselves. Take pride in doing your job well— “knock their socks off!” Work hard to make your ideals take shape in reality. Help build something of lasting value. Grow from your failures—they become the seeds of your success. Always do what is right—it will please some people and it will astonish the rest. We are surrounded today with a deluge of high-profile individuals who choose to be unethical and dishonest (sports, politics). Several years ago, it hit closer to home. Students at 5 dental schools were involved in unethical and unprofessional conduct. They embarrassed their universities, their dental schools, and most of all themselves. Their excuse—“I am okay”—I am “better than most people I know—everyone does it —it is no big deal.” A Stanford study found that “80 percent of honors and advanced placement students cheat on a regular basis.” In my view, one possible answer is that we are ignoring what really constitutes leadership. According to Michael Josephson of the Josephson Institute: “We are focusing too much on issues of style and ignoring issues of true substance— character and values. I believe that a leader’s character is central to the development of positive relationship with followers. Transformational leaders act in ways that turn followers into leaders. By empowering their followers, they build excitement around an appealing vision that creates performance excellence in challenging times.”

Character comes from the Greek words, “to mark or engrave.” Are adults doing enough to engrave ethical values in young people?

x

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Living a life that matters does not happen by chance. It is not a matter of circumstances but one of choice. As health care professionals, you have chosen to live a life that matters. And because you have, many individuals will have a better quality of life, go to bed without pain, have a beautiful smile, live longer, have healthier lives, walk a little taller—and you know in your heart that you have made a difference. Congratulations for choosing to live a life that matters.

Dr. Arthur A. Dugoni Dentistry is both an art and a science, such that judgment calls and compromises are made daily in clinical practice. It is important to recognize and understand one’s own inner boundaries, strengthen this inner compass, and practice with ethical resolve.

Foreword xi

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Preface Dentistry is a learned profession and a career path that demands and deserves respect and trust. It is a privilege and an honor to have one’s fellow human beings trust our skills, judgment, and integrity as our patient. However, it is at those difficult, challenging times that our resolve, our professional ethics, and character will be tested. Never easy, the choices and decision we make will have consequences and will determine the path our lives will take as a doctor. What path will you take? Suzanne U. Stucki-McCormick, MS, DDS

xii

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Chapter

1

Ethical Dilemmas in the ­Education of Dentists Leon A. Assael, DMD

Medicine is like the slow raising of masonry. We are fortunate, in lifetime, to be able to lay a single brick.

Prof. Dr. Med Nasser Nadjmi, Antwerp Belgium The traditional view of ethics in the dental school is that the main ethical problems in dental education are, for example: cheating on examinations, nondisclosure of conflict of interest, commercialism, getting help on clinical exercises, and so forth. Although all these issues are of great importance, none of them are peculiar to the very nature of dental education. In this chapter, a focus on the ethical dilemmas inherent to the contemporary dental education model is discussed. How these dilemmas result in an adverse effect on dental practice are presented. In addition, the solution to ethical problems in dental school is traditionally thought of as occurring in ethics courses and training. In this chapter, instituting structural changes in dental education are considered as a means of promoting the ethical practice of dentistry. The activities that dental students experience while in their didactic and clinical education serve to define practitioner ethical behavior for their entire career and in critical ways. Dentists see their profession first as dental students. They will model their clinical lives based upon their experience, for example, their interaction with patients, how their treatment plan their services, charge for services, evaluate their own clinical outcomes, interact with the health care team, design their facilities, see their professional identity, and most importantly how they view their relationship to their patients. Their love or loathing of the practice of dentistry will be learned on the clinic floor and carried with them to drive the pursuit of excellence 1

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or in contrast the misapplication of patient care. Thus, the public is highly vested in the education of dentists and the ethos that arrives from that experience. Ethics in clinical education and practice is not expressed best as abstract ideas but rather as the application of decisions, behaviors, and skills in the care of patients. Therefore, the application of ethics in the clinical setting is more measurable and can be seen in the health of the patients who get their care in that environment. It is fair to say that most of the care delivered is quite good and meets the standards (or exceeds that delivered) in the community. So, at the outset the measure of dental school ethics is quite good. However, there are shortcomings that need to be addressed. In a vignette format here are some of the ethical dilemmas in dental school education and some of the solutions to mitigate those problems.

VIGNETTE

The patient care delivery environment

Student to the Dean: “Sometimes the faculty just chew me out in front of the patient telling me what I did wrong. It’s embarrassing and I wonder what the patients might think. I feel incompetent and my patient must feel like a guinea pig.”

All dentists first practice as students and model behaviors that they observe in the clinical practicum. The means of educating dentists in clinical procedures is unique. For most dental students, nearly all clinical care they witness in dental school is delivered by them in their own clinical education, for example, the clinical practicum. No similar type of clinical experience exists in any other type of health care education. Dental educators are in a parental role as students sequentially take on the knowledge, skills, and behaviors of dental practice. They do so in a clinical delivery environment created solely for their clinical education. Thus, the first experiences often guide future experiences. As one who taught skiing, I observed two instructors, Klaus, the ski school director, and Linda who worked almost entirely with children and disabled skiers. Klaus: “No you are doing it all wrong! He scowled to the class and called out to the children in his ski class. Fear enveloped a student as he tried to follow a long list of quickly stated verbal instructions and fell on the first turn. Linda: Today, we are going to have fun. You kids are ready. You did so well the last lesson, I know you will do great. The sun is shining. The snow is perfect and everyone is going to learn something today that they are going to love.” Ask yourselves which students are going to enjoy skiing and which will fear it. Those who fear it often become the “speed demons” racing from top to bottom at full speed with no turns and a good measure of bravado to suppress their fear. They ski past the happy former students of Linda who with Zen like pleasure carve turns and enjoy the terrain beneath their feet.

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It is the same in dentistry. Those who fear a procedure take shortcuts and are unable to be self-critical lest they feel as though they are playing the role of the critical instructor, this time chewing themselves out, mercilessly. Instead they often become “speed demons,” bombing through the clinic day without any helpful self-appraisal or true enjoyment or appreciation for the tasks at hand or their meaning. Patients become a sideshow to the inner demons brought on by the dentists own sense of inadequacy. This obviously compromises the ethical construct of their dental practice, obviates continual improvement, and creates a self-hating dentist.

Solutions In the above dental school vignette, it is clear that the faculty member is also frustrated and unhappy. The faculty member does not feel in control of the clinical situation and feels their only avenue toward minimally adequate completion of the procedure is with bitter cajoling. Admittedly, the clinical dental education environment is a challenge (as it is with a class of beginner skiers), but the current environment on many dental school clinic floors creates an unacceptable environment for promoting ethical practice. Dental clinical educators have but one person to “chew out “for inadequate care, it is their collective selves. The construct of the clinical practicum does not ensure direct and continuous responsibility and vesting of faculty for the highest level of care for the patient. In an environment where the faculty see themselves as the patient’s dentist, they would be applying ethical standards of quality beyond how they see themselves on the clinic floor. The distribution of responsibility for patient care across components of treatment and across time is one component of this flawed clinical construct, and the second is establishing who is responsible for clinical care across discipline, and time. Faculty are often supervising procedures they did not treatment plan and would have performed by different means or in different ways. Each visit might include a different faculty member. Patients in the community have a general dentist who comprehensively cares for their patients and makes decisions about when their patient might benefit from other providers. In the dental clinical practicum, a primary care dentist who is involved continuously and responsible for care across time and student’s years would address this problem well. In some schools they are called team leaders, whereas in others, they are referred to as practitioner or as compared to student centered care, dentist centered patient care.

VIGNETTE

The ethical burden of clinical requirements

A group of students are sitting in the library. Each has out their patient care experiences, their current comprehensive patient group, and list of requirements. One stated, “There is no way I can graduate with these patients. None of them need fixed or an RPD. I need to dump them and get new ones.” Negotiations and bartering for patients then ensued.

Students are driven to objectify their patients and to see them as a set of procedures rather than a person with diseases such as caries, periodontal disease, and edentulism among o­ thers,

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that they are working with to improve their health. The requirement-driven curriculum is also divided into extreme subsets of procedures that drive treatment decisions. Thus, if a patient could have a composite or a crown for a lesion, but one is needed over the other as a requirement, that can drive the treatment decision rather than what is medically best and most economical based upon evidence-based practice. The practice of dentistry is then built around the procedures and not about the health status of patients treated for a disease. This results in a procedure-based dental practice. For example, the American Dental Association (ADA) coding resisted diagnostic codes and presents a plethora of codes for nearly identical procedures. Dentists are not seen as providers of health evaluation and management (E & M) services and only recently developed codes for this, which focus on clinical examination, not history or patient counseling or other standard E & M components of medical practice. In the requirements-based environment, the dentist is seen as one who does procedures and not as one who improves health.

Solution Dental school clinical practicum requirements need to be put into broad strokes such as experience with direct restoration, experience with indirect restorations, periodontal care, oral surgery, orthodontics, pediatric dentistry, special care dentistry, and public health dentistry. The measure of performance in the clinical environment needs to be in the improvement of health. For example, were caries controlled? Did periodontal status improve? Did patient change oral health behaviors? Did patient gain access to care and continue to undergo treatment? With regard to psychomotor skills of practice these remain essential for good dental practice, but need to be seen more globally such as in the ability to utilize instrumentation and technique properly rather than the endless step-by-step checking that currently occurs on the clinic floor.

VIGNETTE

The ability to pay drives the treatment plan

Faculty member at a meeting on improving clinic operations: “What we need to do is get these deadbeats out of our clinics. They can’t afford our treatment plans and they are taking up space.” Students are in a vacuum when trying to navigate systems-based practice in oral health care. Although there are about 50 million Americans without health insurance, over triple that number are without dental insurance. When they are in practice, they will quickly learn that nearly all the oral health care that is needed will have to be paid for out of pocket or will not be delivered. Each dentist in America is responsible for about 2000 lives (150,000 dentists for about 300,000,000) but the typical dentist does not even carry half as many patients on their roles. Dental schools do very little to teach or inspire students as to how to reach and improve the care of the majority of Americans who cannot afford the services they were taught to do. This economic model has resulted in great resistance among dentists in extending the capabilities of the oral health workforce. For example, a patient in the dental school today

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might have a myocardial infarction. They would then likely be treated nearly entirely by the extended health care workforce, for example, the morphine, oxygen, nitroglycerine, aspirin, and ECG telemetry IV meds are performed by Emergency Medical Technicians. The cardiac catheterization imaging is performed by technicians. In the operating room, the chest is often opened, veins harvested, and chest closed by surgical assistants and the perfusionist technician carries the heart on bypass while the cardiothoracic surgeon performed the bypass surgery. The same patient returning to the dental school will usually find no one but a dentist or student dentist who can so much as administer a local anesthetic or pack a direct restoration. This makes dental care the last nondistributed health care and promotes its expense. Dental schools have done little to develop a clinical care environment that is efficient, trains a workforce rather than a dentist, and thus addresses the issues of the cost of care.

Solutions Dental schools need to go beyond talking about access to care in didactic courses and instead build a delivery environment that improves access to care and subsequently educate students, the future of the profession, in that environment. Innovative care delivery environments can be built within the walls of the school and experiences by students in the community setting. Dental schools can develop programs for expanded duty dental auxiliaries and dental therapists with the dentist as the head of the oral health care team. Examining the physician’s assistant model will mitigate against the risk of having a twotiered provider, and thus, two-tiered care. The dentist must remain head of the team but can reduce the cost of care by distributing the labor of clinical practice. The ethical outcome will be a dentist capable of caring for all 2000 of the population for which they are responsible and in an efficient, high quality, and cost-effective way.

VIGNETTE 1

Ethical dilemmas in didactic education

A student to faculty member: “I’m not going to be an oral surgeon. I hate oral surgery. Just tell me what I need to know to pass the test.”

VIGNETTE 2 In a student meeting: “Why do we have to learn all this microbiology and molecular biology. I showed my dad this stuff and he told me he never uses any of it in his dental practice.” The dangers of today’s dental students are learning to the test and utilizing technology to limit their engagement and ownership of the curriculum material and the course. The “camel,” the course outline, details and content (often today in a platform called Sakai) often spoon-feeds content in each course. The didactic test in the discipline-based course demonstrates inherent ethical issues as it measures knowledge in a window of time and in a way that does not translate into the

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Ethical Decision Making in Dentistry

clinical setting. Yet, the student is expected to integrate that knowledge and apply it in the clinical setting. What is more likely to happen is that the student will master the knowledge for the test and then jettison that knowledge before the next course and the next test. Nothing in the curriculum reinforces that knowledge. The faculty on the clinic floor are rarely the same that have delivered basic medical sciences and often are part-time clinical faculty that have no detailed knowledge of the material in clinically oriented didactic course. This circumstance encourages the student to devalue didactic knowledge that is not valued by the clinical faculty. This is particularly true in the medical assessment of patients and in the application of basic science into the clinical setting. Evidence-based care is discarded and can be reduced to a “do it my way” approach. The procedures selected are not those that provide the greatest benefit, but are based upon psychomotor needs of the curriculum or personal preference of clinical faculty.

Solutions Movement away from the 2-plus-2 curriculum where students get didactic courses in the first 2 years and the second 2 years are in clinic into a diagonal curriculum where clinical experiences begin in the first week of the first year and didactic experiences continue throughout the 4 years will solidify the relationship between knowledge and skill in the practice of dentistry. The contents of the curriculum selected by the faculty must be directed toward the most effective and evidence-based practice of dentistry. Including faculty members from the didactic curriculum in the clinical practicum improves the connection between knowledge and skill. Although didactic knowledge itself might not be seen by students as an ethical issue, the need to know, the need to be a lifelong learner and to apply the latest knowledge into their clinical practice is an ethical issue with strong applicability in delivering quality and ethical care.

VIGNETTE

The clinical competencies dilemma

On the elevator with two senior students: “I don’t know why I am seeing these patients today. They are for just for alloys and composites and I already passed those competencies.”

In the past decade, the drive toward identification, assessment, and assurance of clinical competencies has reached new heights in dental education. These have been procedurebased even down to small subsets of procedures. Typically, 100–200 competencies are enumerated in dental education. The sheer number and procedure orientation of the lists tend to objectify patients into groups and even define and direct their care toward competencies rather than clinical need. In dental education, the de facto definition of a competency is the mastery of a procedure.

Solutions Medical education has a far more holistic and ethical view of a clinical competency. The American council on Graduate Medical Education (ACGME) has recognized that in the

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clinical practice of medicine, it is not just knowledge and skill that make up a capable and ethical practicing doctor. Behavior and a social viewpoint also make up the practice of medicine. To that end, the ACGME promulgates the core competencies that are defined as “Competencies: specific knowledge, skills, behaviors and attitudes, and the appropriate educational experiences required of residents to complete GME programs.” The 6 competencies include the following:

Patient care Medical knowledge Practice-based learning and improvement Interpersonal and communications skills Professionalism

Systems-based practice Read the ACGME presentation of these competencies and recognize that they address life’s unremitting contingencies of the achievement health as a social and ethical process as well as the technologic application of knowledge and skill. A graduate physician is also taught how to negotiate the health care system for the betterment of their patients in “systems-based practice.” They are also assessed for professionalism, how they interact with patients, colleagues, and other health professionals for the betterment of their patients. In graduate medical education, the ability to treat disease and improve health is what is valued. The application of knowledge in the care of patients is measured. Of course, what is measured is what is valued. Dentistry needs to move away from procedure-based competencies and toward the ACGME model of behavior and outcome-based competencies.

VIGNETTE

Continuity of care dilemma

At the faculty meeting, the impact of implant recalls was discussed. “We can keep having these implant patients return with loose screws and connections and endlessly checking their tissue and prostheses status. Who is going to do all this follow-up? This is not what our students need, and the more implant cases we do, the more this builds up. We should just have the patient sign something that we are not responsible for their postoperative care.” With its procedural basis, continuity of care is not valued and that environment is extended into dental practice where the emphasis is on procedures and not the achievement and maintenance of health. The economics of practice and the perceived needs of dental education combine to create a generation of patients with unhealthy mouths yet, with sophisticated dental procedures evident in their exam. The root-filled and crowned tooth with recurrent caries into the furcation is the typical example of elegant and technologically adept procedures that result in deteriorating oral health.

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Solution Focusing on recalls and health maintenance needs to be incorporated into the dental curriculum and the obligation that dental schools have toward their patients. It is not ethical or supportive of good clinical care to jettison patients who no longer have the procedural needs that are “required” by students. Developing the extended clinical workforce and making these recalls more effective provide a guide for future practice and thereby ethically improve and maintain the health of patients.

VIGNETTE

The rejection of medically and dentally complex patients

At the treatment planning conference: “How are we going to handle these patients on bisphosphonates? First, you tell me they need a drug holiday before extraction and if they get bisphosphonate-related osteonecrosis of the jaw (BRONJ) then who is going to pay for that care. Most of our patients don’t have health insurance. I recommend we do not accept any patients for treatment who are on bisphosphonates.” Dental schools have a poor history of caring for the sick. In the academic health center there are often inadequate programs that link oral health care and education into interdisciplinary health care needs such as those for patients with cancer, HIV, other systemic diseases, and other special needs. This leaves the students with an ability and perhaps a desire to serve only the healthy wealthy. They fear care of the medically complex patient.

Solutions Dental clinical education needs to be integrated into the academic health center care environment. Information systems between medicine and dentistry need to communicate with each other as do faculty and students. Students need to provide patient care in mixed medical and dental environments and see how improvements in oral health status can result in overall improved health outcomes.

VIGNETTE

The ethics of student-delivered care

Imagine approaching decision leaders in a university with the following proposal. We are planning to open a medical school where the students will be practice ready after 4 years. To do so, we will have the medical students admit patients to the hospital and operate on them. Each will treat 1 patient in the morning and 1 in the afternoon. To ensure quality, we will have a clinical faculty of observers that will check each step in the process and ensure that it is properly done.

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On the face of it, this model would be recognized as unethical. Time alone creates an ethical dilemma. For example, 60 minutes to start an IV wounds open for 2 hours that could be closed in 10 minutes. Yet, that is the daily dilemma on the dental clinic floor, patients with mouths open for hours, students waiting for check-offs while the local anesthesia is metabolized. The rate and rhythm of practice is not learned. The patient is objectified as a tool for learning a skill, not as an autonomous human being who deserves consistent and capable care.

Solutions The dilemma of student-based care can be addressed through the development of vertical patient care teams. In patient care teams of physicians, nurses, resident medical students, and other providers, medicine has created a teaching hospital patient care delivery environment that assures the highest level of care with outcomes that favorably compare with nonteaching environments. Morbidity and costs are measured and assurances are made that the teaching hospital is a superior location to have health care. No such data or assurances exist in dental school. Many redo cases and changes in treatment plan results from suboptimal care delivered by dental students, but no data exists to compare this properly to the patient care environment in the community. In this environment, patients getting care in dental school are treated under the fiction that operative dentistry procedures are not surgical procedures and that the success or failure of that treatment does not have true and substantial effects on health outcomes. On the clinic floor, dental care does not feel like health care, and thus it is not treated by a future generation of dentists as health care (let alone surgical care) The open 80-sq ft operatory means that no confidential health information can be exchanged between the dental student doctor and patient. Simple infection control methods are impossible in the dental school operatory and the consequences of that environment are extended into dental practice. A vertical team in dentistry would create a clinical care pod where faculty dentists, graduate dental resident students, and the extended dental workforce work in a team. Students incrementally develop their skills side-by-side with experts caring for their own patients. In vertical teams, the rate and rhythm and the expected quality of care are demonstrated to students who incrementally apply their progressive knowledge and skill into the clinical team. The patients are not seen as fodder for their development but rather individuals in the practice of the faculty member. In this environment teamwork is encouraged and the clinical results achieved are considered the product of a clinical team. This would be a paradigm shift for the practice of dentistry. Encouragement of this type of teamwork will encourage group practice as well, which is an essential element in ensuring quality and ethical practice in the coming years. This is exactly how clinical care has evolved in teaching hospitals with physician faculty and compliant with Center for Medicare and Medicaid service rules.

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VIGNETTE

Treatment planning the mouth and not the patient

Orthodontic graduate program case presentation: Student, “This is a 16-year-old cleft palate patient with a class 3 malocclusion and midfacial deficiency. We are planning 2 years of full banded orthodontics with extractions, alveolar fixation devices, and then mandibular and maxillary osteotomies.” Faculty, “What did the patient think of the plan?” Student, “He didn’t have anything to say. His mother said they are here because after 27 operations they were ready for the last one.” In this case, review of the medical record revealed major psychosocial and medical issues that would impact on the student’s analysis and plans. Dental students are not consistently in a position to consider the overall oral health needs of their patients in the context of their social, behavioral, and pathophysiologic needs. This encourages an ideal of treating the mouth rather than the patient.

Solution Integrating oral health care into human health is a continuous task for faculty but the environment can be improved to accomplish that task. Dental information systems such as Axium need to be integrated into the electronic medical records such as Epic. Dentists need to comfortably and continuously communicate and integrate with other health care needs and venues.

VIGNETTE

The live patient examination

Student: “I have this perfect lesion for a DO alloy, virgin tooth and no other restoration, nice reliable patient, but it is January. How do I keep that until May?

The current live patient examination, perhaps more than any other single activity creates stress and moral dilemmas beyond what can even be presented briefly. Some of the elements of those dilemmas are that the students are judged by their ability and if they fail, a patient is harmed. It would be like asking a pilot to take a flight test with passengers on the plane. Students are measured by procedural accuracy and not by the ability to improve health. The method selected for treatment and its timing is driven by the examination, not by the needs of the patient. It is an object lesson that demonstrates that patients are objects, not autonomous people with individual needs.

Solution There is nothing inherently unethical about the live patient examination, just what is measured and how it is administered. Novel ideas can be incorporated such as using portfolio, objective simulated clinical encounters (OSCE’s), or intake examination, and treatment of patients provided by the board could be considered.

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VIGNETTE

Do as we teach in the classroom, not as we do in the clinic

Then was the dream a faculty member truly had, a vivid, lucid dream, which is a dream like no other. The student in the dental school urgent care had a patient needing an extraction due to caries and acute odontalgia.

Student: “I sent her over to registration to make payment and she had no money. They told me we couldn’t treat her. But she is in a lot of pain. Should I send her to the hospital ER?” “Sure I guess you must. Patients presenting in ER are required to get treatment by oral surgery residents.” “No! Wait a second, read the wall” said the student. “Read the wall?” said the faculty member. “Huh?” Student: “ You know, the dentist’s pledge you faculty said we needed to recite in the white coat ceremony. It’s on the wall.”

VIGNETTE

The Dentist’s Pledge

I, as a member of the dental profession, will keep this pledge and these stipulations. I understand and accept that my primary responsibility is to my patients, and I shall dedicate myself to render, to the best of my ability, the highest standard of oral health care, and to maintain a relationship of respect and confidence. Therefore, let all come to me safe in the knowledge that their total health and well-being are my first considerations. I shall accept the responsibility that, as a professional, my competence rests on continuing the attainment of knowledge and skill in the arts and sciences of dentistry. I acknowledge my obligation to support and sustain the honor and integrity of the profession, and to conduct myself in all endeavors such that I shall merit the respect of patients, colleagues, and my community. I further commit myself to the betterment of my community for the benefit of all of society. I shall faithfully observe the Principles of Ethics and Code of Professional Conduct set forth by the profession. All this I pledge with pride in my commitment to the profession and the public, which it serves.

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And besides the student said “we were taught to follow 5 guiding principles in ethics class that include the following. 1.  2.  3.  4.  5. 

Patient autonomy Nonmalfeasance Beneficence Justice Veracity

“If we don’t get her out of pain we are just a bunch of hypocrites” (Reference to Hippocrates coincidental). Like many dreams, this one was not linear and had multiple endings as I fell in and out of REM sleep.

Faculty: Ending 1: “You learned it well!” “Now send her to the ER and don’t make any trouble.” Ending 2: “Bring the patient back and we will do the procedure, but don’t tell anyone. It will be a lot easier to get forgiveness that to gain ­permission.” Ending 3: “You know these procedures cost money and no pays result in higher tuition for all your classmates. Why don’t you and I chip in together so that we can do it?” Ending 4: “I will go to the school administration and demand that we change the policy to care for all patients without regard to their ability to pay.”

It is obvious that each of these approaches contain significant and insurmountable moral hazard and conundrums that cannot be resolved. For example, is pain as a symptom more significant than dental disease that otherwise destroys essential structure with loss of function, self-esteem, and systemic consequences that can be fatal? How is dental pain, or swelling, or tumor, or uncontrolled caries, or destructive malocclusion, or a temporomandibular disorder unique? Does every human being have a right to good oral health care? If so who will pay? If we are not personally willing to pay for another’s care, what are the implications for a healthy world? Are patients truly unable to pay for oral health care or are they unwilling? Are we charging fairly for our services or do our high fees drive patients away from maintaining good oral health? What are our fixed and variable costs of this extraction? What are the marginal costs? For example, what will it really cost me to extract this tooth. What is a fair profit? Are there solutions to these ethical dilemmas in the education of dentists? Yes, but only if dental education is properly seen in its ethical context.

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Chapter

Ethics in Dental School

2

Michael C. Meru, DDS, MS

Good times become good memories. Bad times become good lessons.

Anon Why did you choose to go to dental school? What made dentistry so compelling that you would take 4 years of your life and dedicate it to becoming a member of our profession. For myself, the answer to this inquiry lies in the story behind the Figure 2.1.

Figure 2.1 A child embraces the author after her dental work was completed on a dental mission trip to Nicaragua.

It was a hot morning on the final day of a weeklong dental outreach trip during my junior year of dental school when I saw the young lady pictured walking across the playground. I had met her 5 days before when she entered our clinic unwilling to smile and having a tough time speaking due to the condition of her dentition. She had never been to a dentist, and a toothbrush was the last item on her parent’s minds as they had a tough enough time putting food on the table. After 4 days, and 4 quadrants of dentistry, the whimpers I heard and the cringes I saw as she spoke initially turned into 13

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smiles and her into a ­jubilant girl beaming with stories to tell. As she approached me on the other side of the playground, she motioned for me to kneel down. As soon as I did, she hugged me and thanked me for taking away her pain. The picture was taken at that instant by a fellow student, but what it doesn’t show was the tear in my eye and the smile on my face as that moment confirmed the reason that I had entered into the profession of dentistry. I wanted to be a part of something that could change people’s lives for the better, all while providing a good living for my family. My hope is that you entered into the profession for similar reasons. This chapter is going to discuss the ethics and professionalism dilemmas encountered at the various stages of dental school as well as suggest activities and best practices to aid you in becoming a successful practitioner on graduation.

Patient-Focused Education

Unlike any other time in your previous education, every principle taught and class attended will focus and hone your skills on becoming a competent dentist with the ability to properly treat and care for your fellow human beings. Unprofessional and unethical behaviors during this portion of your education can have a direct effect on the patients you will treat. If you miss a class, cheat on an assignment, turn in work that may not be yours, and so forth, you will miss valuable information and possibly fail to learn specific skill sets that you will need in the future to properly care for your patients. It is imperative that from this point forward, you maintain the patient as your primary focus and not participate in activities that can affect your ability to properly treat them in the future.

Exercise 1 Take a few quite minutes to reflect on and write down why you joined the dental profession and what goals you have as a dental student. Then, picture yourself years from now at your graduation and heading off into private practice or into advanced training. What kind of dentist do you want to be? How did you arrive there? And what are you goals from that point forward? Write these thoughts down as well on the same document. Now keep this document somewhere safe, yet accessible, and review it each year as you advance to the next year of training to ensure you are heading down the correct path and remind yourself of your altruistic goals and reasons for becoming a dentist. *Exercise to be completed during first month of dental school or within the first month of reading this chapter.

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Impropriety within Dental Education

Cheating and acts of academic dishonesty have plagued all levels of education across the globe for many years. A survey of 43,000 high school students conducted in 2010 by the Josephson Institute found that 59% admitted to cheating within the past year, with 34% doing it twice or more.1 A study by Bowers (as cited in McCabe et al.) in 1964 found that 75% of college students cheated.2 Thirty years later, the study was repeated by McCabe et al.2 and found a modest increase from that number. While US News & World Report revealed the most saddening statistic when it reported that 84% of college students believe that they need to cheat to get ahead in the world today.3 With dentistry being thought of as 1 of the 10 most trusted professions in the United States,4 one might suppose that academic dishonesty and unethical acts within dental education would be much less severe. A 2007 study by Andrews et al. found that indeed behaviors of impropriety continue into dental education. Of the 1153 dental students surveyed, 74.7% admitted to cheating on tests or examinations and 68.4% on preclinical examinations or assignments.5 The old cliché that states, “When you cheat, you are only hurting yourself,” does not hold true in our profession, because in the end, you are cheating the patients you will serve and the community in which you will work.

Didactic Training

Each school of dentistry goes about instructing students didactically in different ways. Some use traditional methods of lecture and testing, while others use small group sessions known as problem-based learning, while others send their dental students to complete their didactic training with their fellow medical students at varying schools of medicine. Regardless of how you receive this training, the principles of remaining academically honest and steering clear of academic dishonesty remain the same. One of the negative byproducts of our ever-progressing technological world is that cheating becomes much easier to take part in and much more difficult for instructors to detect. Upon entering any academic institution, the prevalence of students using smart phones, iPads or other tablets, and apps that allow recording, taking pictures, retrieving information from others computers and devices, sharing of information instantly, and so on, has increased drastically in recent years. For that reason, it is crucial that we as students self-govern to insure impropriety within our schools ceases. The genesis of the cheating dilemma has been cited as being due to competition for grades, large class sizes, an unwillingness to turn fellow students in, cynicism against the school, among others.6,7 That said, I feel two major reasons stand out above the rest: a student’s desire to remain on a level playing field when they see others cheat and the lack of punishment for cheating as decided by faculty and administration.

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Within dental education, there is much competition. With the competition to get into specialty programs, graduate practice residencies, get better jobs, gain more patients, find perfect lesions for clinical exams, and so on, there will inevitably be one or two students who are tempted to gain an advantage that is outside of the guidelines. The behavior of this small minority greatly affects the majority who normally wouldn’t take part in these actions. Andrews et al. reported that “Students stated they were motivated to cheat because ‘everyone does it.’ If their peers cheat, students felt they were placed at a disadvantage by not cheating.”5 In that sense, cheating is contagious to fellow students. The contagiousness of cheating does not only affect fellow students but also degrades the person committing the act. Each time an individual cheats and gains an unfair advantage, he or she becomes desensitized to the act, making it that much easier to commit subsequent acts of impropriety in the future.8 If you combine an increasing number of students who feel they must cheat to remain at an equal playing field, with the degradation of the individual, you end up with an institution whose decaying moral values will inevitably hurt the profession as a whole. In the study by Koerber et al.,9 a dental student stated that “Peers from my school and others agree that when a student was caught for cheating and disciplined by only a ‘slap on the wrist,’ more and more individuals began cheating.” This is a hidden curriculum within education that must be stopped. Another student in the study by Andrews et al. recommended that institutions “Actually follow the enforcements that are listed in the handbook for students caught cheating. Come down hard on cheaters; we had 10 accounts against the same student in writing and signed … nothing happened.”5 The school’s fear for legal action from those who are expelled, the time intensive nature of dismissing a student, as well as the risk of losing popularity among students have been stated by academic deans as reasons that cheating has not been punished.6 So as a student what is your roll in this? First, you must ensure that you as an individual are taking responsibility for your education and are maintaining your own academic integrity. Second, you should encourage your classmates to hold to the same values. If you see someone starting down the wrong path, pull him or her aside and speak with them. If you see something egregious that cannot be remedied with simply discussion with that individual, it is your responsibility to discuss this with the faculty or administration.

Preclinical Training

The preclinical courses you will undertake to develop the hand skills, knowledge, and techniques necessary to practice on a live patient are some of the most valuable you will take as a dental student. As such, it is paramount to your success as a future practitioner that you do not cut any corners during this time. Impropriety in these courses can be similar to those discussed in the previous section as you will be asked to study many concepts and didactic information that will be put to practical use. It is also seen in the actual hands on assignments you

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Best Practice—Use of Old Tests or Remembered Questions10 One of the more common and often complained about means of cheating at dental schools across the country is the use of old examinations, or remembered questions to study from. Often clubs, groups, fraternities, or individuals within the school will compile these banks of tests and distribute them to some or all students to study from. When used, it is common for the questions seen before the test to be identical to those found on the test. Each school has its own policy on whether this is ethical. Whether gained through appropriate or inappropriate means, and whether the school has a policy against this, if these questions aren’t in the hands of all equally, it will destroy the level playing field and give those willing to compromise their values an unfair advantage. The way to solve this dilemma is to collaborate with your administration and create a test bank that will allow all students to have access to these questions. Once the administration is on board, you will then have all groups and individuals within the school submit, without repercussion, all old examinations and remembered questions to a student leader. Then this can be compiled and distributed such that an equal playing field is restored.10 Faculty may not be completely in agreement with this, but it will be their responsibility, as it was previously, to consistently update their examination and ensure its integrity. This has been done successfully at several dental schools and the students, faculty, and administration have been pleased with its results.

will be given. Students have been found paying for dental labs or other students to complete their work, exchanging laboratory work with other students after the first students work had been graded, forging faculty signatures, and so on.5 Such behaviors result in the student missing out opportunities to learn specific skill sets that they will need in future for treatment of patients. Often one will use the excuse that he or she will never have to cast a gold crown or that they will never actually pour up a die-keen model, and so on, but what they fail to realize is that these exercises aid them in developing hand skills that will assist them in completing other procedures they will perform on patients in the future, not to mention they don’t gain the knowledge of the entire process of the product they will be placing in their patients mouths.

Clinical Training

Unlike the aforementioned forms of impropriety, cheating during your clinical training will directly affect the patient you are treating. The methods of cheating have ranged from forging faculty signatures, to overtreatment to satisfy graduation

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requirements, to working during unsupervised clinical sessions, to delaying lesions to use them for the clinical licensure examination.5,10 During my training, I recall being appalled when a student confessed to intentionally placing their bur into the pulp of a tooth during a routine filling because they needed to satisfy an endodontic requirement for graduation. This type of behavior has no place within dentistry, and I urge you to never go down that road and ensure that your fellow classmates don’t either.

Repercussions of Impropriety During Dental School

Those who cheat during dental school will most likely cheat during patient care once they graduate. A study by Sierles et al.11 found a positive correlation between cheating in medical school and cheating in patient care after graduation. B ­ eemsterboer et al.6 draw the same conclusion in dentistry due to the increasing number of fraud cases we see each year. Numerous other studies report similar findings.12–14 If we know that students who cheat during dental school will cheat during patient care when in practice, we absolutely cannot stand for it. We must take a stand ourselves, encourage our schools to deal with it swiftly and justly, and ensure that the patients we profess to serve are always the driving force behind each of our decisions while in dental school.

Licensure Examinations

Graduating from dental school signifies that your school deems you at least minimally competent to treat patients, but before you can do so, there are a minimum of 3 licensure examinations and processes that you must undergo. The first 2 are the National Board Dental Examinations 1 and 2 and cover the spectrum of didactic and clinical information you are expected to gain while in school. These examinations are administered by the Joint Commission on National Dental Examinations (JCNDE), and as of January 1, 2012, will be scored only as pass or fail. The major issue regarding impropriety on these examinations is one that was discussed earlier, the creation of test banks. Currently, the examination is administered at Prometric Testing Centers approximately on every day of the year. With approximately 5000 students taking the examination yearly, and only a limited number of different tests, it is inevitable that students will begin writing down the questions they remember and sharing them with their fellow students. With the technological connectivity of students via social networking and the internet, it is only a matter of time before the bank of “remembered questions” become large enough to potentially encompass all versions of the test.15 Many might feel that the impending pass or fail nature of the examination will curb the cheating via the use of remembered questions that we currently see, as the

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pressure to score high to specialize will cease to exist. I argue contrary to this belief. The current culture that has been developed wherein students know how much easier it is to just memorize “remembered questions” to pass or score highly with minimal effort will most likely continue, and thus, “going to pass/fail will not stop the cheating, but will just enable students to cheat ‘less hard.’’’15 You as a student play a major role in ensuring this practice doesn’t continue. The purpose of the examination is to verify the competency of the student, and you must safeguard that this purpose is met and that you and your classmates are indeed qualified to practice dentistry. The JCNDE also plays a role in this, in that they must ensure that its methods of testing are not easily breached and that they either offer the test less frequently or create a greater number of examinations. The third process you will undertake to begin practicing dentistry postgraduation is the licensure process. The granting of licenses and the methods to do so are decided by each US state individually and not on a national or federal level. Currently, there are various methods of gaining licensure and vary greatly from state to state. The most common is the live-patient examination offered by various testing agencies (WREB, NERB, CRDTS, etc.) or the individual state. Several states allow for a 1-year residency to substitute for the live-patient examination, while New York mandates it. Currently, Minnesota is the only state that offers a nonpatient-based examination, though California will soon have a portfolio-based process. The American Student Dental Association’s (ASDA) L-1 policy on Initial Licensure Pathways states that it does not support the use of live patients in the licensure process,16 and former ASDA President, Dr. Brooke Loftis elaborated stating, “How can we continue to allow an examination process that encourages marginally unethical behavior from students? We must protect our patients and provide them with the best care possible. After 4 years, the clinical licensure examination procedures I recently completed are the last clinical procedures I will perform within my dental school. I will never forget the students who were delaying treatment of patients, overradiating their patients, overtreating lesions, and paying outside services for the supply of patients to use during the examination.”10 These issues, as well as many others, are ones that you will face if you take one of the patient-based clinical licensing examinations. I would exhort you to remember the purpose of the examination and the well-being of the patient when the time comes for you to undertake these licensure processes.

The Hidden Curriculum

The hidden curriculum was defined by Sharp et al. when he stated that “It is well understood that students acquire professional behaviors and notions of acceptable practices through their interactions and observations with patients, faculty, staff, and fellow students during their training. In medicine, this broader learning has been described as the hidden curriculum.”17

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I vividly remember a hearing a report from a student regarding a well-respected faculty member who, while teaching a review class how to pass the National Boards part 1, encouraged the students to collaborate together to collect remembered questions and aid those who wanted to specialize in getting a higher score. Or the report of another student who was shocked to find out a faculty member at their school sold patients for the live-patient licensing examinations at an extremely high premium. I won’t even begin to discuss the major ethical issues involved in each of these reports, but the hidden curriculum is glaring! How do we expect students to make proper choices when they see their respected faculty professing one thing and then doing the complete opposite later? As you go through your training remember that people, including your faculty members, make mistakes and commit immoral and unprofessional acts. Don’t allow this to serve as justification for you to commit improprieties—it is simply not worth it.

Student Professionalism and Ethics Association

In early 2007, a group of students at the University of Southern California (USC) school of dentistry who were concerned with many of the ethical issues and impropriety that they witnessed formed the then Student Professionalism and Ethics Club. Four years later, on October 10, 2011, the small club became a national association (Student Professionalism and Ethics Association [SPEA]) and extended its reach to nearly half of all dental schools across the country. The vision of SPEA is “To promote and support a student’s lifelong commitment to ethical behavior in order to benefit the patients they serve and further the dental profession.” As one of its founding members, I was able to see first hand how the group was able to dramatically improve the ethical climate at USC. As shown in the bell curve in Figure 2.2, with a typical distribution of students, there will always be a small percentage on the far left end of the curve who are willing to compromise their values regardless of extraneous factors and will cheat while in school. In the middle lie the majority who in most situations wouldn’t succumb to the pressures of cheating, though if placed into an environment where cheating is wide spread, they may feel more pressure to cheat to maintain a level playing field and may fall into the temptation. This is illustrated by the purple curve on the chart. At USC, SPEA has had the opposite effect (blue curve on chart) and actually has improved the ethical climate, resulting in those who may have been more prone to cheating, to aid them in maintaining their academic integrity. SPEA was a great success at USC, as well as at many other schools, though it may not be the right group for all. Regardless of whether you have SPEA or not, I encourage you and your class to have some club, discussion group, or open forum where ethics issues are discussed regularly and without fear of repercussion from faculty and administration. If you do this, it will be another great step toward getting your school to fall into the blue curve in Figure 2.2.

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In Negative Ethical Climate

21

In Positive Ethical Climate Normal situation

Figure 2.2 When the dental school environment has a culture of positive ethics and professionalism, the end of the bell curve where those who have lapses in judgement diminishes and the positive environment leads to fewer breaches of ethics. The opposite occurs when cheaters go unpunished.

Organized Dentistry and Protecting Patients and the Profession

The American Dental Association (ADA) defines organized dentistry as, “The combined efforts of all the organizations that work to positively contribute to the dental profession.”18 You will find many different organized dentistry groups at your dental school, some of the most common are ASDA and the ADA, the American Dental Education Association, your state dental association (e.g., the California Dental Association), the Student National Dental Association, the Hispanic Student Dental Association, the American Association of Women Dentists, among others. ASDA and the ADA are the over arching organizations, with the others also playing pivotal rolls in positively contributing to dentistry. As issues arise within dentistry, these groups use their knowledge, resources, and expertise to help guide policy makers in ensuring that our patients and the profession are protected. Often these issues are ethical in nature, and your participation and voice can be vital for these goals.

Specializing

I believe that the greatest cause of competition in dental school is a students desire to specialize. Graduate programs in years past have weighed the student’s board scores, GPA, and extracurricular activities highly when selecting candidates for their residency programs. These factors, especially the first two, caused many to be willing to compromise their values and seek short cuts to higher scores to gain an upper hand in the application process. This then had the contagious effect mentioned previously, on other students, who then fell into the same trap.

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Best Practice—Great Source of Information—ASDA White Paper10 In 2009, the ASDA published the ASDA White Paper on Ethics and Professionalism in Dental Education. The

purpose of the paper is to “provide an overview of the state of ethics in dental education today, as well as offer solutions on how our profession can rectify this dilemma.”10 Students authored the paper, and the best practices suggested were developed for themselves as well as for all other stakeholders in dental education, including predental students, dental school faculty, dental school administration, organized dentistry groups, and examining boards. The paper is a must read for all and can be accessed on the ASDA website at http://asdanet.org/ethics.aspx.

For each of you, the board score is no longer an issue, but the other two remain, and likely you will see some form of required examination in the future for postgraduate residency applications. Regardless of the process, the principles of ethics and integrity in preparing and applying for specialty programs remain the same. Don’t fall into the pitfall of justifying cheating just so you can possibly get into a program. Prepare early. Study hard. Seek good mentors. And maintain a positive attitude through the process. If you follow those steps, you can always feel good about wherever you may end up.

Your Duty as a Student

The whole reason of becoming a dental professional is to serve our fellow man, which means that our patients are always the driving force behind each decision we make. As such, it is our responsibility to ensure that the codes of ethics we profess to abide by are obeyed. The ASDA Code of Ethics states that “All dental students are obligated to report unethical activity and violations of the honor code to the appropriate body at the school.”19 It may be tough to report or speak to a classmate regarding impropriety, but if we don’t, the consequences are much higher than the possible loss of that friend. Aside from improprieties, it is also our duty to take pride in our profession, enjoy what we are doing and take every opportunity to learn that is afforded to us. Each

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of us is fortunate to be a part of the dental profession, and it should show in our works and our attitude.

Conclusion

Years from now when you look back to your dental school career, if you have maintained your integrity and not participated in any form of unethical or unprofessional behavior, it will be with fondness and pride. Your behaviors and actions today will lay the foundation for your time as a dentist, and your patients will be grateful for the extra effort and dedication you put forth while in school!

References 1.  The Ethics of American Youth—2010 Summary. Survey conducted by the Josephson Institute. Press release: October 1, 2011. 2.  McCabe DL, Trevino LK, Butterfield KD. Cheating in academic institutions: a decade of research. Ethics Behav. 2001;11(3):219–232. 3.  Kleiner C, Lord M. The Cheating Game: ‘Everyone’s doing it,’ from grade school to graduate school. US News & World Report. November 22, 1999. 4.  Gallup Poll on Honesty/Ethics in Professions. 2006 Survey Results. http://www.gallup. com/poll/1654/Honesty-Ethics-Professions.aspx. Accessed November 7, 2011. 5.  Andrews KG, Smith LA, Henzi D, Demps E. Faculty and student perceptions of academic integrity at U.S. and canadian dental schools. J Dent Educ. 2007;71(8):1027–1039. 6.  Beemsterboer PL, Odom JG, Pate TD, Haden KN. Issues of academic integrity in US dental schools. J Dent Educ. 2000;64(12):833–837. 7.  Ameen EC, Guffey DM, McMillan JJ. Accounting students’ perceptions questionable academic practices and factors affecting their propensity to cheat. Account Educ. 1996;5(3):191–205. 8.  Meru M. Following your moral compass: ethics in dental school. J Am Stud Dent Assoc (Mouth). 2008:9–22. 9.  Koerber A, Botto RW, Pendleton DD, Albazzaz MB, Doshi SJ, Rinando VA. Enhancing ethical behavior: views of students, administrators and faculty. J Dent Edu. 2005;69(2):213–224. 10.  The American Student Dental Association White Paper on Ethics and Professionalism in Dental Education, April 2009, p. 13. 11.  Sierles F, Hendrickx I, Circle S. Cheating in medical school. J Med Educ. 1980;55(2):124–125. 12.  Rabi SM, Patton LR, Fjoroft N, Zgarrick DP. Characteristics, prevalence, attitudes, and perceptions of academic dishonesty among pharmacy students. Am J Pharmaceu Educ. 2006;70(4): 73. 13.  Harding TS, Carpenter DD, Finelli CJ, Passow HJ. Does academic dishonesty relate to unethical behavior in professional practice? An exploratory study. Sci Eng Ethics. 2004;10(2):311–332.

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14.  Al-Dwairi ZN, Al-Waheidi EM. Cheating behaviors of dental students. J Dent Educ. 2004;68:1192–1195. 15.  Meru M. The hidden curriculum and my three wishes. J Am Coll Dent. 2010;77(3):5–9. 16.  American Student Dental Association, Current Statements of Position or Policy— Licensure. L-1 Initial Licensure Pathways (revised 1998, 2001, 2002, 2005). http:// asdanet.org/_AboutPage.aspx?id=1568#L-1. Accessed November 11, 2011. 17.  Sharp HM, Kuthy RA. What do dental students learn in an ethics course? An analysis of student-reported learning outcomes. J Dent Educ. 2008;72(12):1450–1457. 18.  American Dental Association. Understanding Organized Dentistry: A Guide for Dental Schools & Dental Students. 2011, p. 1. 19.  American Student Dental Association, Current Statements of Position or Policy— ASDA Code of Ethics. E-7 ASDA Student Code of Ethics (2002, revised in 2008, 2009 and 2010). http://www.asdanet.org/_AboutPage.aspx?id=5810. Accessed November 11, 2011.

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Chapter

3

Licensure and Licensing ­Examinations Mark L. Christensen, DDS, MBA

Hakli olmak deg˘il haklilig˘ini surdurmek onemlidir. The rather worthy fact is not being right but to stay right.

Reha Kisnisci, DDS, Ankara, Turkey A license is a privilege—a conditional privilege—granted by the state for the benefit of the people over whom it has jurisdiction. In order to be licensed, one has to satisfy certain requirements. These requirements include specific licensing examinations. All U.S. licensing jurisdictions require passage of the respective National Board Examination for dental or dental hygiene license applicants. Most jurisdictions also require passage of a recognized state or regional practical clinical examination. Although these examinations are prominent, there are also other requirements. Most jurisdictions require completion of a predoctoral accredited dental education program or documented completion of equivalent education. Many also require a passing score on a state- and professionspecific jurisprudence examination and that the applicant be of good moral character. And most jurisdictions require payment of an administrative fee. As part of applicant evaluation, many states now routinely query state and federal databases of professional sanctions as well as criminal and civil actions. Some may additionally require character references or letters of recommendation; however, in the absence of contrary evidence, good character is generally assumed, and if all other qualifications are met, the applicant is licensed. Once licensed, it is incumbent on the licensee to behave in ways that justify the trust that society has placed in him or her. Notorious or illegal behavior in one’s personal life that may have no 25

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direct relationship to professional practice or clinical skill can bring into question one’s character and may result in limitation, suspension, or even revocation of one’s professional license.

National Board Dental Examinations

For dentistry, all U.S. licensing jurisdictions now require passage of the National Board Dental Examination (NBDE). For dental hygiene, there is a single examination, the National Board Dental Hygiene Examination (NBNHE). For dentistry, the examination currently has the following 2 parts: Part I, covering the basic sciences, is usually taken sometime during the first couple of years of an applicant’s dental education program and Part II, covering the clinical sciences, is usually taken sometime later when the applicant has had more clinical experience. Both Parts I and II of the NBDE have sustained recent changes to make them more integrated and clinically relevant. A portion of the items on Part I now consists of scenarios or “testlets” that provide a clinical context for related basic science questions. And a portion of the items on Part II now consists of a series of questions taken from multifaceted clinical cases. These changes reflect a general trend toward greater integration in dental education and testing. A plan to create a new, fully integrated examination for dentistry is now underway. Though the exact timing is unclear, the result is as follows: a single Integrated National Board Dental Examination (INBDE) that students will take before the end of their predoctoral dental education will someday be a reality. All communities of interest, including students and their education programs, will be informed about the upcoming changes in the NBDE examination well in advance of the changes being implemented. Furthermore, at some point, disseminated information will likely include sample items and, possibly, a practice examination that candidates will be able to take in preparation for the new integrated examination. Undoubtedly, there will be a period of time when both Part II and the new INBDE will overlap and be offered in parallel so that students who have taken Part I will have a choice and can take either Part II or the new INBDE. Constantly updated information, including answers to frequently asked questions about the progress of development and implementation of the new integrated examination, can be found on the Joint Commission’s Internet website.* Any attempt to cheat or manipulate any National Board Examination would be unwise. Item remembering or “brain dumping” schemes have frequently backfired for candidates whose examination results are then withheld and who could be required to wait a year or more before being allowed to retest. Furthermore, evidence of involvement that surfaces, even years later, can retroactively impact the license of a licensee. For the website of the Joint Commission on National Dental Examinations, see: http://ada. org/JCNDE.aspx or go to http://ada.org/Professional Resources/Continuing Education and Licensure/Testing/National Board Dental Examinations. *

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Nowadays, the National Board Examinations are administered under strict surveillance at secure testing centers. Candidates who misunderstand the test center’s scheduled or unscheduled break policy or who have inadvertently carried ­contraband items such as a mobile phone or a lucky talisman into the secure testing area are often surprised when they later learn that their scores are being withheld because of a testing irregularity. And then they may need to file an appeal with the Joint Commission and wait for a period of time before being allowed to retake the examination. These are not always conscious violations but are sometimes just the result of carelessness or ignorance. The resulting hassle is not worth the risk. Candidates are advised to pay close attention to all testing regulations and instructions. They should not harbor a cavalier or too casual attitude when taking any National Board Examination. Candidates are generally eager to do whatever they feel may be necessary to pass the examination. It would be well for the examination to test basic science foundation knowledge and clinical science understanding that practitioners need to know and for candidates to remember that they are working to master understanding of this information to skillfully treat the patients they aspire to serve.

Practical Clinical Examinations Why do we also have clinical examinations?

Most dental education programs have economic and logistic pressure to be efficient. Each is a unique system that functions something like a complex pipeline. They matriculate students, move them through the program, advance them from class to class, and urge them finish their requirements and graduate. Programs need students to graduate and leave, so the next class of students can advance and a new class of students can enter the program. A well-designed program efficiently delivers the necessary education and experience with carefully structured use of available resources and a detailed curriculum. For most programs, the surplus clinic facilities and faculty needed to accommodate remedial education or an extension of education time for any significant portion of the senior class are nonexistent. And by the time students have completed the prescribed program, debt has accumulated and they need to begin generating income. Regardless of the benefit or need, few are able to readily absorb the income delay and additional tuition that would be required for them to repeat a year of their education. As a result, there are students who just slip by in some programs, or who, for practical reasons, are inappropriately advanced with the thought that catching up might be later accomplished. Despite Commission on Dental Education (CODA) standards regarding the implementation of certain competencies, exactly how these competencies are defined and verified are decisions left to the programs. Concerned faculty who hesitate to recommend a student for advancement may receive pressure from program administrators to somehow accommodate the student’s advancement. The economics and logistics behind this pressure are completely understandable.

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In addition, nowadays there is legal pressure. In our litigious society, it can be difficult, troublesome, and expensive for a program to inform a student or his family that, after completing several years of training, he may not have what it takes to succeed and is being held back or released from the program. Besides expensive legal challenges the programs face when they attempt to implement and stand behind such decisions, they potentially face additional loss if the student is associated with a wealthy present or future donor. All this is understandable. With the breathtaking expansion of knowledge, increasing complexity of technology, and expanding range of services dentists need to know about and be able to provide, predoctoral dental education programs nowadays perform a Herculean task. They do, every year, turn out thousands of topnotch graduates who are well prepared to enter the workforce and contribute to the profession. Though teaching is the program’s responsibility and learning is the student’s responsibility, not all students apply themselves with the same degree of focus. Despite having graduated, when independently tested, a small minority of students demonstrate that they are not ready to be licensed—not ready to deliver dentistry to the public in an unsupervised setting. The number of graduates not ready by the end of their predoctoral training program is small, relative to the total number of graduates or applicants for licensure. The examination is criteria referenced and occasionally all the student candidates at some institutions satisfy the criteria and pass the examination on their first attempt. Sometimes those who do not pass appear to be well coordinated and seem to have good conceptual skills but, for example, fail to recognize gross caries remaining in their preparation. Some just need a little more experience. For others, the deficit may be something else. Overall, including candidates who repeatedly retake the examination, probably only about 5% of those who challenge the clinical examination ultimately fail. This statistic is fairly uniform across regional dental testing agencies. Most testing agencies can demonstrate that, in the absence of structured remediation, the probability of a candidate’s failing the examination increases with each successive failure. This fact contributes to the body of reliability evidence for these independent practical clinical examinations. Like competency assessments, practical clinical examinations are imperfect. For example, they are not comprehensive but are limited by practical constraints. For example, some things are impossible or impractical to measure during the time interval of the examination. Assessment of ability in areas not directly measurable is generally inferred from the results observed for things that are evaluated. In spite of these limitations, independently administered practical clinical examinations may still be the most effective way for licensing agencies to determine things such as whether a candidate can recognize and appropriately handle dental caries, precisely use dental instruments in the oral environment, plan and organize clinical activity, effectively communicate with patients, and appropriately judge and ­effectively deal

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with the kinds of unexpected things that arise when practicing dentistry. To directly or indirectly assess these things, most licensing jurisdictions still rely on practical clinical examinations that include some patient treatment. Of course it is possible for operator accidents or mistakes to occur during an examination just as they sometimes occur in teaching hospitals, dental education program clinics, or even in practice. During training, procedures are first simulated and then performed on patients. When students begin patient treatment, instructor supervision and procedural stop or “check-off” points are implemented to enable in-process feedback for the student and limit mistakes and potential patient injury. Nevertheless, despite these precautions, accidents occasionally still occur and can be expected to occur until the student has sufficient experience to make sound clinical decisions in real time on his own. If the educational program and student have done their jobs, then the candidate is deemed to have acquired this experience by the time he takes the licensing examination. If he has, involved patients are safe, and so will be the public on whom the candidates will be operating when he is licensed. If the educational program has done its job and the student is ready, then patient risk exposure is completely reasonable. We would not expect a candidate to fail the clinical certification and seriously damage a patient any more than we would expect a student pilot to crash the plane and injure himself or others during his solo test flight. Remember, the examination is not testing patients, nor is it testing treatments; it is certifying—validating by independent assessment—candidate preparedness to practice independently. That is all. Candidates merely demonstrate the clinical skill they have acquired. There is, or should be, no experimentation involved. To refer to patients as live human subjects is to invoke inflammatory rhetoric associated with animal rights groups who oppose investigational testing of materials, devices, medications, or surgical techniques on animals. Such rhetoric is typically invoked for ulterior purposes. The subjects of the dental and dental hygiene practical clinical examinations are the candidates being certified, not the patients. Techniques are standard and the procedures performed are routine. None of the materials, techniques, or medications used in the examination is being investigated. Candidates try hard to do the very best work they can and patients generally benefit from their focus and conscientious effort. For the same reason that there is currently no way to bring candidates to the level of full clinical competence without having them work on patients, many feel that there is, as yet, no other way to certify clinical competence with the high degree of fidelity that assessing their work on patients provides. Although patient-based clinical examinations have been criticized and alternative paths to licensure (e.g., completion of a general practice residency, student portfolio, and OSCE format examinations) are surfacing with increasing frequency, traditional, independent third-party evaluation of treatment on patients remains an important component of licensure for the majority of jurisdictions.

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There was a time, historically, when those who administered licensing examinations for some jurisdictions were blatantly prejudiced, breached candidate anonymity, and favored students from their own state’s institutions or the sons and daughters of respected dental families in the state. This is no longer the case. Standards or guidelines for the development and administration of examinations, including practical clinical examinations, have been widely promulgated.* Testing agencies are now familiar with these guidelines, and it is incumbent on them to follow the guidelines. Grading criteria and scoring rubrics are published. Total candidate anonymity is now standard operating procedure, as is the formal training, calibration, and standardization of examiner judgment. Examiner manuals are typically at least as voluminous as the corresponding candidate guides, and the complexity and sophistication of the statistical analysis performed for evaluating examiner performance typically surpasses that performed and reported for candidate performance. Examiners make their ratings independently, and interrater reliability is tracked. Examiners who fail calibration tests or whose performance is found to vary significantly from the performance of their fellow examiners are typically released from service. And nowadays, examinations usually afford candidates access to a transparent appeal process that, like the examination itself, preserves candidate anonymity. Although there has been sweeping improvement in examination design and administration, pressure associated with high-stakes clinical examinations has motivated a variety of dubious developments. These developments include paying patients who agree to sit for the examination and the advent of examination preparation and patient-finding services. The examination preparation and patient-finding services coach candidates and sometimes provide patients who, they assert, have lesions that are sure to meet criteria and qualify for required procedures. Candidates are not only using these services but many are increasingly compensating patients monetarily and are often transporting, housing, and feeding patients. As a result, ethical positions that the dental education program has been attempting to imbue over the entire course of a candidate’s professional education are, for purposes of examination, at the last moment turned on their head. It can feel like the clinician is not there to serve the needs of the patient as much as the patient is there to satisfy the needs of the clinician. Ethical issues arise in this context. When I was a senior dental student in the early 1980s, the practical clinical examination required as a condition for licensure by the state where I hoped to practice was not offered at my school. Because I was trained in California, I took the California Board examination that was offered at my school, but because I desired to Examinations are typically developed in accordance with guidelines for measurement, test development, and administration published by: *

• • • •

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American Psychological Association National Council on Measurement in Education American Educational Research Association American Association of Dental Examiners

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return to my home state to practice, I also had to take the Western Regional Examining Board’s (WREB) dental examination. I was not alone. That year, the WREB ­examination was administered at OHSU in Portland, Oregon, and there were 11 persons in my class who needed the examination in order to return to our home states. The Dean agreed to allow us to take 3 clinic days off to travel to Portland to take the WREB examination. The WREB examination was conducted on Friday, Saturday, and Sunday. It began Friday morning and was scheduled to finish at about noon on Sunday. Besides a slide pathology examination and prosthetics bench examination that involved reviewing articulators and prosthodontic devices physically displayed at stations and then answering questions about them in a fixed time interval at each station, we were required to perform a periodontal cleaning, a Class II amalgam, and a Class II or Class V gold foil restoration. We also had to prepare, fabricate, and seat an indirect gold casting (inlay or onlay). It seemed like a lot, but in those days, the California examination also required each candidate to complete a full denture setup on a set of mounted edentulous casts. So all 11 of us left San Francisco very early in the morning on Wednesday and carpooled to Portland. We took our dental instrument cases and personal items like changes of clothes and travel necessities. One candidate took his wife with him. She was not a trained dental assistant, but was willing to help. Otherwise, none of us took assistants. And none of us took patients. The drive from San Francisco to Portland takes approximately 11 or 12 hours. We arrived on Wednesday late in the afternoon. We had reserved housing at a dormitory near the clinic and agreed, after settling in our rooms, to meet in the common dormitory foyer to discuss how we might go about finding patients for the examination. Time was of essence. There was discussion and a plan was presented. Someone had contacted alumni in the city and found an alumnus who agreed to allow us to bring patients to his office for screening and to accept responsibility for any necessary follow-up care as long as we purchased all the x-ray film we used. And the 11 of us each contributed toward the purchase of several boxes of duplicate x-ray film and enough to make a donation toward replenishing the office’s developer and fixer solutions. The office, in turn, agreed to remain open later than usual on Wednesday evening and contributed the use of its equipment, the presence of a licensed dentist, and the creation of simple charts where duplicate copies of the exposed films could be filed for any patients who might later return to the office. A small flyer was constructed that contained the address and a simple diagrammatic map showing the location of the screening office. The flyer was duplicated and each of us took a handful. We chose two of the group to staff the screening site, to receive people the rest of us sent there, to assist with the screening process, and to help patients with qualifying lesions fill out forms, understand what to expect, and know when and where they would need to go for the examination. The rest of us fanned out across the city and began looking for patients.

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It was now early evening. We combed public parks. We stopped and talked to panhandlers. We went to the local bus and train stations. We looked everywhere we thought we might find people with time and need who might benefit and be able to sit for the examination on short notice. We woke people sleeping on park benches and asked them if they had any teeth. We explained who we were and what we were doing. We showed them the flyer and map we had made and explained that if they could get themselves to the screening office, people there would take x-rays and screen them for suitability. We explained that there would be no charge for the screening and further explained that if they had the kind of dental problems we were looking for, we would perform a limited amount of dental work for them at no charge whatsoever and that if they showed up on time and were cooperative so that we were able to complete the procedures we needed for the test, we would afterward give them a small gift, perhaps a bottle of Jack Daniel’s Tennessee whiskey, as token of our appreciation. With this last suggestion, we were speaking a language they understood, and on hearing this, many of those we spoke to on the streets became genuinely interested in our proposal and indicated that they thought they could find their way to the screening office. At about 9 pm Wednesday evening, we again assembled in the dormitory foyer. The two assigned to the screening office began passing out forms with attached radiographs for persons with lesions that they felt would satisfy the examination criteria. Forms were evenly distributed and some were exchanged. Then we retired to bed. The next day, Thursday, we awoke early and proceeded the same way. By Thursday evening, we found that all 11 of us had been assigned enough patients to complete the needed procedures and most of us had back-up patients as well. Personally, I was comfortable enough performing a Class V, but most of the gold foil restorations I had performed in school were Class II gold foil restorations, so finding a suitable lesion for a Class II gold foil restoration was my preference. However, since we had arrived only a little more than a day beforehand without any patients at all, I was willing to perform a gold foil restoration of any type on whatever tooth fate provided. Because gold foil is moderately soft, a Class II gold foil restoration is appropriate only in an area with no occlusion. For normal Class I occlusion, this usually limits the restoration to the MO surface of a lower first premolar. The scheme for obtaining patients worked so well that by Thursday evening, I had received radiographs and forms for two patients, each with a qualifying lesion on the mesial surface of at least one of their lower first premolars. Now the only question remaining that evening was whether the patients who had been assigned to us would show up at the appointed time in the morning. They did, and all 11 of us passed the examination. None of us used assistants, except the person who was accompanied by his wife, and he did not use her all of the time. Instead, she ran errands and assisted others in the group, when needed,

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with things like the application of rubber dams or the mixing of impression material. None of us used a laboratory; everyone did their own laboratory work and made their own casting. We had more patients show up than we could use and had no trouble finding patients with conditions that qualified for the periodontal treatment. In fact, several of our patients served as a back-up patient for students of the school whose patient did not show or did not qualify, particularly for the periodontal section of the examination. Patients who showed up that we could not use seemed disappointed, but they received a sincere thank you, a brochure from the school clinic, and the promised gift (a bottle of Jack Daniel’s) just for showing up and being willing to help us. This seemed satisfactory and honoring our promise brought a smile to their faces. A few of these extra patients chose to remain in the waiting area for a while just to see if some other candidate could use them for something. Whether we used them or not, they seemed to appreciate the gift, but more, they seemed to appreciate the attention we had given them which, for some, was probably more attention, interest, and respect than they had received all week, maybe all month. Several expressed interest in becoming patients at the school clinic. Some wanted to know how often we took these examinations and whether they could be patients for us again sometime. We generally advised all of them, whether or not we were able to use them, to register with the school clinic or to return to the screening office for a complete examination, treatment plan, and appropriate preventive care. There is no major city that does not have a population of persons who might qualify for needed examination procedures. Due to current economic conditions, there are now more people like this than ever and more of them have teeth. Some cities have free or low-cost dental clinics for their indigent populations, and these clinics often have people waiting in lines so long that, even after waiting all day, they do not receive the hoped for treatment before the clinic closes. Though it apparently worked well, the 11 displaced student candidates to involve and assist indigent persons in the context of the clinical examination in Portland several decades ago; what they did raises a variety of ethical issues. I am not suggesting that today’s candidates should do the same thing or attempt to replicate their strategy. A single candidate, for example, would have a difficult time accomplishing what the 11 were able to accomplish when collaborating as a group. However, when candidates and, sometimes, even their education programs complain that they are having trouble finding patients with suitable caries lesions or with periodontal conditions that adequately satisfy examination criteria, it would seem they may not be looking in the right places. And there is nothing wrong with involving alumni or attempting to build bridges between new graduates and those established in practice. If one opens to possibility, what initially appears to be an obstacle sometimes grows into an opportunity. There are other issues. Rounding up interested persons to sit as patients for the examination on short notice usually circumvents comprehensive care. There is no argument about this. No comprehensive treatment plan was developed for any

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of the patients in Oregon; none received anything more than a cursory screening examination before one or more definitive restorations were placed, and preventive disease control was not established before initiating restorative care. The importance of proceeding methodically and comprehensively is stressed in dental education, and it should be stressed. The breach of comprehensive evaluation and treatment sequencing is problematic. Of course, treatment sequencing is of critical importance in some instances and fairly inconsequential in others. In the real world, beyond the walls of the education program and, sometimes, in the program’s clinics as well, ideal treatment sequencing is altered or modified for a variety of reasons. These reasons include things like the patient’s desires, the patient’s ability to pay for planned treatment, and a host of logistical considerations, including patient and/or doctor (or instructor) availability. Modification of ideal sequencing often occurs without significantly impacting overall outcome for the patient. However, without the development of a comprehensive treatment plan, it is not possible to know for sure whether the isolated treatment provided at the examination in Portland would smoothly integrate with the total treatment needed for every patient. Against these issues might be weighed the patients’ introduction to aspects of the oral health care system, receiving some education regarding dental care and access to care, and receiving a limited amount of needed treatment free of charge. These are positive benefits that in all likelihood would not have otherwise occurred for these people. Hence, there is concrete evidence that they may have benefited from the experience and little evidence that any of them was seriously harmed or damaged as a result of their participation in the examination. Besides inviting anonymous critique from candidates, the organizations that design and administer practical clinical examinations involving patients usually solicit anonymous feedback from patients as well. These organizations usually receive 50–100 times or more as many positive comments as complaints from examination patients. Patients almost always express confidence in their candidate operator and appreciation for the examination process. Rare complaints usually relate to things like the ambient temperature of the clinic, waiting time, comfort of the clinic chairs, or a desire for background music and free snacks. A significant number of patients return, year after year, to have some procedure performed free of charge or to help some candidate through the examination process. Other than the gift given as a token of thanks and appreciation, none of the Oregon patients was paid. None were housed and transported, and candidate costs were minimal. All the 11 candidates contributed to the gift bottles that were purchased by the case and distributed from the trunk of one of their cars. The gift of liquor, some might argue, may not have been in the patients’ best interest. I am sure the candidates would be the first to acknowledge this. However, a single bottle, more than being anything of measureable impact for this patient population, simply represented the candidates’ ability to speak the patients’ language and provide a token of thanks that would be appreciated.

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In contrast, a few years ago, while functioning as a floor examiner at a regional examination, I was assigned to follow-up with a candidate who had received notice that her patient had been rejected by the examiners for a certain operative procedure. The validated examiner rejection was for overtreatment. When she received the news, the candidate was understandably distraught. I explained what rejection for overtreatment meant and outlined the available options. These included resubmitting the same tooth with a different plan of treatment, selecting a different tooth for the needed procedure, or using a different patient. On the verge of breaking down, she reported that she was not a student at the school and had obtained the patient from a patient-finding service that had charged her $4000 and had guaranteed that the tooth assigned to her would qualify for the examination. She reported that she had not had the opportunity to examine the patient before arriving that morning and had just assumed the lesion would be accepted. I suggested that she might consider examining the patient and the radiographs and then resubmitting for a procedure on a different tooth if she felt the patient had another tooth with a larger radiographic lesion. She reported that, in fact, the patient did have a larger lesion on another tooth, but felt she could not use the tooth—just could not do that to her friend. When asked what she meant by this, she explained that the other tooth with perhaps a better chance of qualifying had been already assigned by the service to another candidate and the other candidate was a personal friend. In states such as Florida and California, candidates have reported paying as much as $5000 and $6000 to examination preparation and patient-finding services. This seems like a high price, but then candidates point out that it also costs a lot to transport, house, feed, and compensate multiple patients if they feel compelled to bring patients with them. Examination candidates are completely accountable for their submissions and their decisions, and they own the results. Patient-finding services are not taking the examination and their liability may be limited to their fee. If the service guarantees that if a patient is accepted for a certain procedure and is rejected, then the candidate has no recourse as far as the testing agency is concerned. Even if the patientfinding service upholds its guarantee and completely refunds its fee, the candidate’s career is still on hold. Candidates can and sometimes do consult with each other and with mentors prior to the examination. However, in the end, the responsibility for patient submission and treatment decisions rests solely with each candidate. Submission criteria are clearly specified and sometimes change from year to year. Candidates are well-enough trained to understand the criteria and successfully make their own decisions. Advice of others, even of well-meaning mentors and peers, sometimes confuses and muddies things more than it helps. Trafficking in patients certainly seems like it should be unethical. Extortion, too. Things like this that turn professional ethics upside down exist to the extent they do only because they are supported by desperate candidate behavior. The things most

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examinations require of candidates are reasonable and straightforward—limited, routine procedures that any dentist should be able to adequately perform. Examination guides are well written. There are no secrets; nowadays the criteria against which candidate performance is measured are published for candidates and examiners alike. Examiners are experienced and calibrated; they too understand the criteria and the variation that is expected when treatment is performed on patients. Candidates can have confidence that they will be treated fairly and need not resort to questionable schemes to pass the clinical examination. Ideally, a candidate would perform procedures on a patient of record whose ability to tolerate planned procedures both emotionally and physically would be known in advance. Treatment performed in the context of the examination would be needed in accord with a comprehensive, preestablished treatment plan for the patient, and treatment would take place at the candidate’s place of training so that the candidate would be familiar with clinic facility and its operational protocol, as well as available equipment and supplies. Ideally, there might be a single national clinical examination that would be recognized as fulfilling the licensing requirements for all jurisdictions and with results that would be fully portable. From the current vantage point, the advent of such ideal circumstances would appear to be yet some distance in the future. Although movement is underway, history has demonstrated that change in this area occurs incrementally and by fits and starts, now advancing two steps, now staggering back one. As a stage or practical phase in movement toward the ideal, a world might be envisioned where, absent a single national clinical examination, applicants for licensure would be able to take and pass, at their own institution, any of the several clinical examinations and have the results recognized and accepted for licensure by any state to which they might want to make application. Fortunately, states are increasingly recognizing that the large clinical examinations administered by multistate regional agencies are, though not identical, nevertheless consistently producing results on which they safely can rely in making valid licensing decisions. A number of state boards now belong to multiple regional testing agencies, and a growing number of states now accept, for purposes of licensure, the results of any of the large regional examinations. As a consequence, it is becoming increasingly likely that a student candidate will be able to take a practical clinical licensing at his or her own school and qualify for licensure in the state or jurisdiction of his or her choice. Furthermore, state boards have been modifying their rules and regulations to accommodate licensure by credentials for both specialists and for general dentists with a clean practice record who have been licensed and in practice for some specified length of time in another jurisdiction. These changes represent positive movement in the desired direction. However, it is well to remember that under our system of government, authority and a certain

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amount of autonomy reside with the state. As long as its actions do not unreasonably interfere restraint of trade or other federal mandates, the state retains the prerogative to decide exactly how it will license, not only dentists and dental hygienists, but contractors, attorneys, teachers, cosmetologists, massage therapists, physical therapists, physicians, and nurses—professions of all types. States are not likely to abandon their responsibility or relinquish their authority. There are more than 50 licensing jurisdictions and each is, in some respect, unique; each has its own traditional operational idiosyncracies. This is a staggering array of dynamic agencies whose decision makers, appointed only for a term or two, constantly come and go—a group of agencies that remains tricky to corral at all, let alone control, or bring into absolute uniformity. Portfolio designs that enable evaluation of treatment performed on patients of record during the course of one’s training program solve some issues, but unravel others like assurance that the candidate is working independently, that the candidate has absolute anonymity, and that there is independent third-party control of the evaluation process—issues that are well tied down for contemporary clinical examinations. Whether the resulting tension can be worked out and whether state licensing authorities will find the necessary reassurance and become convinced that the trade-off is acceptable remain uncertain at this point. Even if differences are resolved and acceptable portfolio-style examinations can be used for some student candidates in some jurisdictions, traditional examinations may still be needed for other nonmatriculated segments of the candidate pool. Of course there is pressure for agencies to develop and states to accept a practical clinical licensing examination that does not involve the assessment of treatment performed on patients at all. However, those who rely on the results of the examination to make valid licensing decisions and have the authority to decide the matter are hesitant to abandon the practice and forfeit the fidelity that independent thirdparty evaluation of at least some treatment performed on patients provides. Whether it be a National Board Examination administered at a secure testing center or a practical clinical examination involving treatment on patients, licensing examinations are an arena where ethical decision making and ethical behavior are of paramount importance.

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Chapter

4

The Joy of Solo Private Practice Lilia Larin, DDS

Work hard and be nice to people. (By British graphic designer Antony Burrill.)

Dr. Javier González Lagunas, Barcelona Spain The Victorian poet William Earnest Henley (Invictus, 1849–1903) wrote, “I am the master of my fate: I am the master of my soul.” Thus is the essence of solo private practice. As a solo dentist in private practice, all of the responsibility is mine, as is the joy, worry, and financial reward. I have not always been in a solo practice yet my career has evolved as such. Originally, I was in a group of three. In the beginning, it worked well. We all had young families and co-sharing space led to a group practice. The collegiality was exciting, being able to discuss cases, to have “back up,” and to interact with the other two dentists was welcome. What was not so ideal was the struggles that every partnership can encounter: the lengthy discussions of everything, including what materials and equipment to buy, the employee favoritism of one dentist over the other, and the fact that not all three of us worked with the same production goals, yielding different monies collected. In brief, the three of us had different practice personalities. It is these conflicts that led to partnership problems that could not be resolved, and thus a parting of the ways. Our saving grace was that when we had originally established, a partnership agreement was written that detailed everything including the buyout. Starting a private practice is similar to developing a garden. First, choose a location. This may vary depending on your practice style. You may choose a location close to where you choose to live, or one where there is increased potential for patient traffic, such as a corporate center. Ideally choose a location where there is potential

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for patient growth. Keep in mind that if circumstances change that you can always change as well. Be careful not to “marry yourself to only one option.” For example, a well know dental plan recently announced at significant percentage cut in payment to participating providers. As a participating provider, you are considered a preferred dentist for the plan. However of the majority of your practice is dependent on only one plan, then be aware that if the terms of the plan changes, as in this case, then you may find yourself at disadvantage. During this process, and especially when negotiating the contract for your office space, equipment, etc., believe in your instincts. I had the experience of having an opportunity to buy an established practice. The seller was older and the physical plant beautiful. The practice consultant said it was a great deal and a good opportunity. Yet, something did not feel right. Sure enough after meeting with my attorney, I chose to stop the transaction and walk away. Several months later, I heard that someone else had bought the practice and was taken advantage of in the deal, and I was grateful that I had “listened to my gut.” Next, choose your practice style: full scope or limited. Regardless develop a practice philosophy and most important be passionate about your career. As part of your practice style, also develop a lifestyle philosophy, for this will determine how you will practice. For the advantage of solo practice is that you have the freedom to choose and not to need to ask permission of anyone else, especially another business partner. However, the responsibility then rests solely on your shoulders. Truly understanding what your wants, needs, and desires are helps you form the vision and philosophy of your practice. Using the garden analogy, recognize that there is a vast difference in a grass lawn and a formal garden, both in the plants chosen as well as the upkeep and maintenance. It is also important to recognize that it is difficult to “have it all.” It can be achieved, yet compromise is the key to success. For example, you may choose to locate your office in a desirable setting, yet in turn you may be one of several dentists in the area, leading to stiffer competition and slower practice growth. Conversely, setting up a practice in an area where there are fewer dentists may allow for rapid practice growth; however, this may require you to drive a considerable distance to your office or live in a rural area. Once your practice is established, then you must tend to your practice. It is common for the solo practitioner to recognize that their business acumen may not be the best and thus hire an office manager. However talented this person may be, it is your responsibility to watch over your practice. You must be an active participant! Be disciplined and mindful of your vision and practice goals. Read the financial reports weekly to keep a feel of your practice, no matter how busy you become. Similarly be involved in all of the major decisions affecting your practice, for it is your license and your good name that is involved. Recognize that one disadvantage of a solo practitioner is that you may pay more to be on your own. Financially, a solo practitioner does not have the buying power that a several dentists may have, to

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buy in bulk, or negotiate as favorable a price. Consider teaming up with a few of your other solo practice colleagues to purchase supplies etc., as a group, especially if you office is in a large medical or dental complex or practice in close proximity. Maintain and grow your practice by becoming involved in your community. Genuinely give back to your local community for it pays dividends exponentially. I continue to be involved in several community organizations including: San Diego Association of Women Dentists as President, Hispanic Dental Association/Binational President and the President of the San Diego Chapter of the Academy of General Dentistry (AGD). There is no greater advertising, both good and bad, than word of mouth. I find that my participation in these local groups helps keep me involved with my local peer group and keeps my practice relevant and in their minds. Community service is the cornerstone of my building a great referral source. Additionally with service, I have been able to rise to leadership positions within the field of dentistry including serving as the national President of the American Association of Women Dentists and the national President of the Hispanic Dental Association. This in turn had allowed me to follow my passion and also to rise to leadership positions in nondentally related organizations including Damas de San Diego, serving as their Vice President. Recognize you practice strengths and weaknesses. Develop good relationships with other peers. Study clubs offer the opportunity to network with your local peer group. Study clubs also are a good source of referrals as well as an opportunity to serve as a mentor to a colleague. Similarly, study clubs are a good avenue to keep current and maintain you own continued competency. However when indicated, refer patients to specialists, your patients will appreciate your tending to their well being. For doing what is best for the patient should be of utmost importance. Following this path will allow your practice to grow and to become self sustaining, usually in 5 to 7 years. When your practice is at the steady-state level, it is important to continue to be as vigilant as you were when you first started your practice. Most important is that you must be a good leader, and a problem solver. To do so, you must be happy to be in charge. Again having a clear vision and goal for your practice will allow you to be an effective leader. Convey this vision and goal to your team and allow them to be participants in your practice. Acknowledge and appreciate their efforts. Your staff is “the face of your office.” Their mindset will impact the feel of your office and how your patients perceive you as a clinician as well as how your patients will perceive your practice as a whole. In the end, solo private practice affords you the freedom to choose your own path. The profession of dentistry allows you to follow your life dream. Enjoy what you do. As I tell my son, who will soon be graduating from Dental School: treat your patients well. Be genuine. Be compassionate. Be grounded. Maintain your internal standard, and remember patients appreciate respect and candor.

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Chapter

The Ethics of Referrals: Building Relationships to Build Your Practice

5

A conversation with Dr. Larry Stigall

No man is an island, John Donne, Meditation XVII, 1624.

Suzanne U. McCormick, MS, DDS and Larry Stigall, DDS When asked what the secret to his highly successful golf career was, Jack Nicholas said, “I always play within my own game.” Jack Nicholas thus won more than 118 tournaments and was named Sports Illustrated “Greatest Athlete of the Year.” Jack Nicholas knew his strengths and weaknesses and always researched each golf course; he played and knew which shot he could complete and which shots he should avoid. Understanding that we all have limitations in our clinical skill set is essential to practicing dentistry within the ethical boundaries that our profession requires. We tend to recognize our strengths, yet we need to understand the boundaries of our skill sets. Patients entrust their care and oral health to us and we in turn must treat our patients to the best of our abilities. Often our best is to refer our patients for another opinion and/or for treatment by a specialist. Failure to recognize your limitations and refer patients can be actionable against your license. Patients may encourage you to perform the suggested procedure rather than refer them to another clinician. Perhaps your patient may feel confident in your abilities or the patient may want to avoid seeing another practitioner. In any case, it is your duty to know your limitations and refer patients to an appropriate colleague.

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Sometimes patients or even your staff suggests that you start a procedure and “see how it goes.” This is not ethically correct for you, your patient, or the dentist to whom you are making the referral. The best referrals are based on a collegial relationship that you have with that referral. You should advise your patent to see a colleague in whom you have confidence, someone that you know as a professional as well as a person. Someone who shares in your concept of the ethical treatment of your patient, for you are entrusting your patients’ care to this specialist, who is assisting you in the overall care of a person’s oral condition. As the relationship you have with your patient is based on trust and clinical ability, the referral to another office must be made by you personally. In a busy office, this responsibility may be delegated to staff; however, the actual referral should be made by you the clinician. It is your responsibility as the license holder to initiate the referral. Also, your clinical decision making is what led to the choice of persons to whom the patient is referred. Again this is a licensing and liability concern, as you are advising your patient who they should see for treatment of their condition. Often clinicians may opt to give their patient two names of referrals, thus allowing the patient to choose between the two referrals. The mechanics of the referral and of having the patient be seen by the specialist can be delegated to staff; however, staff should not influence the referral that you make. Human nature is for your patients to ask your staff about the referral/specialist and even who they should pick if you choose to give your patients the names of two specialists. Your staff should be aware of your policy concerning referrals as untimely it is you, the clinician, who is responsible and accountable not your staff. The referral relationship is based on the confidence that you have in the clinician as well as the confidence you have in the office. This is built over time. Often a lunch is scheduled for the doctors to initially meet. This is an excellent opportunity for them discuss clinical ideas/goals and understand if the office and patient treatment philosophies are congruent. Similarly it is common for the office managers to meet as well to establish a working relationship between the two offices. To facilitate the referral, the indicated treatment should be in writing. Should the patient present without the indicated treatment in writing stop, and obtain it. By e-mail, fax, and so on get the planned treatment in writing. As a specialist, assume nothing and avoid a lot of misunderstanding later. It is also optimal for the ­referring dentist to give a brief summary of the clinical situation. Here a ­telephone call or e-mail prior to treatment between the two clinicians is ideal. Radiographs can be reviewed, any concerns regarding the patient’s clinical c­ ondition or health ­history can be discussed. It is also an opportunity for the relationship between the two offices to grow. Similarly, a letter, e-mail, or telephone call after the ­procedure by the specialist to the referring doctor is advised. It allows for continued ­communication between the doctors and the two offices, as well as to give information concerning the patient’s condition and any clinical findings that may affect future care. The referring dentist will let you know how best to communicate with them. Some prefer a telephone call or e-mail on the day of the procedure

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and a follow-up written treatment summary; others prefer communication only in the form of the treatment summary. Occasionally, the specialist may need to act as the “back-up” should their dental colleagues find themselves “in over their heads.” Patients are referred and seen on an urgent basis. Again the referral should be in writing as well as the medications given, dosage, and time of administration. Pre-treatment radiographs are useful. Once referred to your office, the patient is now considered to be part of your practice. All consultations, pre-operative teaching, consent, and clinical information including radiographs should be obtained as is usual for your practice. Patients should be advised of the fee associated with your services and understand that payment is expected. The original dentist may offer either the patient or you to pay for your services as the specialist, yet the ethics here can be complex. It is best advised to have the patient deal with you the specialist directly concerning financial arrangements, as it would be common knowledge to accept that the patient would similarly return to you, the specialist for follow-up care. It is you the specialist who has a contact with a patient and it is you the specialist who ultimately completed the procedure. As you are accepting the patient’s case and rendering care, it is imperative that you complete an independent evaluation. It is the duty of dentist to D ­ iagnose ­Disease. The ability to diagnose disease and formulate a treatment plan ­distinguishes dentist from other dental healthcare providers in our offices. Consequently, you must confirm the clinical finding and concur with the diagnosis of the referring dentist. It is not acceptable to merely look at the referral note as your “prescription” and follow these without question. The clinical information that you obtain must support the diagnosis and treatment plan that you generate, and in the best of circumstances is congruous with the treatment plan provided by the referring dentist. Sometimes in this acute clinical situation the patient may present with a disgruntled attitude. It is best advised to refrain from derogatory remarks concerning the referring dentist. A philosophy of treating patients with kindness and allowing them to “be heard” goes far to diffuse the situation. However, patients do have the right to follow up with the Ethics Committee of the local component of the American Dental Association and the State Board. As a specialist, recognize that by accepting the patients as a referral into your office, you are assuming patient care as well as potential complications associated with the first clinician’s efforts. Whether that is a fractured root close to the inferior alveolar nerve, a sinus opening or a broken endodontic file, patients should be advised of their clinical condition prior to initiation of your treatment/corrective measures. Here documentation in your patient record is of utmost importance. Additionally, communication with the referring dentist is key. The pattern of referral is truly based on the relationship between the referring dentist and the specialist. It is common for clinicians in group practices to have their own individual referral sources. A good working relationship is augmented

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with great communication. As a specialist, meeting regularly with the referring dentist is advisable. Here any concerns can be aired and discussed. However, the giving of gifts to the referring dentist should be approached with caution. Excessive gift giving or giving different “levels” of gifts based on the number of referrals could be considered “Fee Splitting” and/or violations of the federal Anti-Kickback Act, the Protection and Affordable Care Act and each state’s Dental Practice Act, which governs your license. Creating incentives for the referral of patients by gift cards and so on are also unethical and in violation of these statutes as well as the Code of Ethics of your state Dental Association. Gifts given to your referring doctors should be the same for all offices regardless of the n ­ umber of patients referred. Often it is best to send a gift at holiday times that the entire office can enjoy. To renew or maintain the referral relationship an office, gifts could be sent at unique times of the year such as 4th of July or the opening day of baseball season, should your office be baseball fans, etc. Should you choose to use a service for patient referrals, the contract should be “flat fee” and not based on the number of patients referred to your office. Untimely you want to Build your Practice, not “get patients.” Patients themselves are your best referrals. A simple “Thank you” is all it takes. Treat patients well and they will respond in kind. This is also true of the dental practice that is your referral source. Treat these practices and their patients well and the relationship will grow. Referrals and patients alike respond to The 3 A’s of Referrals: Availability, Amicability, and Ability.

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Chapter

6

Ethics of Professional Group Dental Practice Bruce Whitcher, DDS

Tartismayi kazanabilirsin ama arkadasini kaybedebilirsin. Mind your goal, as you may win or overcome a dispute but may lose a friend.

Reha Kisnisci, DDS, Ankara, Turkey Whether a dentist works alone or with other dentists, the doctor–patient relationship and the duty of care remains the same. To adhere to the guidelines of ethical practice, dentists are obligated to provide the best oral health care to their patients regardless of their practice setting. This chapter will focus on the group private practice, although similar principles may apply to community clinics, federally qualified health care organizations, and other group practice models. The dentist in the group practice must usually work more closely with his colleagues than the dentist in a solo practice. Group practices usually share staff, management, marketing, and facilities as well as patient care. Each of these activities carries with it ethical considerations. Although adherence to ethical principles will facilitate the functioning of a group practice, it is unlikely that there will be complete agreement on all aspects of ethics between any two or more practitioners. It is therefore necessary for dentists who participate in a group practice to, at a minimum, have shared practice philosophy. If the group practice is to be successful there needs to be agreement about the mission of the practice and whether its purpose is to benefit the management company, the senior partner, the individual practitioners, the patients of the practice, and the community. Although it is conceivable that a successful practice may not necessarily adhere to professional ethical principles, it has been the experience of 47

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the author that group practices that adhere to these principles are far more likely to remain viable over the long term. Participants should have a similar approach to patient care, work ethic, staff management and financial management. In 2010, the American Dental Association’s (ADA) Health Policy Resource Center defined a group practice as five or more dentists. The ADA does not yet have statistics focusing specifically on group practices, but the 2009 ADA Survey of Dental Practice shows that 22% of dentists work in a two-dentist practice and 18.2% of dentists work in practices with more than two dentists, which includes group practices. Traditional group private practices are usually one-office practices that contain four to seven practitioners plus related staff. Additional practice models that include two or more dentists ­are Dental Service Organizations (DSO), which are companies that offer practice management, marketing, and administrative services to dentists who own practices. DSO may be engaged by either solo or group practices. There are consolidated organizations in which a corporation or central entity owns or partners with a large number of dental offices each of which might have one to three practitioners. There are dental practice management companies that manage practices owned by dentists. In this model, the dentist determines fees, hours, and patient mix and the management company manages around these decisions. In many states laws that limit corporate ownership of dental practices may apply. One major incentive for dentists to join a group practice is the high cost of establishing a new practice, particularly in the face of accumulated student debt. Additional benefits include shared staff and facility expenses as well as an economy of scale for supply and capital equipment purchases. An important motivating factor is the ability of the dentist in group practice to delegate management and administrative responsibilities and concentrate on patient care. Particularly for the dental specialties, shared emergency coverage affords free time away from practice responsibilities. There is an opportunity for quality assurance within the group practice through shared oversight of the member dentists. A new dentist entering a group practice should serve as an employee of the practice for enough time for all to agree that he or she is compatible. This trial period should not be extended indefinitely or the associate may lose interest. There should be a contingent offer of secure status within the group once compatibility with the practice is established. The terms of this initial period of employment should be established in a written employment agreement that enumerates compensation, working hours, benefits, and emergency call responsibility. Responsibility for the cost of professional liability insurance, professional dues, and continuing education should also be described. In general, all members of the group are required to have the same professional liability carrier, particularly when patents are shared.

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Terms of the employment agreement should establish the responsibilities of both parties should employment be terminated. Although restrictive covenants for ­dental practice are sometimes included, they are rarely enforceable.

Compensation

Should professional compensation be proportional to production or collections? There are many arrangements that can be made to establish fair compensation for practitioners within the group. What is important is that they agreed upon arrangement provides reasonable compensation for the services provided and are ­perceived by all parties as fair. There should be a written agreement that describes what is to occur in the event of disability or incapacity of a practitioner. Events such as personal bankruptcy and professional misconduct resulting in a restricted license must also be ­anticipated. This agreement should also describe the terms of dissolution or liquidation of the group practice, including a plan for disposition of patient records as well as the circumstances under which a new dentist is added to the group. Such agreements may include a trial period of employment and terms for assignment of patients. A written agreement is only as good as the understanding between the parties to the agreement, but having such a document is a significant aid in preventing ­misunderstandings. It also gives all involved the opportunity for legal review.

Philosophy of Care

There should be an established policy for shared philosophy accepting patients into the practice. Once a patient is seen for evaluation, the dentist within a group can determine whether he or she is capable of competently treating the individual. There should be a policy regarding the treatment of physically impaired individuals. Dentists in any practice setting must be aware of laws and regulations that govern discrimination and access to care.

Emergency Care

There should be an understanding among members of the group practice that a dentist should be available, within reasonable limitations, to address acute dental conditions. In such situations, the patient’s health and comfort must be the dentist’s primary concern and not compensation or convenience. If a dentist cannot accommodate the patient’s emergent needs, a reasonable effort should be made to have the patient seen in a timely manner by someone capable of treating the condition.

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Practice Management Responsibilities

The group should have a written policy regarding practice management responsibilities and how and if they are to be shared. Some practices may delegate management duties to a practice manager or managing partner. Others will choose to rotate management responsibilities among dentist members of the group. What is critical to the success of the group is to have open communication between practice management and dentist members so that disagreements can be resolved. Regular practice management meetings are important to maintain communication. Establishing the office work schedule for both participating dentists and staff is a crucial responsibility. The schedule has important implications for patient care as well as individual earnings of group members. It will also determine emergency call coverage responsibilities, time away from the practice, and time available for professional meetings and related activities. There must be an agreement regarding the approach used for marketing and advertising of the practice. The present practice environment makes some advertising almost essential if the practice is to be successful, and all dentist members of the group should agree to promote the practice as a whole and not only solely promote development of their own patient base within the practice.

Staff Management

Group practices may utilize many different arrangements for managing staff. In some cases, each dentist will have dedicated staff and in others, the staff may be shared by different practitioners. What is important is to establish agreement between the group members regarding staff management. There are usually legal requirements for hiring, firing, wages, and hours of practice employees. Group members must all adhere to these requirements. It is essential to have a uniform employment policy within a group practice. There should be ­participation of all group members in staff management activities such as performance reviews, but many aspects of staff management are best delegated to a competent office manager. Employment of family members or significant others within a group practice must be done with caution. There is a tendency for this to create the potential for conflict of interest between the employee and members of the group practice, so this should be done only with clear agreement among all dentist members of the practice. The dentist must avoid conditions or actions that promote harassment or abuse of staff, patients, or other related parties in any professional setting. Sexual harassment may be the most familiar form but harassment may also be physical, verbal, or psychological in nature.

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The dentist must be aware of signs of harassment and must strive to eliminate it from the workplace. A superior–subordinate relationship is often associated with cases of harassment. Dentists must be careful not to misuse their inherent positional power. The dentist must take appropriate corrective action when conditions favoring harassment exist or when harassment is recognized. Patients and staff are to be treated with respect. The dentist must avoid creating a hostile work environment by giving tacit approval to conditions or actions that may be interpreted as offensive or abusive. The dentist must be aware of laws and regulations that govern harassment.

Financial Management

Members of the group practice must have a clear understanding of how patient financial arrangements are made. Group members are individually legally ­responsible for the accuracy and completeness of insurance billing performed by staff. Fees should be consistent and fair to all parties. There must be a shared understanding regarding pro bono care for patients. All members of a group practice should have a similar approach to establishing fees and payment options. To avoid misunderstandings, the books of the practice should be open to inspection by any of the dentists participating in the group practice. There should be a clear understanding of how professional expenses such as ­meeting expenses, travel, automobile expenses, and professional dues are to be shared.

Professional Development

Ideally, the group practice would foster professional development through continuing education as well as participation in professional and community organizations.

Conclusions

Although more than 60% of dentists maintain solo practice, there is a growing number who chose to enter a form of group practice. Ethical considerations apply to professional practice in any setting, but there are unique considerations in the group practice that have been described in this section. A group practice may be particularly attractive to the recent graduate because of the offer of a steady salary, an opportunity to retire debt, and a steady flow of patients that can be adjusted to fit the practitioner’s skill level. Ideally, the group practice allows the dentist to concentrate on patient care and provides an opportunity to delegate some management responsibility and lead a more balanced life.

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References 1.  American College of Dentists. Ethics Handbook. Gaithersburg, MD: American College of Dentists; 2008. 2.  DiMatteo AM. Flying solo? Understanding the trends driving large group practice. Inside Dent. September 2011;7(8). 3.  American Dental Association. 2009 Survey of Dental Practice - Characteristics of ­Dentists in Private Practice and Their Patients. Chicago: American Dental Association; ­December 2010.

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Chapter

Ethical Considerations in ­Dentistry

7

Jonathan Rudin, DDS, MS, MPH

Treat your patients as you would like to be treated, you are a potential patient!

Dr. Olugbenga Ogunlewe, Lagos, Nigeria

Introduction

What can help create a good night’s sleep for you as a dentist? I would suggest that when you believe you are doing right by both your patients and yourself, you would be going far to ensure profound rest and pleasant dreams. What do I mean by “doing right by the patient?” You can answer that by asking yourself if the treatment you provide coincides with what you believe to be in your patients’ best interest. And what is meant by “doing right by yourself?” That is answered in part by your belief that you are earning a good living. This chapter deals with the first part of the formula for sleeping well at night. Doing right by your patients—that is, practicing dentistry in an ethical way. This ­practice entails listening to your patients about what is important to them, addressing their expressed needs, educating them about what dentistry can offer to fulfill their desires, honoring informed consent, and delivering the highest quality service ­possible. Everyone has faced and will face ethical challenges. I offer a framework for ­ethical practice, developed from my own experience over years of practice. First, I’ll present several true scenarios from my professional experience that I found to be ethically challenging. Then, I will introduce you to an ethical practice framework and illustrate it with a simple but realistic example. Before getting started, however, 53

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Table 7.1 Relationships Between Ability to Make a Comfortable Living and Providing Ethical Patient Care

Ability to Make a Comfortable Living

Highly Ethical Minimally Ethical

Level of Patient Care

Good

Poor

Embrace the belief that maintaining high ethical standards will enable you to earn a good living.

Embracing high ethical standards for your patient care should not prevent you from earning a good living. How will your patients benefit if your practice ultimately fails?

Strive to operate in this quadrant.

Avoid this quadrant.

Making ethical compromises in caring for your patients will not help you make a good living in the long run.

The natural consequence of maintaining low ethical standards in your patient care is to make a poor living over time. Consider the effects of being fined and losing your license.

Avoid this quadrant.

Avoid this quadrant.

I want to provide insight into an underlying belief that I think is all too common in our profession and presents a considerable challenge to ethical practice: To make a comfortable living, dentists must make ethical compromises in patient care.

It may be tempting to think that to make a lot of money, a dentist needs to cut ­corners. In other words, to practice in an ethical way will lead to struggling fi ­ nancially. I invite you to consider the idea that it is not only possible to make a comfortable living practicing in an ethical way but is actually the only way to do so in the long run. These choices are illustrated in Table 7.1.

Ethical Challenges—Real-World Examples

The following examples of ethical challenges in dentistry are taken from my own experience with the exception of the last example. As you read through these vignettes, consider how you would handle similar situations.

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Language Barrier While staffing at a community clinic, I examined Ms. Nguyen, who did not speak English. She pointed to her lower anterior bridge, which was so mobile I was ­surprised it was still in her mouth. I planned to extract the abutment teeth. I administered local anesthetic and wanted to verify that my patient would be comfortable for the extraction. I summoned the supervisor for help in assessing the adequacy of anesthesia. He told me that everyone understands the word “pain.” Consequently, he yelled (in English) “Are you in PAIN???” The patient, saying nothing, looked bewildered as her eyes darted back and forth between us. The supervisor turned to me and said (as though the conclusion he was about to state was patently ­obvious), “See? She’s not in pain.” I wondered how in the world he could know that. I extracted the teeth despite being unsure that my patient was comfortable. In hindsight, I recognize that, among other things, informed consent had not been obtained for this procedure. How would you handle a similar situation?

Obligating a Patient to Follow Through on Full Mouth Reconstruction As a contractor in a general dental practice, I was assigned to Mr. Jones and told that he had agreed to full mouth reconstruction. Before Mr. Jones could leave the office, the owner dentist asked me to quickly prep all the teeth and place temporary crowns on them. When I responded that prepping the teeth was an involved process and I would need a significant amount of time to accomplish that, the owner stated that all I needed to do was a 30-second prep on each tooth. He acknowledged that the preps would be rough but they would be refined at future appointments. I asked the owner why he wanted me to buzz down all the teeth in this way. He stated that initiating irreversible treatment on a large scale would obligate Mr. Jones to follow through on his decision to have full mouth reconstruction—it would prevent him from backing out. I told the owner that I was uncomfortable with his request and left that practice soon afterward. How would you respond to a similar request?

Keeping the Patient Flow Moving While working in a military clinic, I was assigned Recruit Smith and told to restore tooth #20 with an amalgam crown—essentially an MODFL restoration placed on a tooth following root canal treatment. An amalgam crown typically entails r­emoving gutta percha from the occlusal two-thirds of the root, cementing a pin into the

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­ repared root canal space, shaping the remaining coronal structure, placing amalp gam, and carving the amalgam to correct anatomical and functional form. This time-consuming process is not easily reversed if retreatment of the root canal filling becomes necessary. Typically, when faced with placing a coronal restoration following root canal treatment (especially when a post would be cemented in the root canal space), I examine the tooth to make sure that it is asymptomatic. This practice is to rule out the persistence of pulpal or periapical pathology. When I tapped on tooth #20, Recruit Smith virtually jumped out of the chair—indicating that further evaluation of the root canal and possible retreatment were needed. On reporting this finding, the managing dentist complained about the patient flow being slowed down and insisted that I comply with his request. I responded that I could not in good conscience put the patient’s well being at risk. So, the managing dentist reassigned Recruit Smith to another dentist, who placed the amalgam crown on tooth #20 as ordered. Recruit Smith was deployed soon thereafter and essentially relegated to experience whatever symptoms associated with unresolved pathology might arise— whenever and wherever that may occur, including while engaged in military action. How would you respond to orders similar to those I received?

Fast-Paced Community Dental Clinic As mentioned in the first example, a community clinic setting can present ethical challenges. The pace of work can be so intense that certain important responsibilities are not addressed as they should be. In the case of one such clinic, the managing dentist told the dental staff to prevent complaints from the patients and we had to work at such a pace that there was inadequate time to update the medical history, do a full examination and treatment plan, obtain informed consent, and provide treatment. Despite the managing dentist’s request to speed things up, I chose to take the time necessary to comply with all necessary steps before treating the patient. As a result, the manager reprimanded me for taking too much time per patient. Later on, I learned that had I not obtained informed consent for the procedures I performed, I could have been charged with assault and battery. How would you handle a similar situation?

Nitrous Oxide for Everyone I interviewed for a contractor position at a private practice office and noticed, while I was at that facility, that every patient presenting for treatment was given nitrous oxide—even those having dentures delivered. When I asked about this practice,

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the owner told me that giving nitrous oxide to everyone increased the chances that they would come back for further treatment and that it created a great referral source. I chose not to work in this office. How would you handle a similar situation?

Maximizing Cash Flow In his first year out of dental school, one of my classmates worked for another ­dentist. He was assigned to do root canal treatment on retained roots. Soon afterward, he discovered that these roots were extracted. He subsequently learned that the practice owner’s intention was never to rehabilitate those teeth but to maximize the income that could be generated by their being treated in multiple ways—with no benefit to the patient yet with all the risks associated with the dental treatment. How would you respond to a similar situation?

Now that I’ve presented some of the ethical situations that challenged either me or my classmate, I will present a framework that I have conceptualized over time that has provided me with the ethical foundation for my practice. I will demonstrate a simple tool, the Importance-Performance Analysis, which you can use right away in the treatment planning phase of your practice. The following section will show you how the treatment planning phase fits into the greater context of what we do as dentists.

What We Do for Our Patients: Diagnosis, Treatment Planning, and Treatment

Essentially, when we see a patient, we can engage in 3 main activities: (1) the Diagnostic Phase, (2) the Treatment Planning Phase, and (3) the Treatment Phase. Each phase is based on the preceding step. Yet, these steps are totally distinct as far as execution is concerned. For example, consider a patient whom you diagnosed as being completely edentulous. Once you have arrived at that straight forward diagnosis, you can choose to present a treatment plan—or not. And following the treatment plan presentation, you may choose to provide the treatment itself—or not. It should be clear that there is nothing inherent in any one step that obligates you to move on to the next step. Your ability and willingness to refer a patient for whatever reason can be quite liberating (and contribute to sleeping well at night). The first two parts of this sequence, the Diagnostic and Treatment Planning phases, are discussed below. The third phase, Treatment, is beyond the scope of this chapter.

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Diagnostic Phase .

The diagnosis is arrived by collecting information during the following six steps: 1.  2.  3.  4.  5.  6. 

Chief complaint History of present illness Medical history Social history Clinical examination Adjunctive diagnostic examinations and testing

Chief Complaint This term is borrowed from the symptom-reactive practices of our medical ­colleagues, where patients seek relief for an ailment. Dental patients may not be aware of any particular ailment. Thus, their Chief Complaint can range from an asymptomatic, “Doc, I think I’m OK but can you tell me how am I doing?” to a very symptomatic, “Doc, I have this horrible pain in my upper right molar!” You would record what the patients say in their own words as the Chief Complaint.

History of Present Illness This step is also borrowed from medicine. In this step, you would elicit details about the Chief Complaint such as duration of pain, initiating factors, such as hot or cold temperatures, the character of the pain, and so on. You would record the patient’s answers to your questions in the oral health record.

Medical History This step is necessary for all evaluations. The Medical History essentially reviews all the physiological systems (e.g., cardiovascular, neurologic, gastrointestinal, etc.), medications being taken, allergies to medications and other agents (e.g., latex), and surgical history. The Medical History also covers patient symptoms (e.g., weight gain/loss, chest pain, etc.) that may be indicative of undiagnosed and/or poorly controlled illnesses (e.g., diabetes and heart disease).

Social History This step is a summary of lifestyle practices that may have an effect on your patients’ health. These practices can include occupation, habits such as alcohol, drug use, and smoking, interests/hobbies, diet, and exercise. It is also important to note communication issues such as hearing, visual and cognitive impairments, language barriers, and preferred communication style (e.g., verbal, visual, auditory, and ­kinesthetic).

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Clinical Examination In this step, you would look for clues that would help arrive at a diagnosis. Optimally, the Clinical Examination is comprehensive; you would examine everything in the oral cavity, head, and neck areas avoiding focusing initially on the patient’s Chief Complaint. The information gathered is primarily visual, but may also be tactile (e.g., fluctuant vs. indurated swelling) and auditory (dull vs. resonant sound when tapping on a tooth). During the Clinical Examination, the decision about the need for adjunctive diagnostic examinations and testing is made.

Adjunctive Diagnostic Examinations and Testing The final information gathering step of the Diagnostic phase is Adjunctive Diagnostic Examinations and Testing. This step includes radiographs and other imaging modalities, blood pressure measurement, heart and respiration rates, as well as clinical laboratory tests. Once all the steps of the Diagnostic phase have been completed, you can come up with a diagnosis, or more generally, a differential diagnosis. The diagnosis then maps directly to a spectrum of treatment options—ranging from doing nothing to offering the most elaborate treatment conceivable. Communicating this range of possibilities to your patients is discussed in the following section.

Treatment Planning Phase This phase provides a tremendous opportunity to learn about your patients’ preferences and educate them about what dentistry can and cannot do to fulfill those desires. On the basis of what you have learned about your patients to this point, it is important to present your information at a pace, vocabulary level, and voice volume that can be readily understood by each patient. Consider using the following 5-point framework to present the treatment options available to your patients: 1.  2.  3.  4.  5. 

Name the treatment option Describe what is involved in implementing that option Describe the benefits of treatment Describe the risks of treatment Describe the likely consequences if no treatment is selected

After letting your patients know the full spectrum of treatment options, it’s time to learn about what is important to them. What values can your patients share with you that will help in choosing a mutually acceptable treatment option? And what level of importance do your patients assign to each of those values? When you consider that two patients with exactly the same oral condition may end up choosing vastly different treatments, you can understand the importance of considering the characteristics of the “patients attached to the teeth” you are looking at.

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Importance-Performance Analysis Tool This tool can help make the process of accounting for your patients’ priorities and constraints systematic and easy to document. Although this tool does not provide an “answer” about what is best to do, it does provide an excellent basis for discussion with your patients—acknowledging their priorities while apprising them of what is possible with treatment. How does the Importance-Performance Tool work? First, you describe to your patient those characteristics that distinguish one treatment option from another. Next, your patient indicates how important each characteristic is to him or her. That importance level remains constant for all the treatment options under consideration. Then, you as the knowledgeable professional assign performance levels for each characteristic for each treatment option. You’re essentially answering the question, “How well does this treatment option fulfill the patient’s desire?” This assignment of performance level provides the opportunity to talk about the pros and cons for each treatment option. An illustration of a specific case using the Importance-Performance Tool is presented below.

Specific Case Using the Importance-Performance Tool Your patient is a 32-year-old healthy female with a diagnosis of irreversible pulpitis secondary to a coronal vertical fracture of tooth #14 (Figure 7.1). Tooth #14 was extracted (Figure 7.2), and Teeth’s #12, 13, and 15 are asymptomatic and have no apparent pathology associated with them. Tooth #15 has an intact well-sealed occlusal amalgam restoration. The opposing dentition is complete and asymptomatic. The diagnosis now is partial edentulism, tooth #14. What is the range of treatment options to consider for this patient? Consider the continuum: No treatment ® RPD ® Bridge ® Implant Where RPD = removable partial denture. What are some considerations that would help your patient decide which treatment option is best for her? As a short list, your patient would likely be concerned with the following 5 conside rations or characteristics of the treatment: 1.  Low Cost—Low out-of-pocket cost of ­treatment 2.  Minimal Tooth Preparation—minimizing the extent to which adjacent teeth require preparation 3.  Easy Maintenance—the ease of practicing good oral hygiene in the area ­being treated 4.  High Chewing Comfort—the high level of chewing comfort provided by the treatment 5.  Long-Term Stability—the anticipated long life span of the treatment

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Figure 7.1 Periapical Radiograph Teeth #13–15

61

Figure 7.2 Panoramic Radiograph Left Side

You should feel free to expand on the treatment characteristics listed earlier. For example, you could address the invasiveness of the operative procedure involved in each treatment option (e.g., Low Invasiveness). After laying out these characteristics of treatment, you now ask your patient how important they are. It is important to listen to your patients’ feedback without judging or attempting to influence them. Their responses should reflect their values, and not yours. For the earlier example where your patient is missing tooth #14, the following scenario is presented. You describe the characteristics of treatment and your patient assigns the following importance levels on a 1 to 10 scale: 1.  Low Cost: 10—Very important. Your patient has a limited budget. 2.  Minimal Tooth Preparation: 7—Fairly important. Your patient prefers not to have other teeth prepared to any great extent. 3.  Easy Maintenance: 6—Moderately important. Your patient is fairly dexterous with flossing and brushing and believes she can address any hygiene challenge. 4.  High Chewing Comfort: 9—Very important. Your patient really wants to chew comfortably. 5.  Long-Term Stability: 10—Very important. Your patient wants her restoration to last for many years. As you elicit your patient’s level of importance for each consideration, make sure to fully acknowledge her desires and take care not to comment on how likely a given treatment fulfills her wishes. That will be addressed later. You are simply collecting information about what your patient desires. Remember that just because she may want all these features does not mean that you are able to identify a single solution that satisfies all that she is seeking.

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Table 7.2 illustrates the characteristics of treatment that will help your patient distinguish between the different treatment options and the level of importance she places on each of those characteristics. After collecting information on Importance, you can advise your patient on each treatment option’s Performance, which is the extent to which a particular treatment option can deliver on each characteristic of importance to her. This is your opportunity to use your knowledge, clinical experience, and evidence from the biomedical literature to address how well a given treatment option can fulfill your patient’s desires. Once you suggest the Performance level for each characteristic, you can calculate an overall score for each treatment option. This overall score is simply the product of the patient-assigned Importance level and the dentist-assigned Performance level for each characteristic of treatment added together. The overall score reflects your patient’s desires and your ability to fulfill them. The higher the score, the more likely she will consider that treatment option as the best one for her.

Option #1—Nontreatment For this option, you might advise your patient that the Performance on Low Cost, Minimal Tooth Preparation, and the Easy Maintenance characteristics would be 10. There obviously would be no cost associated with nontreatment nor would any adjacent teeth be prepared. Similarly, it would be extremely easy to keep the area clean because of the total access for brushing and flossing. High Chewing Comfort would be 0 in this case because there would be no improvement in chewing comfort. Finally, the Long-Term Stability characteristic is questionable due to the possibility that over time mandibular teeth may super-erupt and teeth’s # 13 and 15 may tilt toward the edentulous area. These tooth movements may lead to treatment recommendations in the future. The Importance-Performance analysis can help illustrate this uncertainty when talking with your patient. The Importance-Performance analysis for the n ­ ontreatment option is shown in Table 7.3.

Option #2—Removable Partial Denture For this option, you might advise your patient that Low Cost performance is moderate, say a level 6. The performance for Minimal Tooth Preparation can be relatively high, say a level 8, because only slight adjustments may be required for creating

Table 7.2 Characteristic of Treatment and Relative Importance to Patient

Characteristic of Treatment

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Importance to Patient

Low Cost

10

Minimal Tooth Preparation

7

Easy Maintenance

6

High Chewing Comfort

9

Long-Term Stability

10

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Table 7.3 Importance-Performance Analysis for Nontreatment Option

Characteristic of Treatment Importance (I) Performance (P) Product (I × P) 10 10 100 Low Cost 7 10 70 Minimal Tooth Preparation 6 10 60 Easy Maintenance 9 0 0 High Chewing Comfort 10 ? ? Long-Term Stability 230? Overall Score for No Treatment Option

rest preps and guide planes on the teeth involved in supporting and retaining the RPD. Performance for Easy Maintenance can be considered to be relatively high, say a level 7, due to the ease of access to the interproximal surfaces of #13 and #15 when the RPD is removed and also accounting for the ease of cleaning the RPD. The performance for High Chewing Comfort can be considered as moderate, say a level 4, due to the movement of the RPD in function and that the patient may not be comfortable chewing sticky foods that may dislodge her prosthesis. Long-Term Stability performance can be relatively low, say a level 3, due to the need to replace the prosthesis over time because of changes to supporting teeth, alveolar contours, and wear on the prosthesis itself. The Importance-Performance analysis for the RPD option is shown in Table 7.4.

Option #3—Bridge (Fixed Partial Denture) For this option, you might advise your patient that because of the relatively high cost of the bridge, the Performance for Low Cost is relatively low, say a level 2. Since adjacent teeth would need significant preparation as bridge abutments, the performance assigned for Minimal Tooth Preparation would be 1. The performance for Easy Maintenance would be moderate, say a level 6, due to needing floss threaders, interproximal brushes, and other hygiene aids. The performance for High

Table 7.4 Importance-Performance Analysis for the RPD Option

Characteristic of Treatment Importance (I) 10 Low Cost 7 Minimal Tooth Preparation 6 Easy Maintenance 9 High Chewing Comfort 10 Long-Term Stability Overall score for RPD option

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Performance (P) Product (I × P) 6

60

8

56

7

42

4

36

3

30

224

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Chewing Comfort would be relatively high, say a level 8, reflecting the greater rigidity and natural feel of this option. Finally, the expected lifespan of this restoration is moderate, with the need for replacement bridges to be made over the patient’s anticipated lifetime, so the performance assigned to Long-Term Stability can be 6. The Importance-Performance analysis for the Bridge option is shown in Table 7.5. Table 7.5 Importance-Performance Analysis for the Bridge Option

Characteristic of Treatment Importance (I) 10 Low Cost 7 Minimal Tooth Preparation 6 Easy Maintenance 9 High Chewing Comfort 10 Long-Term Stability Overall score for Bridge option

Performance (P) Product (I × P) 2

20

1

7

6

36

8

72

6

60

195

Option #4—Implant For this option, you might advise your patient that because of the relatively high cost of the implant, the Performance for Low Cost is relatively low, say a level 2. Since adjacent teeth do not need any preparation, the performance assigned for Minimal Tooth Preparation would be 10. The performance for Easy Maintenance would also be high, say a level 9, because the implant would require similar to hygiene efforts as the other teeth. The performance for High Chewing Comfort would be relatively high, say a level 9, reflecting the natural feel of this option. Finally, the expected lifespan of this restoration is extremely long, so the performance assigned to Long-Term Stability can be 9. The Importance-Performance analysis for the Implant option is shown in Table 7.6. Table 7.6 Importance-Performance Analysis for the Implant Option

Characteristic of Treatment Importance (I) Performance (P) Product (I × P) 10 2 20 Low Cost 7 10 70 Minimal Tooth Preparation 6 9 54 Easy Maintenance 9 9 81 High Chewing Comfort 10 9 90 Long-Term Stability Overall score for Implant option 315

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Discussion

The Importance-Performance overall scores for all 4 treatment options are summarized in Table 7.7. Notice that the Bridge option has the lowest score (195), whereas the nontreatment and RPD options had slightly higher, similar scores (230 and 224, respectively). The implant option had the highest score (315). How would you use this information to have a meaningful conversation with your patient? You might consider starting the discussion by asking your patient to offer her thoughts on the differences between these overall scores. What does she think the high score for the Implant option implies about her overall values? What does the fact that the Bridge option scored even lower than nontreatment imply? What would she think if the uncertainty about the tooth movement occurring with the nontreatment option could be minimized? What might happen if there was a viable substitute to the aggressive tooth preparation necessary for the Bridge option? Through this discussion with your patient, it may become clear that if the nontreatment option were chosen, then stabilizing the teeth with a device (e.g., occlusal nightguard) may prevent super-eruption and tilting into the edentulous space and may provide a reasonable strategy until a more suitable option can be implemented. This strategy may allow the high scoring Implant option to be considered, especially if a payment plan that works within your patient’s budget could be designed. Alternatively, if an alternative for the aggressive full coverage crown preparations was available for the Bridge option, then this may make the overall score for this option higher, possibly placing it in contention with the Implant option. Table 7.7 Summary of Importance-Performance Scores for 4 Treatment Options

Characteristic Low Cost Minimal Tooth Preparation Easy to Maintain High Chewing Comfort Long-Term Stability Overall score

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Importance Nontreatment P I×P

RPD P I×P

Bridge P I×P

Implant P I×P

10

10

100

6

60

2

20

2

20

7

10

70

8

56

1

7

10

70

6

10

60

7

42

6

36

9

54

9

0

0

4

36

8

72

9

81

10

?

?

3

30

6

60

9

90

230?

224

195

315

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As mentioned above, the Importance-Performance analysis tool can be expanded to account for other characteristics such as invasiveness of the treatment. Patients’ health issues affecting the available treatment options can also be addressed. For example, a patient with marginally controlled diabetes, prosthetic heart valve, and hypertension might be considered a poorer candidate for a surgical procedure like implant placement than your healthy 32-year-old patient described earlier. In addition, a patient with xerostomia would make the prognosis for a fixed restoration more guarded than otherwise. The Importance-Performance analysis method can accommodate these issues simply by setting up new characteristics that can be compared across all the treatment options. For the surgical risk example, the characteristic Low Surgical Risk can be created. Similarly, for xerostomia, the characteristic Low Cariogenic Potential can be created. With these examples, your input as a knowledgeable professional will be critical when talking with your patients about the importance level for those characteristics. Although you could reasonably expect patients to know the importance of a characteristic like Low Cost, it is unlikely that they could know what level of importance Low Surgical Risk or Low Cariogenic Potential should be without your guidance. This is yet another opportunity to educate your patients and bring value to the relationship.

Conclusion

This chapter on ethics in dentistry has presented some scenarios of ethical challenges you may face in your career along with a conceptual framework for working with your patients, namely the Diagnosis, Treatment Planning, and Treatment Phases of patient care. The Importance-Performance analysis tool has been presented. It can be used to account for both patient preferences and the degree to which multiple treatment options can address patient desires. Although using the Importance-Performance tool does not answer the question as to which treatment option is best, it does provide an opportunity for: 1.  2.  3.  4. 

enhancing interaction between you and your patients sharing the decision-making process being objective in discussing treatment options presenting a comprehensive overview of important considerations in treatment planning 5.  enhancing documentation in the oral health record, including the rationale for treatment choice and informed consent All of these benefits can ultimately help protect your dental license, thereby enabling you to provide high-quality dental services that your patients value for years to come. You will be able to sleep well knowing that you are doing right by both your patients and by yourself.

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Chapter

8

Esthetic Dentistry: When Is Too Much Too Much and What Is Enough? Randy Mitchmore, DDS, MAGD

Never make technical decisions thinking in profits; you will pay for it.

Prof. Dr. Miguel Burgueño Garcia, Madrid, Spain

Purpose

The main objective of this chapter is to enable dental students to make ethical decisions when patients have esthetic issues. This involves first getting to know the patient, establishing what the patient really wants, and determining the patient’s overall circumstances. Then, dentists must have the appropriate skills to resolve those issues and meet their treatment needs. Considering that technological advancements continue to increase the possibilities for making a smile more esthetic, it is a disservice to possess skilled knowledge without properly applying it. What constitutes an esthetic concern? Who is the judge? What does the patient want? How do you find out? What are the patient’s overall circumstances? Why is that important? Do you offer the most modern dentistry or the minimum amount of dentistry to satisfy the original goal? What is your skill level? What if you have advanced skills and knowledge and you do not apply them for the patient’s good? 67

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When most people receive something that they like, they want more of it. What are examples of similar instances? How does that relate to esthetic dentistry? When is the line crossed to malpractice by simply covering everything with no-prep porcelain veneers to give the patient a straight, white smile? What is a fair fee? What is it based on?

What Constitutes an Esthetic Concern? Who Is the Judge?

After four or more years of dental school, dentists’ eyes may be cursed to focus on a person’s teeth before looking at their smile, eyes, face, or other interesting aspects of their human form. Even after many years of professional practice, they may catch themselves staring at the teeth of the person they are talking to. Or when watching a movie in which the face and teeth are enlarged to appear two stories tall, dentists may analyze the teeth, gums, and lips to determine what has been done and how they could do it better. This epitomizes the fascinating and incredibly complex world of ethical decision making in esthetic dentistry. For the purpose of this chapter, esthetic dentistry is the process of changing the appearance of the patient’s smile and changing the patient’s perception of his or her smile. Some might argue that all dentistry should be esthetic dentistry, because if time is taken to restore or repair aspects of the teeth or smile, it should simultaneously be accomplished to look good. It is to be noted that the definition of esthetic dentistry does not describe how to achieve esthetic outcomes. Technological advancements in bonded porcelain veneers, CAD/ CAM-designed orthodontics, orthognathic surgery, implants, composite bonding, and other restorative techniques enable dentists to create magical smiles. It would be easy to highlight case after case of beautiful full-mouth restorations, or before and after pictures involving orthodontics, whitening, laser gingivoplasty, and combinations of porcelain bridges and veneers in which the teeth are literally transformed into things of beauty. Instead, what defines esthetic dentistry—and how the results the patient wants are achieved—are answers to important questions that must be addressed before deciding upon the dental problem and initiating treatment. Surprisingly, I learned some of these questions from some of my most disadvantaged patients and from my hygienist.

What Does the Patient Want? How Do You Find Out?

How many times has a stranger asked you, “How are you doing?” to which you automatically respond, “Just fine,” when in reality you might be suffering from the

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worst hangover or a bad cold, or just lost your favorite pet? People do not always tell you what they really mean. For this reason, if you were to walk the halls of my office, you would find a beautiful and clean space, a small team of well-trained professionals, portraits of smiling patients, fresh flowers, pleasing aromas, and a view overlooking a pool and tropical garden. The question you will hear repeated more than any other is, “What do you want?” It is the one simple question repeated more than any other because it is carefully designed and orchestrated to dig into the inner psyche of the patient. Ultimately, understanding the patient’s psyche is important to providing what they want. Dr. L.D. Pankey, in honor of whom the Pankey Institute was named, was an extraordinary communicator whose philosophy for a successful dental practice included a 4-way balance. This involves knowing yourself/knowing your patient, which is intersected by knowing your work/applying your knowledge. Before ever beginning to treat patients with the skills dental students are so anxious to apply (and get paid for), they must get to know them and what they really want. What patients really want may not be what dentists think is obvious or what they see as the dental problem. That is why the same question is repeated so many times. When a new patient comes into the office and after the usual greeting, repeating the question might be woven into the conversation like this: You: What do you want? Patient: I want to have my teeth cleaned. You: Great! We can do that. Why do you want to have your teeth cleaned? Patient: Well, they are starting to look a little yellow. You: Yes, I see that. Is there anything else? Patient: They are not as straight as they used to be. And these old fillings are turning black. You: I am curious, why is that important to you? Patient: I do not want to look old. You: If there were a way to make your teeth white and straight and not have the black fillings, is there a certain time that you would need that by? Patient: Why yes. I have an important reunion coming up in three months! This scenario is actually very real and quite common; the patient initially said that they wanted their teeth cleaned, when in reality what they really wanted was to not look old and have a smile with straight white teeth in time for a reunion. How many times would you have to ask variations of the same question, “What do you want?” before getting the real answer? How easy and tempting it would have been to stop asking questions after any response and start offering dental solutions?

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If you further break down the conversation, after the first response of “I want my teeth cleaned,” you could have immediately started talking about the wonderful new technology of ultrasonics and the latest polishes and remineralizing pastes, DNA testing, and C-reactive protein testing. The hygienist then could have cleaned the patient’s teeth, feeling smug and professional that he or she gave the patient what they wanted. However, this conversation in its entirety represents only the first round of questions. You still really do not know the patient well enough yet, but such a conversation illustrates how most esthetic dentistry comes about. Typically, a patient enters a practice in this manner; it is not the norm for someone to call up and say, “I would like to make an appointment for 12 porcelain veneers.” Esthetic dentistry evolves from a process of determining what the patient wants, which is usually “a nice smile,” followed by a dialogue about how that can be accomplished and how much it would cost.

What are the Patient’s Overall Circumstances? Why Is that Important?

What patients want and how it can be accomplished depends on their overall circumstances. Dentists cannot be the judge of what will satisfy a patient’s esthetic concern without knowing his or her overall circumstances. To fully ascertain a patient’s circumstances, the rule should be patients talking 80% of the time, dentists talking 20% of the time. By following this formula, dentists and their staff will appear smart and establish a successful relationship with their patients. Consider a patient’s esthetic circumstances. A patient may have a huge diastema between their central incisors and initially say that they want to close some spaces. Do you immediately tell the patient how you can do that with bonding or other treatments? Do you learn more about the patient? For example, maybe the patient wants to keep the diastema as a character trait and close the spaces on the other teeth. Consider a patient’s financial, social, medical, and home circumstances. A patient may have just lost their job, be going through a separation, be behind on bills, or just told they have a serious medical problem. How do such circumstances affect what the patient wants and what constitutes an esthetic issue? Would it be a disservice to present a large bonded porcelain veneer case with a large fee?

Do You Offer the Most Modern Dentistry or the Minimum Amount of Dentistry to Satisfy the Original Goal?

Some of the most important principles of esthetic dentistry can be learned from some of our most disadvantaged patients. The American Academy of Cosmetic Dentistry has a wonderful Charitable Foundation that supports the Give Back a Smile

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program, which consists of a volunteer network of dental offices and laboratories that will help a survivor of domestic violence with a damaged smile, pro bono. In some of these cases, complex esthetic restorative dentistry is required. In others, the extent of dentistry required to achieve an esthetic transformation is minimal. Consider Suzanne, who suffered a Class IV fracture to her central incisor when her husband hit her several years ago. To a dental professional, it appears to be a rather routine small fracture. What do you see when you analyze this case closely? Do you see the reverse smile line? Would it look better to lengthen the centrals and laterals to follow the beautiful curvature of the lower lip and be in line with the incisal tips of the posterior teeth? Would it be better to veneer all of the teeth that show in the smile, in this case all the way back to the molars? Would it be wrong to prepare or grind down perfectly good and beautiful enamel on all of the teeth to achieve a better look if that is what the patient wants? Would you encourage or recommend that? Why or why not? What material would you choose, bonded porcelain, bonded composite, fullcoverage, prep, minimal prep, or no-prep restorations? What part does your skill level play in the decision process? If this will be a laboratory case, what kind of laboratory will you use, a foreign laboratory that charges $49 per unit or an accredited custom laboratory that might charge 20 times that amount? What will your fee be? Now consider the patient’s circumstances. For Suzanne, every time she looked in the mirror, the fractured central incisor was a constant reminder of the abuse she endured and a horrible time in her life. It continued to give her a message of unworthiness and defeated self-esteem. Bruises and scars can heal on their own and go away. A broken tooth cannot fix itself. In psychological terms, it is described this way, “An impaired self-image may be more disabling from

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a developmental aspect than the patient’s actual physical defect. The more attention is focused on a particular area, the more people tend to acquire a negative self-image relative to this area. In general, the clinician is not aware of the degree of the patient’s perception of dentofacial disfigurements. The effect of such restorations may be underestimated in terms of their potential benefit to mental health.”1

Suzanne’s “esthetic” issue was the constant reminder of abuse she saw—the fractured incisor. In considering her circumstances and what she really wanted— to smile again and feel good about herself—it was determined that a thorough cleaning, tooth whitening, and direct composite restoration of only the fractured tooth would truly complete the restoration of her life. This represents true esthetic dentistry, because it is the process of changing a life, not the nuts and bolts of how to fix a tooth, and is best described in Suzanne’s own words: In two weeks, Dr. M and his wonderful staff gave me the most beautiful smile! Custom whitening trays were made for me to use for two weeks, and my hygienist cleaned… and cleaned. The bonding procedure was done very subtly, with different shades and transparencies and took two hours of concentrated work by Dr. M and both dental assistants. When his assistant first handed me the mirror after the bonding procedure, I cried, and she kindly told me that there had been many tears of happiness there. I had forgotten how it felt to really smile—this realization is so profound. My family is very thankful, as well, and is amazed by how natural it looks. I had forgotten that my youngest child had never seen me any other way, so you can imagine how wonderful all this is to me. Dr. M and his entire staff gave selflessly of their time, skills, and caring to help me again become the person I really am—happy, outgoing, and productive.

Suzanne’s words describe the real soul of esthetic dentistry, which is finding the sweet spot of where the appropriate dental technology and skill matches perfectly with and brings about that inner satisfaction and pride within the patient. She writes more about the change in her feelings about herself, how others perceive her, and how the restoration looks. She also talks more about how she was treated and how hard people worked just for her!

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What is Your Skill Level? What if You Have Advanced Skills and Knowledge and You Do Not ­Apply Them for the Patient’s Good?

One of the interesting things about dental practice is that dentists realize that they become better than they were 10, 5, or even 2 years ago. They can look at some cases they did 10 years ago and realize that now they could do them better and perhaps want to do them over. However, they take comfort in knowing they did the best that they could with the technology and circumstances of the time, and most patients understand that. Just like today’s computers are better than the same computer 10 years ago. I have had a number of patients have an esthetic case redone because better things are available now. The other side of knowing the patient equation is to know yourself, and it is incumbent upon you to deliver the best dentistry that you know how to perform. At this point in your dental career, you do not know how to do everything. In fact, there are some technologies or procedures that most dental students do not even know are possible. How they wrestle or come to peace with those facts is part of being a caring professional. Likewise, it is equally important to determine how much or how little dentistry is needed to achieve an esthetic solution. Consider this scenario. A dentist has recently furthered his or her education and skills in dental implants and sculpting ovate pontic receptor sites by completing hands-on coursework in these areas. They are eager to apply their new knowledge and skills to benefit patients in need of such treatments. They are also donating their services to treat a survivor of domestic violence, and the laboratory will donate any lab work to help this survivor. The fee is not an issue, and the dentist does not have financial or procedural constraints dictating that only specific therapies be considered. Trisha is a survivor of domestic violence a number of years ago that left her embarrassed about her smile. She lost her home and lives with her daughter. She loves to sing in the church choir and is very concerned about being able to sing every Sunday. Trisha lives 60 miles away in a community that was recently economically devastated, and her daughter had to give her a ride to the dental appointment, dragging her hyper 5-year-old son with her. They are an hour-anda-half late for the examination appointment, during which the boy trashes the reception room and eats and drinks the refreshments that were so tastefully set out. The oral clinical findings included moderate periodontal infection, moderately acceptable oral hygiene, a few treatable caries, and tongue thrust. Teeth Nos. 2, 3, 7, 13, 14, and 1 were missing, and tooth No. 9 had a broken off root tip.

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Considering the overall circumstances, what would you do? What is the best treatment plan for all concerned? Is there a difference? Now, evaluate the postoperative photographs, noting that the esthetic results were achieved from a treatment plan involving extractions and a complete full denture! The patient’s beautiful smile emphasizes the fact that full dentures can be an equally esthetic solution as full-mouth bonded restorations, implants and bridges and should be considered based on patient circumstances and needs.

Dentists have no way of knowing how a minor dental defect or multiple missing teeth are impacting a person’s life until they begin to ask questions and get to know them. In the first example, a woman felt devastated by a small chip in a tooth. In the second example, the patient was totally missing a front tooth, embarrassed about it, yet maintained a more laid back and happy-go-lucky attitude about it. However, after being restored, her life was also transformed into something more wholesome and productive that surprised her. Perhaps she was in denial about how her appearance was really affecting her self-image. Now, understanding the role that circumstances play in determining and treating esthetic issues, what other treatment options would have been equally successful?

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When Most People Receive Something That They Like, They Want More of It. What Are Examples of that? How Does That Relate to Esthetic Dentistry?

Most people who receive something that they like want to receive more of it. If they receive love, they like getting more of it. If they receive health after being sick, they want to be healthier. Here is the fun application to esthetic dentistry. Most people when they think they want their teeth just a little better, usually want them even better when they attain the first goal. For example, many times patients will be fitted with a full-mouth provisional restoration that is just a bit whiter than their natural teeth because the patient said that would make them happy. Typically when they return for a provisional check, they almost universally ask, “Can it be made even whiter?” But keep in mind a Texas saying shared by an attorney, “You can shear a sheep many times, but you can only skin it once!” In other words, as long as you charge a fair fee, a patient will return to you many times for care. However, if you take advantage of or gouge a patient, you will only do it once and your reputation is damaged.

When Is the Line Crossed to Malpractice by Simply Covering Everything with No-Prep Porcelain Veneers to Give the Patient a Straight, White Smile?

Bonded porcelain can achieve beautiful, esthetic results while totally restoring a malocclusion. I believe this so strongly that I have had my own teeth restored in this manner. I also subscribe to the concept of minimally invasive dentistry in which minimal preparation porcelain veneers are extremely esthetic and very healthy for the teeth and soft tissue. However, they require the same attention to detail and expertise as some full preparations. Unfortunately, current trends have twisted the noble concept of minimal dentistry. Some dentists and laboratories promote no preparation of teeth, with the laboratory making very white, opaque, and bulky porcelain veneers that simply cover the teeth and everything underneath, including old amalgam, composite fillings, and even decay. Such procedures can be highly profitable for dentists. While marketing messages touting “no shots, no drilling” and beautiful white teeth could satisfy a patient’s esthetic desires for straight, white teeth with no pain, are such procedures the right thing to do, even with a very broad informed consent? Here is one such example. Roger is a successful CPA at a large corporation. He was nearing retirement and wanted to “upgrade his smile.” He has high anxiety when

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any dental work is done. He was attracted to the idea of no shots, no drilling, no prep veneers. He had the upper and lower smile zone done that way and he was pleased with the results seen in this photo.

Here is what the same patient looked like one year later.

What do you see? What is the Periodontal Condition? The patient was happy with the esthetic result. What are you going to do for him? The teeth are much whiter than his natural teeth and to the lay persons eye they may be quite acceptable. To the discerning eye, the veneers are monochromatic, lacking in texture, opaque, and the embrasures are not well developed. The lab that is most famous for making these Lumineers makes them over contoured at the gingival margin. The bonding instructions call for bonding the restorations and then have the patient back after 24 hours of curing to feather the gingival margins by

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hand. This of course will leave a roughened surface devoid of porcelain glaze and can never be polished as smooth as a glaze. The ginigiva that was once healthy has reacted badly to the violation of the biologic width and the rough margins. Aside from the obvious bleeding, on closer inspection you can see a cauliflower appearance to the gingiva at the margins. They bleed easily upon probing. Dentists new to the profession may not know the answers to some of the questions about this case and, further, may not know that these question need to be asked. What is your ethical duty when you are thrust into situations such as this? It is your professional duty to tell the patient what you see and, clearly, there are a lot of issues that the patient does not see and is mostly unaware of. The caveat of educating patients about their condition is doing so without making disparaging remarks about the former dentist or making it sound like you are trying to do more than what the patient wants for your own financial gain. The solution that worked for this case was asking the patient’s permission to tell him everything the dentist observed and having a frank discussion of the oral findings. Of course, it was the dentist’s duty to do that anyway, but by asking if the patient wanted that, it opened the door to engage the patient and let him know that the dentist wanted to be his counsellor, not just a “repairman.” The conservative rescue for this situation was careful recontouring of the porcelain at the gingival margins using fine diamonds and polishing paste. Diode laser gingivoplasty was also performed. Here are the results after two weeks.

What is a Fair Fee? What is it Based on?

A discussion of fees is included in this chapter, because it is part of the esthetic treatment process and an area that can cause very bad feelings if not handled in an upfront manner. If patients are surprised, have a misunderstanding, or are unhappy about how the fee is handled, it can easily transform into perceptions of bad treatment, even though that may not be the case.

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Fees are an important part of treatment. If it is too low, the treatment is not valued. If it is too high, dentists risk losing or embarrassing the patient, or creating a disgruntled patient who damages the dentist’s reputation. Therefore, it is important to begin discussing fees early in the treatment planning conversation, not later, to help avoid the topic of fees becoming the big elephant in the room that no one wants to talk about. It works well to talk in general terms first to see where the patient is. For example, asking the following question gives a wealth of information about a patient’s perception of the value and cost of certain treatments, “Would it surprise you that some people pay the price of a small car to have a smile like this?” Do not create an elaborate and detailed case presentation, then drop the bomb of the fee at the end of your conversation, when the patient has no earthly idea how much it may cost. In addition, there are ways of discussing the fee early in the treatment conversation without detailing a cafeteria-like itemization of procedures, which would be a mistake. Esthetic dentistry costs are, and should be, highly variable. Most large law firms have different hourly fees for attorneys doing the same work in the same firm, with a senior partner charging double or triple the hourly rate of a new attorney because the senior attorney has a higher skill and experience level. They are selling a service and not a commodity. A dentist’s fees should be set on certain identifiable business factors, not a fee schedule from an insurance company, for the same reasons. Variable factors include skill and experience, level of care expected, the expected time involved, and how demanding the patient is for something clinically acceptable or close to perfection. Fixed and variable overhead costs and laboratory fees should indicate what the hourly rate should be to cover these expenses. Combining these factors determines the fee for an esthetic case. Dr Pankey believed that a fair fee is any fee a patient is willing to pay with gratitude. If a patient hastily scribbles out a check or shoves a credit card to the business assistant and angrily says, “Here’s your money,” a fair fee was not negotiated, most likely because the dentist did not build value for the treatment, not the particular dollar amount of the treatment. Imagine that a young woman—an hourly worker with a child to care for—desires esthetic dentistry, but she has a high fear of dental care. The fee given is significant for her budget and requires some sacrifice because it is much more than she thought about spending for dental care. A desired outcome is the following. Do her preliminary phase 1 care of periodontal health and caries removal under IV sedation. Become her friend, advocate, and cheerleader. When she brings her check in to begin the esthetic phase, she also brings a large beautiful platter of fresh fruit as a gift to the office that treated her so well and show her gratitude and excitement for what was happening to her life.

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The dentist smiles with gratitude, knowing it’s going to be a beautiful case because the patient is getting something she wants badly and is happy to pay for it. In making an ethical decision of what to do for a patient, I like to recall the Rotary International Four Way Test of the things we think, say, or do. 1.  2.  3.  4. 

Is it the TRUTH? Is it FAIR to all concerned? Will it build GOODWILL and BETTER FRIENDSHIPS? Will it be BENEFICIAL to all concerned?

Summary

Esthetic dentistry is such a fascinating aspect of our profession, because frequently there is no one clear answer to a problem. The dentist and patient make choices based on the overall circumstances. It is your professional duty to make those choices based on ethical decisions. When those trusts are violated, dentists open themselves up to shame, misery, and a bad reputation. When dentists make choices and treatment recommendations that give the patient what they want through utilization of unique talents and skills as an esthetic dentist, it creates a win–win for all that can be both spiritually and financially rewarding.

Acknowledgment

The author thanks his very skilled, gifted, and talented hygienist, Janie Robinson, RDH, for providing insights into the important questions that help identify what patients want for themselves and their dental treatment. He would also like to thank Antonio, Toni, and other members of his staff for providing exceptional and compassionate patient care.

Reference 1.  Rufenacht CR. Fundamentals of Esthetics. Hanover Park, IL: Quintessence Publishing; 1995:chap 3, 59.

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Chapter

Patient’s Perspective on Medical Ethics

9

Rocco Gemma

Keep your words soft and sweet, for someday you may need to eat them.

Johan Reyneke, BChD, MChD, FCMFPS(SA), PhD, White River, South Africa

Ethics

Latin: Mores/Cognate: Mor.es- ium mpl

Ethics

Modern: More $ / Cognate: Do only what is right / Do what it takes to make money. - ium/I understand money

Ethical

A fine line between being imbued with ethics… …the honesty of ourselves to ourselves, or Dean: Say what? Class: CHA CHINGGG Dean: Say what? Class: CHA CHINGGGGGG Yo! …having a good deal more money.

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OATH TO THE PROFESSION “In the presence of classmates, family, friends, and teachers, I (you will say your name here) pledge to faithfully fulfill my obligations as a member of the dental profession…”

I’ve always held to the image (my criteria only) that whether one chooses to be a dentist, a dental specialist, or right on up to a maxillofacial surgeon; they are all first and foremost health-care providers. Trained in their field? Yes. Specialized in their field? Yes. Having the ability to take care of, maintain, and promote my dental and attendant overall health? Most certainly, Yes. Does it behoove me to seek you out when I have a dental problem, an image malfunction, or because the pain is so debilitating that even though one may dread it, an appointment is made to go see the dentist? Again, yes. I make that leap to voluntarily allow you to enter into the realm of my health, trusting you to do good, to fix right what is wrong, and because of who you are and what you represent, and my being on the outside of your knowledge and expertise, I have to implicitly trust you, to give myself over to you so that again whatever is wrong is righted, and I can heal and continue to be healthy again, mentally, emotionally, and physically. I do not like pain, especially in my mouth, as that is the source of comfort for me in all of its sensory applications such as eating, speaking, breathing, intimacy, or just the calm comfort and warmth of an easy smile. Yes, pain takes some of that away in its restrictive presence within the confines of my mouth. And you, you are the arbiter of what should and can be done to alleviate it. I have come to you for a yearly examination, as I am assiduous in my dental hygiene, cavity-free because I do not like or want to go to a dentist’s office and have someone probing into my mouth, picking away my teeth, and I absolutely cannot handle the sound of a drill grinding away a tooth. And then, as will be described shortly, I am informed by you, whom I have known in a professional capacity for a long time, that I have a cracked filling, and in all of the unbeknownst attending and upcoming procedures (crown, root canal, apicoectomy), is there one word uttered about reparative dentin or an anti-inflammatory regimen? Pain killers, sure, let’s mask it, only knowing that it’s going to be still there at the end of the day, at the end of the prescription cycle. And the inherent concern and the utter ease of conversation between you, the doctor, and me, the patient at the possibility of another procedure that may have to be performed. Oh yes, and there will be yet another pain scrip. For as the entire scenario unfolds, there will be another procedure, and another. More procedures entail more money. Reparative dentin? What? How about, or maybe, or possibly the taking of an anti-inflammatory before and after each proscribed procedure? Never mentioned. Didn’t happen. An alternative for the pain and

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­ iscomfort? The patient never knew, even after handing over all of that raw trust. d Ethics? Hmmmmm. “My responsibility is to promote the health of the community and those I serve…”

At what point in one’s career does one begin listening to an inner voice or grasp onto the choice of no longer rendering one’s undiluted oath to their patients? Why would they no longer desire to be in that ethical embrace of “the honesty of ourselves to ourselves”? What story do they concoct? When do people (the dentist) start telling themselves such stories, and why? Possibly, and for a myriad of reasons, their new embrace became one of the desperation? But as it can be fraught and oftentimes overly burdened with selfishness, and like a fractured mirror, the endless attendant excuses that could and would be used to give it a sense of rationale, there can be no desperation here. Ethics aren’t about desperation, they are about choice. Doing the right thing. Character is what you are in the dark. At the end of the day, when all is said and done and the patient list possibly scrolls through one’s head one last time before tossing it aside before entering into the innocence of sleep, do we question our motives, choices, and actions? The character that makes us who we are and the foundation that we stand on are the stanchions of our own individual morality that support the foundation of our character. Are they hewn from the unmistakable, clean, clear line and depth of ethics, or are they just self-constructed props whose justification is built on money accrued, where the end is not true patient satisfaction, but maybe she or he is a satisfied patient after we have seen and treated them through the prism of “This one is good for two procedures, this one three, possibly four, etcetera.” If that is justification as the means to a money-driven end, then that is the polar opposite of you being helpful. I am being treated as if I, as your patient, and my trust on you are flagrantly immaterial. Without your ethics, I am being misled, and that misdirection is ultimately false. Let us begin from the beginning. I’ve called your office for an appointment, and always remember that that person answering your telephone is the voice that represents your business. It is the individual who deals with me in a warm, friendly, and professional manner. A little lightheartedness and humor can go a long way in reassuring me that I am going to be taken care of in a way that from the jump street makes me feel comfortable. That day has arrived, and, with trepidation duly clutched in my psyche (after all, I know that there is going to be some impending discomfort and pain), I arrive at your office, give my name, take a seat, and my evaluation begins. In many stressful situations, visuals can be important in alleviating anxiety. Sitting there, I always take my time and slowly scan all that is around me, taking everything in from the magazines on the tables, the artwork (if any) that is there on the walls, any elements of nature, real plants (soothing) or fake plants (harsh, especially the dusty ones), and, most importantly, the cleanliness and tidiness of the waiting room area. I’ve been

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in offices where the magazines looked as if they had been plucked from a dumpster, plastic plants that were grey with dust, and rugs that looked as if they hadn’t been vacuumed since tooth extraction involved strong twine tied around the tooth and attached to a doorknob. When in waiting rooms such as those, I always wondered why someone wouldn’t just come out from behind the front desk and take 5 minutes straightening up the area. After all, hasn’t anyone ever noticed what that area looks like after a mother has been waiting with her one or two rambunctious children in tow, or the uncaring patients who left their unfinished take-away drink just sitting there? What does any of this have to do with ethics? It’s all part of the package. Lesson 1 in business: “Appearance is 90% of the sale.” If responsibility hasn’t been delegated to take care of that waiting room area, then that’s one aspect of your practice that is not important to you, but hey, it is my first impression. And if that first take by me is that the place seems to be a little sloppy, or is in somewhat of a disarray, then that means that you are too busy to take heed of something like a first impression or your staff is too lazy or it’s beneath them to go beyond anything other than making the office pot of coffee. Since those in the dental profession are detail oriented, at least that’s what I think you are, for it is you who is continually working in a small, defined space, on small units of enamel, with all of the attendant bright lights and hand-held mirrors. Even if you have a separate entrance to offset “Sorry, but the doctor’s running a little late today, there was an emergency,” translated: you were stuck in traffic. No problem, you can enter through someplace else other than through your waiting area. But in any part of the workday, do you go out to greet a patient, or make an appearance just to say hello to all of those that may be sitting there? If you do, a quick, cursory scan of the area will tell you everything you need to know as to what kind of first impression statement your practice is making, and whether your staff is upholding your particular ethical standard of what you are trying to convey to your patients. As for the ambience, dental posters on the wall with professional models smiling to show off their Chicklet teeth, or nothing but magazines and dental information folders does not hack it. If I peruse the walls, and there are some framed prints, it tells me that you’ve put some effort to give me something to look at as I nervously wait for my upcoming procedure. I remember one doctor’s office had artwork of different areas of Tuscany, all artistically lit, and again (soothing), it was a very comfortable and relaxing experience to sit there and gaze into the countryside. It felt more like a comfortable room in someone’s home rather than the standard waiting area. You may be of the opinion that would be lost on most of your patients, but the presumption leaves you with a choice to use a little less effort in what you wish to use as a first impression, but in ethics, all decisions are connected, from first to last, that “Character is what you are in the dark” is more than just the Colgate pledge. “The health of my patients will be my first commitment…”

One of the front-office staff, or maybe one of the the dental assistants, steps out and my name is called. Now we enter into your arena, your workspace, where I am entrusting my care, my problem, and my reason for being there, along with all of my

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inherent and current trepidation, to you. Please understand that when a patient gets to sit in that reclining dental chair and the bib is put in place, we are told that the doctor will be right with us, I, for one, really begin to take stock. I vividly recall being in one particular office staring at the floor and noticing that there were numerous dust balls collected under the baseboard heaters. First mental response: “Who cleans this place, and how could they possibly miss that?” The attending impression being how dirty could the rest of the place possibly be? Are the tools clean? Was the autoclave used properly? Or, if and when (and I have) noticed dried water stains along some of the instruments near the receptacle when one is told “you can rinse you mouth now,” and I thought that area hadn’t been cleaned well from the previous patient’s visit, or maybe even from the day before or the day before that. I recall one time, when my dentist was performing a root canal on me, his partner came in, the fingers on his gloves all wet, and began opening the drawers that contained the dental instruments, looking for a particular tool that he needed for the procedure he was doing, and these were the same drawers that my dentist was using with his own wet-fingered gloves. His partner gave no notice of me, only asking where a specific instrument was, and I thought, “cross contamination?” And this was during one of the high media points of the AIDS crisis, when all dentists, including mine, had signs everywhere stating that all instruments were sterilized and/or disposable instruments were used in the practice. Didn’t matter a whit in that situation. When I brought up the incident afterwards, my dentist’s explanation was that his partner was a bit aggressive in his office etiquette and, as an appeasement, stated that his partner had done that before while other patients were in the chair and that he had spoken to him about it, apparently to no avail. Ethics? At the very least, diminished. “I will honor my peers and respect the diversity they bring to the profession and commit to our mutual success…”

And with regards to that dentist’s response, herein lays the core of my interaction with you. Your attitude. I know that you are a professional, and I respect that. Actually, I admire you for the choice of your profession, as it took a long time, a truckload of work, and a lot of dedication for you to walk into and see me as your patient. But it is at that very moment when the doctor/patient interaction begins, all the rest of my experience with you will be influenced by the texture of those first few moments. Are you friendly beyond the usual work smile and manner? Do you take time to sit for a few moments and talk to me beyond why I am there? After all, that is a given, but what is more important is for you to try and establish a rapport, a sense of emotional equality, and by that I mean for me to feel that you are talking to me, not at me. A small, inoffensive personal inquiry interjected in the conversation by you takes little to no effort, but it makes me feel that you are genuinely interested in me as an individual. It sets up an emotional equilibrium and allows you to direct the ebb and flow of our interaction. I am not asking to be coddled, pampered, or doted on, but on a subliminal level you are making yourself human, by that, meaning I can get past the medical aura of instruments, the clean sterility, the uniforms, and feel that this professional in front of me regards me as more than just another procedure. If that is done, you are showing care, kindness, consideration, and effortlessly extracting from me my trust.

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“My practice depends upon the trust of my patients. I will not violate that trust. I will do no harm…”

My Perspective as a Patient

I went to my long-standing dentist for my yearly checkup. After the examination, he informed me that I had a cracked filling. I was more than surprised, as my dental hygiene is quite assiduous, and I had no noticeable symptoms that would indicate that such was the case. He explained that oftentimes the crack could result from it just being an old filling, or that the constant pressure from eating and time itself had caused it to wear out. No symptoms? Yes, but down the road, as the crack became more pronounced, I would begin to feel discomfort, and it would more than likely become more problematical. Tend to it now, and that would be it. Okay, let’s do it. Filling fixed. And then, after all was said and done, that slow, distant, and almost imperceptible discomfort began way, way back, to be precise, probably in the furthermost row of my psyche, but it was there. Signaling. At that juncture, I wouldn’t even have called it pain. More analogous to an annoyance, a minute pressure, something distant, put down and off as just the residue of the procedure, a minor, not quite diminishing ache that would soon go away. But it didn’t. It just hung there, in the periphery, slowly and effortlessly circling inward, a few rows at a time, the timbre building, the interruption of my thoughts becoming more frequent, until it finally sat itself down dead center, just a few rows back from the front row of my consciousness, clearly interrupting the soundtrack of my everyday existence. At that point, I finally turned around from the ongoing screen of my life to see what the annoyance could possibly be, and there it was, the constant, low-level pain, like a Japanese Kodo drummer slowly pounding away on that massive, oversized drum, the slow rhythm emanating out like ripples of water in a pond when a stone is dropped in, only this time it was the repetitive emanations of discomfort resulting from a dentist’s drill that had been slowly eased into the enamel of a tooth. One of the most selfish things that can embrace any individual is pain. How effortlessly it sidles up next to us, drapes an arm across the back, hand gently resting on the far shoulder, pulling us in, whispering its pervasive sweet nothings, and we, of course, flick the hand of irritability away, attempting to ignore it, dismissing it, the innate mentally chaste attitude being no more than “Go away, leave me alone.” But it doesn’t. The sidling becomes more frequent, more immediate, our attempts to flick away the hand an inadequate chastisement at best, the imprecations and protestations of our inner voice unable to penetrate that proverbial wall of pain. So we turn away in frustration, maybe take an aspirin or two so that we can again begin to concentrate on our life screen that is in front of us, the distraction of everyday’s moments being enough to put out the pain, and that, combined with the aspirin, will make it exit stage right.

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“I will honor my patients’ dignity. I will be their zealous advocate, sensitive to their feelings, needs, and thoughts. I will not discriminate against any person in my decisions and care…”

But it won’t. As we attempt to refocus on that soundtrack of our daily existence, blocking our view, right there, again dead center but this time in the very front row, therein is the pain that just refuses to go away. Back to the dentist’s office. “I don’t know, Doc, the pain just won’t dissipate. It just seems to be getting worse.”The examination ensues, and the conclusion is that the tooth has to be replaced with a crown. There was the advice to take aspirin. A prescription was given for Acetaminophen with Codeine. I acquiesced, as my trust was still in play, and, of course, the decision of a medical professional is based on the ethical standard of that given profession, right? So, procedure number 2 was undertaken. Fast forward to recuperation, and once again, the attendant pain made no attempt to recues itself or even work its way slowly to the forefront. It just sat right down dead center in the front row of my thought processes and hammered away at what was seemingly becoming a fractured sanity. Calls to the office, concern, a refill of the prescription, the pain just hammered away. “We are going to have to do a root canal” the doctor stated. The anecdotes that had been related over the years in relation to root canal procedures were more than enough to make me hesitate. But the pain remained steadfast in its persuasive embrace. The root canal proved to be extremely problematic, both in the procedure itself and my ongoing discomfort. At this point, the persuasive embrace of pain allowed me to put my complete trust in the dentist, even though I kept wondering how I went from no symptoms, from a cracked filling, to my now third procedure. And this is from someone whose dental experiences in life began as a youth, when the first foray into that chair resulted in a diagnosis of having to have a tooth pulled. Trust was in play at the time between parent and professional, even though the parent was surprised because I and the rest of my siblings were taught and practiced good dental hygiene. Trust is trust, especially coming on down from the professional high road to the flat stretch of belief of the lay person. After all, we do look up to you because of your training, your expertise, your ability to heal, and most importantly for you, because you took and oath. We all go through, at one time or another, the obstacle course that set parameters requires us to do, so that when we get to end of the line, we believe you when you state that a particular procedure has to be done. After all, we passed all of the requisite markers, those being your reputation, your office demeanor, your CV so prominently displayed in all of those framed diplomas on your office wall, and the absolute eye contact trust that you imbue when discussing what has to be done. But back then, when I, and my siblings, and the rest of the neighborhood kids were having teeth extracted, all of the parents thought the individual was a good dentist. Who knew, until he was finally challenged, that his exodontial obsession was based solely on his greed for more money. Trust? It was there, and to what end? He lost his license, only to get it back at a later date, and all of the neighborhood kids unknowingly became members of the Diastema Tribe.

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As other d ­ entists came and went, my ability to trust was always held in check, until finally I chose the one who was working on me, after having gone through an extensive obstacle course, and all of the criteria were met, including the fact that he was a teacher at the local and renowned dental college. “I recognize the limits of my competence. I will seek knowledge and inspiration from my colleagues whenever my patients’ needs require. I will strive to improve my knowledge and skills…”

At this point, I was somewhat taken aback when his diagnosis was the only way to relieve the postoperative pain from the root canal to have oral surgery for an apicoectomy. I didn’t question, as the pain at that point had pulled in so close that no questioning light would have been able to permeate my consciousness. I was recommended to an oral mallofaxial surgeon, who performed the procedure, and the pain finally released its embrace on my existence, and all went comfortably forth at that point. I stayed away from the regimen of annual checkups for quite a while, until that distant and almost forgotten acquaintance came back as if to cling to a distant remembrance. There was pain in an upper tooth that became quite bothersome, and the day I arrived at the office, my dentist was out unexpectedly for the day, so his new partner did the examination. The x-rays came back, and to my astonishment, she stated that I had seven cavities and that one tooth possibly need to be extracted. I insisted that that wasn’t possible, not with my dental hygiene, and she was just as insistent that the x-rays told her otherwise. In desperation, with the former procedures as a reminder, I sought out a second opinion. Having no health insurance at that time, I went to a dental clinic that charged only a nominal fee for its services. The entire establishment spoke of nothing less than that of an assembly line for a dental practice. I was about to get up and leave when I was called. The dentist entered shortly after I had the bib place around my neck. He listened patiently as I explained my symptoms of my doctor’s partner’s prognosis. He examined my teeth and then suggested for another set of x-rays to be taken. “I am responsible for contributing to the improvement of the community. I will strive to prevent disease and correct adverse social conditions. “I will serve as both a teacher and role model for my patients, my successors, and the public. “I am responsible for upholding my profession’s integrity. I will strive to counsel those deficient in character or competence and expose those who engage in fraud or deception. I will use my professional knowledge according to the laws of humanity. “With this oath, I willingly assume these responsibilities.”

I’ll never forget, there was a window to my immediate left, and the nurse opened it, reached in, and pulled through the long arm of an x-ray machine. It turns out that every two rooms along the corridor had a window for the same purpose, and I had an image of having another dentist reaching through the window to borrow an instrument in mid-procedure. The films came back, the dentist returned and

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showed me a darkened area and said, “See that area there, that’s the source of your pain. You don’t need to have an extraction.” Puzzled, I replied, “I don’t?” “No, you don’t. But if you want to me to pull the tooth, I will.” I looked at him, and he was quite serious. Shades of youth and my embraced ­experience with the Diastema Tribe, “What?” “Hey, years ago, when I graduated from dental school, I took an oath. As I recall, it went ‘I promise to take out the tooth, the whole tooth, and nothing but the tooth.’” I just sat there, not knowing how to respond. A slow smile broke on his face, and he said, “Hey, dentists swear to defend the constitution against all enemies, foreign and domestic. It’s a noble profession. That’s why most only work 3–4 days a week. We need time to perform our superhero duties.” The smile grew as he continued, “You take that oath after Jack Bauer 101 (JB101) during your first year of dental school.” We both burst out laughing, and he said, “You don’t need an extraction, you have an infected sinus.” He pointed to the x-ray and explained everything. Afterward, he actually walked along with me to the door. I asked him for his card, and it turned out that he was the head dentist there and it was his practice. I was astounded at his honesty and his commitment to help those less fortunate. He was the epitome of when we speak of the honesty of ourselves to ourselves. Being ethical is more than just a moral code. Ethics is the sine qua non of being in the business of that of a dental professional.

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Chapter

10

Dental Board and Licensure: Where the Rubber Meets the Road of Ethical Decision Making Maxwell Finn, DDS, MD and Miro Pavelka, DDS, MSD

Da siempre lo mejor de ti. Somos eternos en el recuerdo de nuestros pacientes. Always do your very best. We are eternal through our patient’s memories.

Jorge I. Ravelo, DDS, MS, Caracas, Miranda, Venezuela Obtaining a license to practice dentistry is the goal of your professional ­education. Although the perceived goal of dental school is to graduate, it is just one requirement for the achievement of licensure. Without a dental license, you may not ­practice. This is true for all 50 states. Thus, your dental license is your most v­ aluable asset of your dental practice and must be protected. A dental license is under the umbrella of the legislature of each state. In Texas, the legislature first provided for licensure of dentists in 1897. In 1911, the Legislature established the Board of Examiners. In Texas, the dental board consists of 15 members, 5 public members, 2 hygienists, and 8 dentists; some of whom are specialists, yet all are appointed by the Governor. We serve for six-year teams. The governor appoints the presiding officer, and the members of the Texas State Board of Dental Examiners (TSBDE) elect the board secretary. Each state will have its own composition and governance of its particular dental board as put forth by statute established by each state’s legislature. 91

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It is the Board of Examiners of each state that oversees the licensure process. The state legislature, who are the elected officials of each state, determine the laws that govern your license, but gives rule making authority to the board. It is the license holder’s responsibility to be knowledgeable of said laws and rules and obey them. The primary mission of the dental board is to protect the public. In addition, our mission is to ensure that only qualified people are licensed to provide dental care and violators of laws and rules regarding dentistry are sanctioned as appropriate. The TSDBE consists of the following 5 divisions: Executive, Administration, ­Licensing, Legal, and Enforcement. The Enforcement arm includes 10 investigators, who are given  peace officer authority by 78th Legislature in 2003 (HB 875, CCP 2.12 (34). These officers are distributed throughout our state. They investigate cases ­pertaining to: •  patient injury/death •  drug diversion •  impairment •  dishonorable conduct •  standard of care •  records •  advertizing •  sanitation The complaint process begins after a complaint is filed with the dental boards. All complaints filed with the SBDE must be reviewed for jurisdiction. Jurisdictional complaints are forwarded to investigators to start the investigation process. Completed investigations are reviewed by at least two members of the Enforcement Committee (board members). Cases where violations are found are forwarded to the legal division for disciplinary hearings (informal settlement conferences, State Office of Administrative Hearings, etc). About 1–3 board members preside over informal settlement conferences. Settlement conferences are much like a deposition, but less formal and there is no record. The dentist (respondent) and his or her council, as well as the patient (complainant) may all be present. The circumstances of the case are heard by the board member or members present and an offer of a board order is made or the case may be dismissed. If needed, a respondent can take the offer or go to trial as far up as the state supreme court. Most cases, however, are resolved at this level. Any recommendations for disciplinary actions must be ratified by the full board to become effective (board orders). These board orders are subject to open records request and available to the public. Often, they are posted on the board’s Web page for public view. Conversely, complaints dismissed without action (complaint history) are not subject to open records request. The process discussed here is for the State of Texas. Each state has its own governance. For example, in California, the dental board members are not involved in the investigation process or the settlement conference. However, it is all state boards of dental examiners

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that vote on and ratify the recommendations for disciplinary actions, based on the disciplinary guidelines as set forth by the state legislature or the board. It is important to remember that the state dental board deals with allegations. The reason patients complain is very often totally different from the actual allegations. For example, the reason may be rudeness, but the allegation is failure to meet the standard of care. The board has no jurisdiction over rudeness, but can take action over standard of care violations once the complaint is filed. Current and ex-employees will often complain to the board for the same reason. The top 5 reasons for patients to decide to complain to the board are as follows: •  rudeness (chair-side manner) •  unresolved fee issues/disputes •  unreturned calls left with staff •  patient has no clear expectation of treatment outcome (no informed consent) •  no attempt to resolve a dispute by the dentist Conversely, the top violations discovered by the board are as follows: •  general record keeping violations »» no baseline vitals recorded »» no informed consent (general consent to treat is not informed consent), etc •  failure to provide records to the patient or the board •  sanitation issues •  unprofessional conduct »» fraud »» impairment »» prescribing for nondental purposes, etc. •  advertising violations The board may emergently suspend a license when evidence indicates that the action(s) by a practitioner, “constitute a clear, imminent, or continuing threat to a person’s physical health or well-being.” Most emergency suspensions are the result of impairment (alcohol, drugs, or mental impairment) or death or serious injury of a patient as a result of a violation of the standard of care. If a license holder has problems involving impairment, then he or she may be referred to a diversion program. In Texas, it is referred to as the Professional Recovery Network (PRN). Here, licensees are referred to PRN for drug/alcohol testing. PRN provides board ordered substance abuse monitoring for the board. Those license holders who recognize that they have an impairment problem and voluntarily elect to present themselves for testing and subsequent treatment, may suspend eminent emergency suspension proceedings by the board. However, volunteering for PRN monitoring/testing after a complaint is filed does not stop the investigative process by the board. PRN and similar diversion programs are

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available to licensees. Voluntary participation in PRN is not reported to the board as long as the licensee is not a danger to patients. In summary, in order to stay out of trouble and protect your license: •  communicate openly and fairly with your patients •  do what you are taught •  keep good records •  stay aware of your state’s dental board of examiners statutes and regulations •  do not do drugs

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Chapter

11

Conscientious Billing ­Practices: ­Ethical Decision Making for ­Patient Billing and Dental ­Benefit Company Relations Sheri B. Doniger, DDS

Before you set out to treat a patient, always pretend that you are the patient and then treat your patient how you would want to be treated.

Ladi Doonquah, MD, DDS, Kingston, Jamaica One of the main content areas that was lacking in my dental training included business management. Upon graduation, we were set loose on to the world to become small business owners, CEO’s of our own company. As we are thrown into practice, we become human resource managers, chief financial officers, inventory management control specialists, and corporate relations liaisons, all in addition to focusing on our dentistry. No one gave us a course on how to manage billing or dental benefit companies. We created a fee schedule from various practice management gurus, respected journals, thought leader articles and word-of-mouth discussions with colleagues. We filled out claim forms (sometimes by ourselves, occasionally by a team member) and prayed for accuracy and timely payment. The world is a little different now. Currently, with the Health Insurance Portability and Accountability Act (HIPAA) and Fair Credit Billing Act, the way we charge for and collect professional services has changed. We are not allowed to harass patients, through the office or collection agencies, if they do not pay their bills. I remember, many years ago asking a patient, in complete frustration, “Why do you have money 95

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to pay for your (Chicago) Black Hawks tickets, but do not have anything to pay me?” It was not a good tactic then and certainly not now. We have to protect the sanctity of our patient’s privacy. As mentioned, one of the first tasks in starting your practice is to set a fee schedule that you feel is a fair return for your professional skills and knowledge. Once a fee schedule is determined, it is necessary to stick with those fees. Charging differently for the same procedure is not a good practice protocol. It is also unlawful to charge dental benefit patients differently than fee for service patients. It is also unlawful to charge for procedures you have not provided. In addition, it is unlawful to overcharge for procedures provided to maximize either your or the patient’s return from the benefit company. Billing the patients should be fairly basic. The first rule of thumb: be honest with your patients and only charge them for procedures that have been performed. Have financial discussions prior to treatment. These discussions should be held by your business manager, front desk manager, or yourself. The entire treatment plan should be described, with alternatives of care, demonstrating fee schedules of each procedure. The more conversations you have with your patient regarding their financial obligations, the happier the relationship will be. Patients leave dental practices for many reasons such as moving, changing dental plans, and owing money. If you are able to avoid trying to track the patient down after he or she leaves your practice, then you will save yourself a huge headache. If a patient has a dental benefit, offer to submit the treatment plan as a pretreatment estimate to their company. This will allow you to know the “estimation of benefits,” the amount the benefit company plans to pay. This amount may vary, due to other dentistry being performed outside of your office. It will also indicate the percentage breakdown for each procedure. You will be able to explain these benefits to the patients. It is to be noted that treatment planning is between the dental professional and our patient. Although dental benefit companies feel they have the “right” to dictate treatment, they are only offering suggested amounts of reimbursements. This should never dictate the treatment you feel is best for your patient. Regardless of your office policy to accept or reject dental benefit, it would be prudent to have these pretreatment authorizations in place. It will also indicate if a procedure is covered under the plan and will lead to an easier discussion of financial obligations with your patient. Early on in my practice, I had a new family join us. The wife was a stay-at-home mother with three children, one new born. The reason they were changing dentists was inconceivable. Their former dentist had all the dental benefit information, knew the father’s (head of household) information, as it was the same for the other children, and filed a claim for a preventive visit for the young child who had never visited his practice. This is major fraud and not a wise choice. Only request payment for procedures you have personally completed and list the procedures thoroughly and accurately. I also had an opportunity to work for a major dental company in the fraud division. I was assigned a group of dentists who were “on hold” from this carrier because

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they repeatedly filed similar claims for large groups of patients. For example, some dentists only charged for the initial oral examination for an entire group of residents at a nursing care facility, some of whom had no teeth, never had prosthesis, or were physically unable to wear prosthesis. Another group of dentists charged out single surface amalgams on every posterior tooth, from molars to premolars, regardless of the age of tooth eruption. For the most part, none of these procedures were necessary; some were not even performed. Again, if you think that you are submitting claims unheeded, then beware. With electronic claims payment, the accounting is simple. There is always someone evaluating the number of claims and procedures processed. If you perform too many of one procedure, you may receive a letter from the company, requesting files and treatment plans. Regarding dental fees, it is prudent to reassess them on a yearly basis. Try not to change fees midyear. If you have a treatment plan in place with a patient, it is not wise to alter the contracted amount. One option would be to set a time limit with the patient. “This treatment plan is in effect for _______.” Oral conditions do change. Treatment may not be as expected. Patients need to be aware of this from the onset of care. They should sign the treatment plan and the financial arrangement to agree that there may be unforeseen changes. It does not make for good business or client relations to radically increase fees in the middle of a treatment, unless there is an unforeseen gap in the treatment. Then, you may reassess, reanalyze the oral conditions, and create a new treatment plan. Do remember that the best patients will come from your best patients. It is wise to make patients happy by having open and honest communication. To accept or not to accept a dental benefit is the question you must answer when you begin your practice life. If you are in an associateship, you will be under the restrictions of your employer. They may or may not take dental benefit, and you are obligated to work with their restraints. As a solo practitioner, or as the partner in a group practice, you need to decide if you want to enter into the “insurance game” or go it alone. Many dentists decide from the outset of their practices not to accept assignments from third-party payers. I use this term, “third-party payers” to include all forms of dental benefits. Their practices are considered “fee for service.” They prefer to receive direct reimbursement from the patient, rather than going through a third party. Patients pay for their professional services at the time of the visit, or with a prearranged financial contract. These nonparticipating practices will give the patients all the appropriate documentation to submit their claims to the dental benefit company. The positives with this system are you may receive your funds quicker and you do not have to deal with the bureaucracy of the system. One of the downsides, patients are used to submitting forms and paying remainder balances, as in their medical offices. Although, as a new dentist in a new practice, you are certainly under no obligation to enter into a financial arrangement you do not want to, such as accepting third-party payments. There are different obligations with different dental plans. In most cases, the patient/employer pays a premium to have access to the dental coverage. All types

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of dental plans are under the auspices of the state insurance regulatory board. Accepting dental benefits comes with some parameters. Primarily, there are limits of coverage on all procedures. All fees are subject to usual, reasonable, and customary (URC) amounts. So, you are not able (or allowed) to charge $400 for a full mouth series of radiographs, merely to cover the full amount of the fee. The benefit companies have their limits, even with self-insured plans. Second, the year is the year. Once the calendar year ends, dentists are not able to “go back” to claim procedures that needed to be done to utilize the patient’s annual maximum limit. If a patient has $1000 per year, and only uses $400 for preventive care, the dentist is unable to bill procedures that were not completed in that dental year or bill procedures that another family member incurred to “claim” the money. This is not ethical. Procedures must be charged for the calendar year in which the services occurred. Breakdown of services is routine or preventive, minor restorative, and major restorative. Routine or preventive services include dental prophylaxis, fluoride treatments, radiographs, and examinations (limited, comprehensive, or recall). Minor restorative procedures include amalgams and composites. Major procedures are surgical, implants, and prosthetics. Endodontics will vary from routine to major, depending on the dental plan’s rules. There are limits of coverage on all procedures. All dental benefit companies set their own limits of payment, as well as their own standards of fees for the procedures they cover. There are four main different types of plans available (Table 11.1). An indemnity plan is more of a traditional package. The dentist charges his/her amount for a procedure and the benefit company (third-party administrator) pays between 50% and 80% of the cost of covered procedures. The patients will be responsible for paying the remainder balance. Patients will have a deductible and a “maximum” amount of funds available for their dental care. These funds are determined by the policy the patient’s employer contracts with the dental benefit company and may vary. Interestingly, the maximum amount limits have been virtually unchanged since the inception of dental insurance over 50 years ago. Although $1000 would cover a lot more than it does these days, the maximum benefit has remained steady, between $1000 and $2000 per patient. Self-insured plans are self-funded. Patients do not pay the premiums. The employer does not seek out a third party, such as a dental insurance company, to administrate the payment of benefit. There are usually limits as to the annual benefit amount, and they vary widely. Patients enjoy the same amount of freedom of choice of provider as a traditional or indemnity plan. Some plans offer a similar breakdown of fee percentages as indemnity plans and some pay 100% up to a certain dollar amount, then a varying rate up to the plan maximum for the year. Managed care plans include Preferred Provider Organizations (PPO) or Dental Health Maintenance Organizations (DHMO). The PPO includes a group of dentists who agree to a standard fee schedule and will accept the agreed upon amounts from the contracted plan. Patients are allowed to go to a dentist outside of the plan,

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Third-party administrator

Between $50 and $100

$1000–$1500

Yes

Most should be covered

Routine: 80%–100% Minor: 50%–80% Major: 50%–60%

No

Yes

Who will administer the plan?

Deductible

Annual maximum

Submit treatment plan prior to starting dentistry

Noncovered expenses

Percentage of fee covered

Probationary or waiting period prior to the treatment

Able to seek an own dentist?

Traditional or Indemnity Self-insured

Yes

No

May vary with the amount spent per year. It will usually mirror indemnity

Most should be covered.

May not need it; check with the employer

$1000–$1500

Between $50 and $100

Employermanaged plan

Table 11.1 Dental Benefit Options Available

Depends; if you visit a dentist in the group plan, then out-of-pocket payment is less

Depends on the plan contract

Depends on the network participation

Yes

$1000–$1500 (depending on you are an “in” network or “out” of network dentist)

Between $50 and $100

Third-party administrator

Preferred Provider Organization

No; must be in the group plan

No

Will have noncovered expenses

Yes

$1000–$1500

Between $50 and $100

Third-party administrator

Dental health Maintenance Organization

Yes

Does not apply; patient pays out of pocket

Does not apply; patient pays out of pocket

Yes

Depends on the patients finances

No

None

Out of Pocket Payment

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but their annual maximum may be greatly diminished as well as the fee percentage covered. The DHMO, similar to Health Maintenance Organizations from medicine, are plans where the patient must select only from a group of dentists inside the plan. If the patients seek care outside of the plan (without a referral from a dentist in the plan), nothing will be covered, not even dental emergencies. Be cautious about the patients you accept in your practice. Check out their dental coverage prior to starting. If you or your business manager are able to confirm the status of the plan (if you do accept assignment), then you will be in a better position to determine your eligibility to treat this patient. If you treat a patient who does not pay at the time of service, and expect payment from a dental carrier, please be certain that you are aware of the type of benefit the patient presents to the office. We have been in a few situations over the years with no ability to collect from patients who sought care and were unaware of their dental plan. Sometimes, we are asked by patients to assist in either finding or helping them choose between dental plans. My response is to accept the plan that gives you autonomy of choice. We try to guide patients to choose their own dentist. If it were between a PPO and an HMO, then the PPO would be a better option to retain the choice factor. For the most part, claims are handled through automated services, rarely with human intervention. Dental consultants are paid to check out more difficult claims. For the most part, nonpayment is a clerical error, possibly to data entry or misinterpretation of the code. It is important to choose the correct codes for each procedure. It is also important not to “unbundle” the claim. Unbundling a code would be similar to a hospital charging for each gauze or box of Kleenex. Unlike our medical friends, we do not charge separately for the anesthetic, etch bonding, dentin protectant, and composite. We have 1 professional fee for a “composite,” an “amalgam,” and a “maxillary denture.” We do not break apart the steps but submit for the whole procedure. Benefit companies and patients do not look kindly on this process. The most important component of your dental benefit knowledge is to remember that the dental benefit is a contract between the employer and the employee. We are not allowed to get in the middle of that situation. We are able to direct the patient to contact their state’s Department of Insurance (DOI) and file a claim. Patients have all the rights in this situation. The DOI has jurisdiction over the companies and individuals that are licensed. The DOI oversees and approves any and all insurance plans sold by an insurance company or licensed insurance producer. For any licensed company or licensed individual to offer any insurance plan in Illinois, it must be approved by the DOI. When consumers make contact with DOI, it generally has to do with a claim not being paid; not handled correctly or not handled in a timely manner; a coverage question; a claim being denied; or a policy not issued that was paid for by the consumer. For example, a patient feels there has been some fraud perpetrated by the dental insurance company by not carrying out its end of the contract, especially if they were owed a payment and then denied. Patients will file a claim for misrepresentation.

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According to the statute, payment is expected within 30 business days. The funds the benefit company has “delegated” to claims should not be held longer than 30 days after a claim. The money is to be used for reimbursing patients and practitioners; not held in interest-bearing accounts. These funds are a combination of employee and employer contributions to the dental plan. Years ago, when interest rates were very high, companies could make money off of these accounts. Regarding a late payment, there may be some mitigating circumstances, as the claim was filled out incorrectly; missing data or more information is needed. But, for the majority of claims, payment is due within 30 business days. If payment is not received, the patient is due a response and a claim may be filed. As dental practitioners, we know treatment should be determined between the dentist and the patient. Often times, the dental benefit company is a silent partner in this decision. Patients may rely on the $1000 the dental company has to offer, and believe, to their core, that is all they should spend on personal dental care in a year. As we know, there is no easy crystal ball to determine the patient’s dental needs for a particular year. They may be new to our office and need only restorative or they may need major reconstructive treatment. With patients of record, they may only have preventive and a few restoratives or have a failed endodontically treated tooth that results in a surgical extraction, bone augmentation, implant placement, and the subsequent prosthesis. This patient went from being under their maximum to way over it. On occasion, the benefit to the patient is either not as promised in the preauthorization or nonexistent. Benefit companies frequently request supporting information, such as radiographs, photographs, or periodontal charting. Submit as much information to the company with the initial claim form as possible. If you do not receive the expected benefit, contact the carrier. Submitting the claim a second time with a written statement as to the necessity of the treatment may also help. Advocating for the patient does two important things: it shows the patient that we care and will go the extra mile to assist them in paying for their necessary treatment, and it also informs the dental benefit company that we are accurate in our diagnosis and would like reimbursement for our procedures. If the claim is returned a third time, then you may need to contact the dental insurance consultant at the benefit company. Ethical billing systems need to be established from the onset of your practice life. It is important for you to be honest with your patients, have open lines of communication, and request payment for the procedures you have actually performed. It is easier to be honest than trying to remember different stories you have told to different patients. Believe it or not, some of them do talk outside your door. The last thing you want is a reputation of being overpriced, nickel and diming, or demanding. Yes, we do perform dentistry and would like to be reimbursed for our professional services. It is how you manage your billing practices to establish a framework of conscious procedures in your practice that will gain you the most trust. Your patients will appreciate your integrity. It will be a source of practice growth.

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Points to Remember

✓✓ ✓✓ ✓✓ ✓✓ ✓✓ ✓✓ ✓✓ ✓✓ ✓✓

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Determine a fair value for your fees Open lines of communication with patients will avert most financial issues Fees should be the same for each and every patient Determine your methods of billing and keep them stable Decide if you will or will not accept payment from third-party payers Never unbundle a procedure to increase revenue Be honest with your patients Never bill for procedures you have not done Never increase the procedure to bill more than the actual cost

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Chapter

12

The Ethics of Career-Long Learning James R. Hupp, DMD, MD, JD

It is good to know how little you know, but it shouldn’t discourage you.

Prof. Dr. Med Nasser Nadjmi, Antwerp, Belgium Our knowledge and understanding of the world and the universe around us are exploding. This constant expansion is even more phenomenal in the realms of science and human health. Dentistry shares this growth in that our scientific understanding of dental physiology, microbiology, pathology, devices, and materials continues to increase at a remarkable rate. This proliferation in scientific discoveries of relevance to dentistry relate, to a great extent, to the application of genomic investigations, the use of nanotechnology, and the movement toward nontraditional restorative techniques such as dental implants and colored tooth-filling materials. Today’s dental students are, hopefully, receiving an education that promotes evidence-based concepts and hones critical thinking skills. At graduation, students should be competent generalists with state-of-the-art knowledge and the ability to practice using contemporary approaches. However, even the finest educational and training program cannot provide their trainees all the knowledge and skills to sustain them for their entire careers. The relentless growth in human knowledge makes this impossible. This is the juncture where an additional educational process is necessary, namely, continuing education (CE) (called “further education” in the United Kingdom and Ireland). CE, as discussed in this chapter, refers to the formal or informal manners in which individuals build upon their formal education as they are practicing their careers. Therefore, for a dentist, CE is the education undertaken after professional school 103

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and, when applicable, residency training. CE can take many formal forms, including: (1) structured classroom or online courses presented by content experts, (2) “handson” courses where clinical skills are taught, (3) individual study programs through special sections in journals or online, (4) participation in dental meetings or “study clubs,” or (5) even by being the instructor of a CE course offered to other professionals. There is no reason why CE cannot be an informal process involving learning through reading or watching instructional videos. However, most groups who regulate CE will not accept informal individual study as an approved CE program, mainly due to problems in documenting participation. One might ask, why does the topic of CE for dental professionals appear in an ethics book for dentists? Well, one must take a step back to recall why becoming a well-educated health professional has an ethical basis at all. Typically, the first real patient a dental student encounters and begins to manage comprehensively is initially seen during the second year of study. This is because the professors, and in the end the students’ patients, expect the student doctor to possess a certain degree of fundamental knowledge in the basic biomedical and dental sciences, and have some preclinical preparation before being given the privilege of doing potentially harmful procedures on another human being. Patients do not understand what their student doctor should know and be able to do before doing a procedure. They, instead, place their trust in the school and its agents (the faculty and staff) that they have made sure the student is ready to safely manage patients. The faculty designs the appropriate curriculum, decides on the equipment, instruments and supplies that should be available, and determines the correct staffing of the clinical areas. All that the student needs to do, for the most part, is to follow the path laid out by the faculty. The dental school has a duty to the patients of the school to ensure that each of the faculty-designated parameters creates a situation whereby the risk to any patient of something being done inappropriately is minimized. The burden of fulfilling this duty rests almost entirely on the school. Of course, a student may deviate from what they are being taught by the school to do or use on a patient, which is clearly an ethical violation. (This kind of ethical problem is covered elsewhere in this book.) Students eventually graduate, obtain a license, and leave the school’s domain. Who is now responsible for ensuring that a patient of the graduated dentist receives appropriate, safe care? Hopefully, it is obvious that the duty is inherited by the new dentist. It is now the dentist’s ethical responsibility to make sure that the equipment, instruments, supplies, and other members of the dental team are all poised to deliver safe and effective care. However, how does CE fall into the duty now transferring to the new dentist? Well, just as dental student patients expect that their caregiver is providing the best possible advice and care, so too do patients of licensed dentists. For the recent graduate, this preparation was provided through their dental school curriculum. However,

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as was previously discussed, science moves on, and it takes very little time for what was learned in dental school to no longer be fully accurate or complete. In addition, the wide scope of modern dentistry makes it virtually impossible for any dental training program to give all graduates the knowledge and skills on every aspect of general dentistry. The onward march of science and acknowledged gaps in the dental education are the reasons why it becomes a duty for all dentists to seek CE throughout their careers. Major dental associations appreciate the importance of dentists keeping their knowledge and skills updated. The American Dental Association (ADA) addresses this topic in two parts of their Code of Professional Conduct. Section 2.A on education states, “…All dentists, therefore, have the obligation of keeping their knowledge and skills current.” Also, in Section 5.D.2, relating to a manufacturer’s or distributor’s representations of efficacy of products, the code explains, “The dentist has an independent obligation to inquire into the truth and accuracy of such claims and verify that they are founded on accepted scientific knowledge or research.” Similarly, one of the core values of the Academy of General Dentistry (AGD) is “Continuous, life-long learning.” The California Dental Association’s (CDA) Code of Ethics contains Section 5 Continuing Education that puts forth, “The rights of dentists to be accorded professional status rests primarily in the knowledge, skills and experience with which they serve their patients and society. Dentists have the obligation to advance their knowledge and keep their skills freshened by continuing education throughout their professional lives.” Hopefully, most dentists appreciate the value of regularly updating and expanding their knowledge in their profession. For the few who do not, dental licensing boards leave no other option. All parts of the United States and Canada require that all dentists obtain a certain amount of approved dental CE in each licensing period. This is because licensing boards, whose constituency is the patients of dentists in their state or province, understand that one cannot practice quality dentistry without ongoing CE. So, if CE is mandatory and one has no choice of whether or not to take any CE, why are there any ethical issues? The ethical issues arise because even the most stringent CE regulations do not ensure the following 3 things: 1.  the CE being delivered is of high quality, 2.  the CE received is relevant to each attendee, and 3.  the individual taking CE is paying adequate attention. Each of the above possibilities requires more elaboration.

Continuing Education Quality

There is a huge market for CE for dental professionals, because it is required of all licensed dentists. In response, an entire dental CE industry has developed. CE

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is provided by dental schools, dental associations and societies, and private forprofit firms. For the most part, dental CE providers are well intentioned and deliver courses of good quality; but, unfortunately, poor and/or biased programs do exist. In recognition of this possibility, organizations such as the ADA and the AGD have set up CE certification programs. In these programs, CE courses that require certification must meet specific criteria to gain approval. These include having speakers with valid credentials and disclosed conflicts of interest, setting clear learning objectives, and then, at the end of the course, perform post-course surveys of the audience to see if the stated objectives were met. CE programs sanctioned under the ADA CERP (Continuing education recognition program) and AGD PACE (Program approval for continuing education) programs can generally be considered of good quality, particularly if they have been delivered several times. The ADA and AGD programs also approve other organizations to provide programs that earn participants credit hours as long as those organizations follow similar CE course vetting and quality assurance procedures. Nonetheless, there are states that accept other forms of CE that do not have any quality assurance behind them. These are often seen with some local dental groups who may have a difficult time-identifying or affording good speakers. Their answer is to sometimes use dental industry representatives or speakers paid by such companies to deliver the CE. Some of these can be of good quality, but frequently they are not or have undisclosed biases. Knowing that one has an ethical responsibility to their patients to obtain quality, CE puts the burden on the dentist to self-police. One cannot always prospectively determine if a particular CE program is of sufficient quality to help the dentist deliver better care. But on those occasions when a poor course is encountered, the dentist should not use such a course to satisfy their state-mandated CE requirements.

Continuing Education Relevance

There are some CE programs that are, or should be, mandatory for all dentists, such as basic life support. However, for most dentists, it is up to the dentist to determine which CE courses to take. The ethical dilemma in this circumstance boils down to whether someone truly appreciates the value of required CE or simply views it as an unneeded regulation and ignores its spirit. The ethical dentist should seek out the kinds of courses likely to have an impact on the dentist’s practice, rather than just taking courses because they are convenient or low cost, regardless of their relevance. Courses on practice management or estate planning may be of value to the dentist, but it is a stretch to claim they help one improve their clinical skills. The dentist should be able to fully justify how a particular course will improve their knowledge and/or skills in a way that will help their patients. That justification is not to some authority figure, rather one must be able to justify it to themselves–their conscience. It is likely no one else will know if a dentist simply took a CE course because it was packaged with a cruise, a ski trip, or a trip to an exotic destination, or to game the tax system. Only the dentist’s ethical bearing will know, and, hopefully, provide good guidance.

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Continuing Education Effectiveness

The most difficult aspect of CE for any organization, be it a licensing board or the ADA, AGD, and so forth, is a determination of whether the dentist participating in a CE course is actually mentally engaged. Some courses do testing, especially those delivered through media such as journals or online. They do this to help decide if participants are paying attention and understand the material. In addition, hands-on courses tend to require participants to actually participate, rather than just watch. However, most CE courses only require some determination of physical presence and nothing more. Many do require completion of a course evaluation form before providing CE credit, but the format of these forms does not really allow detection of a person who was mentally elsewhere during the course, or even if they were awake. Thus, the duty of being actively engaged in the program is borne by the dentist. The quality and relevance issues go out the window if the dentist attending a CE course was thinking of their next vacation, the stock market, or doing a crossword puzzle rather than paying attention. Again, it is left up to the dentist’s ethical beliefs to determine whether they will accept credit for a course in which they were physically present, but mentally elsewhere. There is an ethical aspect of CE related to being engaged deserving of some mention. It relates to the counting of CE credit hours. Programs use various means of trying to match a participant’s actual time of attendance and the number of credit hours awarded. Some have participants sign in or trigger a bar code sensor at the start of a session and again at the end. Some will not give credit unless the participant stays until the end of the entire session, but do not document when they entered the room. However, no process seems foolproof. This leaves it to the individual to be honest, and only accept or count the appropriate amount of credit. To conclude, dentists have an ethical duty to keep the knowledge and skills they use to provide patient care as up-to-date as possible. They should seek out quality CE programs, hopefully guided by organized dental groups that certify CE programs. The dentist should find courses of relevance to their daily practice that are likely to enhance their care-giving capabilities. Dental professionals should be focused on the content of the CE program they are taking. Finally, CE should not only occur with formal courses. Regular reading of peer-reviewed, scientifically sound dental articles, meeting with fellow dentists to share evidence-based concepts, and attending quality, relevant educational programs that do not offer CE credits are all valuable means of staying abreast of developments in the dental field. Dentists have a career-long ethical obligation to their patients to deliver high safe, high quality, and scientifically sound contemporary care. Regular participation in dental continuing education is a major means of fulfilling that duty.

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Chapter

Office Management

13

Sunny Stewart, MS, MBA, SD, PhD, Ric Salvati, OSA, and Suzanne McCormick, MS, DDS We make a living by what we get, we make a life by what we give.

Winston Churchill Its 6:30 at night, the office is closed, the last patient and staff have left and it is quiet. You wonder, “now just how was it that I got here?” Four years of undergraduate education, 4 years of dental school and 2, 3, or 4 years of residency and how do I run this thing? We enter dental school with aspirations of patient care and even s­ pecialty care. However, the import of what we do should not overshadow the how we make it work. We are proficient at the most precise aspects of odontogenic ­disease control and restoration of form, using an instrument such as an explorer with the point diameter of less than 0.5 mm to determine clinical success, yet are we that precise in running our business? The general consensus would be a resounding “no.” Greater than 85% of all dentists graduating from dental school will enter into some form of private practice setting. Some dentists will choose to be in solo practices with one office or a few satellite offices, while others in multi-group practices with several offices employing up to 20–30 persons. The economics of these situations can be significant. Yet, it is joked that doctors and dentists are often poor business people. And let’s face it, the majority of us are. Ironically, the dental school application process can self-select for those who are compassionate caregivers as most applicants discuss how their matriculation from dental school will result in positive social change and giving back to one’s community. We have never read an application that says, “I want to become a dentist because I want to make money and have a study income with few persons to answer to.” However, that is the precise business model of a private dental practice. The following are situations/conditions that can occur in one’s day-to-day practice 109

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that test our moral compass. Some situations hold seemingly obvious answers until it is you who have to make the decision. Ultimately, as we will see in the following, it is the leadership style of you, the dentist, which determines the tone and moral fortitude of your dental practice.

Business 101

The dentist, as the practice’s leader, determines the scope of dentistry to be performed, sets the fee schedule, the insurances accepted, the size of the office staff, and salary of the employees they hire. The dentist and their team must balance the wants, needs, and desires of their patients versus the goal of the practice. At the helm, the dentist reaps the rewards and also holds the ultimate responsibility, for it is their license that can be disciplined should deviations occur from the community standard. Unlike a traditional business that when poorly managed fails; failure of a dental practice from poor ethical decision making may result in not only the loss of a business, but it can also result in the discipline of a license, and thus, the potential loss of a career along with the loss of all the time and money invested in 4 years of dental school and even more years in postgraduate training and building a practice. Admittedly, our lives get busy especially as clinical and business success comes our way. However, the business of a dental practice must be cultivated, guarded, and maintained to ensure long-term success. Developing a business plan is central to defining the direction of a business and is useful when considering decisions concerning the money aspect of the business. Core to a successful practice is your dental team, your staff. Managing the two aspects, money and personnel, is the cornerstone of any business venture. The simple act of hiring staff is not so simple an action. The salary offered is not the true number affecting your bottom-line budget. One must factor in the benefit package the practice offers its employees as well as payroll taxes, social security and unemployment taxes, and so forth. It has been said that the actual salary one must budget for is 1½ times the salary offered to an employee. The salary should reflect the employee’s worth to the practice and still be within the fiscal goals of the practice. Firing staff can also lead to moral decisions. Practices strive to adhere with 100% compliance to the complex local, state, and federal regulations. The human condition always allows room for improvement such that all of our practices are vulnerable to audit. The dentist, as the owner of the practice, is ultimately responsible for compliance with these regulations. This very fact can be a source of concern in the workplace especially when an employee is terminated from their position. It is well known that a disgruntled employee, even one still in your employment, may report the practice to the authorities and thus initiate an audit. This audit can be warranted if the practice is grossly negligent in its procedures, or the audit may not be warranted and a nuisance case. The stress, time, lawyers, and consultant fees that one may need to invest to deflect such an audit are monumental. Consequently, some

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may offer a severance to an employee who is fired just to “keep the peace” even though it may not be warranted. A decision that is based on an office policy applicable to all who are employed is preferred to a decision that is based on an individual case or situation, where emotion may overshadow good judgment. The act of setting one’s fees is a similar challenge, for your fee structure is what drives the cash flow of a practice. It is considered unlawful to discuss fees for services among colleagues. Yet, there are practice surveys that one can purchase that gives the average fee charged per procedure code based on the zip code in which you practice. The decision still remains, where in the spectrum of the local fee structure should you set your fees? Should you place your fees at the higher 95% range or lower in an effort to be price competitive. It is important to realize that the fees must be sufficient to fund the practice and pay for the overhead. Some practices choose to set the fees higher and then offer discounts to appear to be offering the patient a “deal.” Others offer free examination, radiographs, or teeth bleaching trays, and so on in an effort to draw new patients to their practice. Remember that these offers may be under the jurisdiction of your state’s Dental Practice Act. For example, your state may have laws governing advertising and claims made. These offers must also be “as advertized” regardless if the new patient chooses to remain in the practice or not. For example, in California, the Dental Practice Act specifically addresses that a patient has the right to a copy of their chart and may only be charged a reasonable fee for duplicating their chart. So, a patient who was offered a free examination and radiograph cannot be charged the full fee for a service, such as an x-ray ($300) should they choose to leave the practice and obtain a second opinion. The patient may only be charged a reasonable duplicating fee ($10–$20) for the x-ray. It is the dentist’s responsibility to be aware of their state’s Dental Practice Act and adhere to these statutes and regulations.

Practice Consultants and Other Sources of ­Practice Advice

Recognizing that a dental education does not ensure business savvy, we often turn to outside sources for business advice. It is easy to find resources for advice as companies offering to help, for a fee come to us through the mail, fax machine, and e-mail. Practice management courses are given through competent and national dental societies. We may even hire a Business Manager to help in with the ­day-to-day ­running of the office. However, do not forget that it is your tax identification number and your license, not your staff’s, that is on the documents that are submitted during the normal course of a day. Thus, the ultimate responsibility for the office and its decisions are with that of the license holder and no one else. It is advisable to attend practice management courses with the staff rather than innocently sending them to these classes while you, the license holder attend another class on the latest technique. Similarly, it is advisable to “keep a finger on the pulse of your practice.”

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Weekly, monthly, or quarterly meeting and review are advisable to keep informed of the direction of your practice. Again your leadership style will dictate the frequency and depth of the information covered during these meetings. At minimum, a profit/ loss statement should be reviewed frequently by you, the business owner. Practice management courses and study club meetings are a great source for lifelong learning as well as social exchange. It can also be a source of friendly competition among colleagues. Recognizing that being successful at competition allowed us to be selected as a candidate for dental school, it is this same competitive nature that can be our foible. In discussing the success of our practice, we may ask a colleague who appears to be successful how we can emulate their success. We glean information and possible business advantages or “tricks” that we can incorporate into our practices. We also learn of new operative procedures to improve and expand our practice scope. Here, we must always be mindful of the context in which the advice is given. The advice or new technique may not be applicable in your state based on the Dental Practice Act. Similarly, the advice or new technique may be helpful, but not useful, for your own practice environment. Carefully evaluate the source of that practice advice, for although sage, the advice given may not fit to your practice style or your particular dental specialty or patient base. Understanding your practice as a business entity with a distinct personality can help guide you to make good choices when it comes to implementing business changes. It is up to us, the business owner, to understand the nature of our practices. This is often best framed with a business plan. The best business plan is one that can be stated in 1 or 2 sentences with a clearly defined vision of the goal. Using a business plan helps buffer the human tendency for decisions based on emotion and immediacy rather than decisions based on a clear vision and direction. Recalling one colleague’s experience who attended a practice management lecture was so impressed with the concepts that the Practice consultant offered that they hired the Practice Consultant, at a significant cost, to review their office and offer advice as how to make improvements. The practice management advisor visited their office for three days one week, and two days the next. One piece of advice offered by the Practice Consultant was to fire one of the office team members as he/ she was deemed by the consultant to be a “toxic personality.” The dentist labored over the decision to fire this team member, as the team member slated to be fired was the dentist’s best assistant. However, having faith in the advisor, the dentist went ahead and fired the team member, for the Practice Consultant was seen in the eyes of the dentist as an expert and thought of as someone to be listened to. Within 6 weeks, the office rhythm was in shambles and the remaining office staff was nonfunctional. The firing of the supposed toxic team member had the opposite effect and cost the practice dearly. For not only did the office lose a valuable team member, the practice lost the dollars invested to pay the consultant’s fees, lost camaraderie, and morale. One key decision by the dentist/business owner had a huge impact on the business and little to no impact on the well being of the Practice Consultant. The consultant received the fee and went on to advise yet another ­client, the practice in this case was n ­ egatively impacted.

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Decisions involving the change of a business culture can be the most difficult to make and implement. The challenge is to choose wisely. Change is good. Change can invigorate a practice and bring in new business. However, change that is not perceived as authentic or not well received by your patients and the community in which you practice can be disastrous.

Keeping Current: New Technologies

A part of any business is innovation. Whether that is incorporating new technical skills or updating equipment. Dental society meetings are great opportunities to get hands-on interaction with new and existing products. Attending the vendor portion of a state or national dental meeting is impressive. The venue can be the size of several football fields, with endless choices and opportunities to buy new and exciting equipment. We realize that in order to compete in today’s market place, the acquisition of new technology is mandatory. When we hesitate at the cost, we are told by the sales team, “Can you afford not to buy it?” in effect, spurring our competitive nature. Sales people, including those in the dental field, are in the business of selling things. That is their business model. They, too, are competitive and have sales goals. It is up to the business owner to determine if we need the new technology or product that the sales team is offering. Some new products are true innovations, whereas others are merely a fad. So the question to be asked is, “can we afford the new technology?” or better said “can we afford it today?” The cost of new technology is not only the equipment itself, but also the costs for installation and downtime/potential office closure, maintenance, disposables, and staff training. These secondary costs must be recognized and factored in when determining the actual fee for the equipment to be purchased, along with the time required until the new equipment or technology shows a profit. The return on investment (ROI) from the new technology purchased is either directly linked to our ability to directly generate patient fees, or indirectly related to the ROI from the added value to the practice we perceive as gained, such as a new big screen television for the waiting room. The business plan can help answer these questions. The business plan can determine the budget, the predicted ROI, as well as depreciation and other aspects of upgrades to your practice. Understanding and adhering to your business plan will allow you to spend prudently. Once the decision has been made to purchase a new technology, the only question remaining is “When?” It has been said that a wise man learns for his mistakes, and a wiser man learns from other’s mistakes. For a new technology or product to gain traction, it must obtain 16%–17% of market share. Then, the new product will go on succeed as the sales and perceived value follow a bell curve. During the upswing and plateau of the bell curve, the majority of practices in a given region will incorporate the new technology into their practices. In turn, the technology is no longer perceived as new, and becomes “standard of care.”

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Introducing a new technology into your practice can test your practice style and moral compass. Promoting a new technique or technology is an opportunity to improve patient care and thus also improve the financial basis of your practice. Good practice management and communication skills are important to educate your patients as to the need and perceived benefits from the new technology. Some patients will accept the new technology, others will resist, as is human nature, ­testing the doctor–patient relationship. It can be tempting to advise all patients to embrace a new technology or technique. However, as patient care is involved, we must show good judgment in the true clinical indications for care when offering new treatment modalities to our patients. A dentist in our community favored the use of a locally administered antibiotic for adjunctive treatment of periodontal disease. Their philosophy was to encourage all patients to have this therapy for all pockets greater than 3 mm. One of the authors of this chapter told us of how they spent close to $6000 in local antibiotic therapy alone in conjunction with a routine dental cleaning. Being perplexed as to the cost, the patient went to the internet and researched online about the medication and its indication for use. They wondered if their periodontal disease was so significant as to warrant such extensive treatment and to multiple exposure to antibiotics in one clinical setting, for they recalled that their dentist had mentioned 3–4 mm periodontal pockets with only a one or two 4–5 mm pockets in the molar areas, and no mention of scaling and root planning, only routine dental cleaning. Needless to say that the doctor–patient relationship was strained thereafter. Remembering the axiom of the restaurant industry, a satisfied customer will tell of a great dining experience to only 3–4 friends, yet a dissatisfied customer will tell of a bad experience to 16 of his friends. The short-term monetary gain was offset by the loss of a valued patient.

Patients: A Resource to Be Cultivated

The dental business model is in essence to diagnose oral disease, remove the ­diseased or affected portion of the tooth and/or supporting structure, reconstruct the site, and restore oral health. In turn, the dental team gets compensated for this service by the fees paid by a patient or their insurance company. After the examination and gathering of diagnostic data (physical examination, periodontal probing depths, radiographs, caries risk assessment, etc.), a comprehensive treatment plan is formulated. Some patients prefer having all of their dental needs addressed at once. Others may prefer to observe watchful waiting and defer certain aspects of their treatment. Some patients respond well to the phrase, “So tell me what you don’t like about your smile,” other patients abhor this phrase. Regardless of your clinical style, the establishment of a treatment plan based on a valid structure of clinical decision making/decision-making tree is the cornerstone of patient care. Patient acceptance of a treatment plan is the economic driving force of a dental practice. Consequently, it is of no surprise that techniques encouraging getting a patient to accept a treatment plan is the subject of numerous practice management seminars. Some offices monetarily reward staff based on patient acceptance of their

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treatment plan, and even scale this compensation on the percentage ­portion of the treatment plan a patient accepts. Although such business practices can improve cash flow and profitability, it can strain the doctor–patient relationship. It is not uncommon for patients to express second thoughts if they perceive that they have been swayed to “say yes” to dental treatment by techniques they thought of as overly aggressive. Especially, as patients now have access to web-based information on fees charged by other dentists in the area and numerous social networking opportunities for information and opinion exchange. It is becoming apparent that social networks will soon drive the market place for businesses including dentistry. It is becoming more and more common for patients to negotiate and ask for a discount during the presentation of the treatment plan, citing the fee schedule of other practitioners in the area whose practices they have shopped. However, the dental team must be aware and vigilant for those patients who are unethical themselves. We have heard of the father of a patient in a pedodontic practice refusing to pay the agreed to fee on the day of service. After the dentist had rendered the service to their child, the child’s father commented that the procedure went quickly such that he no longer believed that the procedure his child received was worth the agreed to fee, and now was only willing to pay a lesser amount! The issue at hand was not that he could not afford to pay the fee; he could, and even double the quoted amount. This child’s father thought that after the service had been rendered, he now was in a power position to re-negotiate the fee and felt entitled to do so, leaving the dentist at a loss. Ultimately, it is the dentist who is responsible for the treatment plan and its implementation. Excellent communication and documentation are paramount to success. As is the realization that not every patient may be a good fit for your practice, and that you may be better served to have the patient to go elsewhere, thus avoiding potential problems, especially if patients ask you to make decisions or concessions that are not ethically sound. A patient may initially ask you to “overlook the rules” perhaps in the codes you use in billing their insurance. Out of compassion you say yes, however if improper, you and your license may be at risk for discipline, ­regardless of how compassionate or good your intentions are.

Insurance Companies and Vendors: The Business Interaction

Technically, a private practice is considered a small business employing anywhere from a few to several employees. However, a private dental practice is a unique environment due to its autonomy. Unlike other businesses where the doors are  open for business and consumers come and go to shop, in a dental practice, the consumer is traditionally seen by appointment. The patient arrives and services are rendered by the dentist and their team. The dentist is autonomous in the entire process of establishing a treatment plan, prioritizing that plan, and

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­ xecuting it. This is in contrast to the medical model, where by physicians tends to e be part of large groups or associated with hospitals where there are more opportunities for peer review. The sense of autonomy found in a dental practice can lead to pride of the profession or on the other end of the spectrum, an opportunity to take unfair advantage from the perceived lack of direct oversight and peer review. In the era of computers, this perception of autonomy is no longer valid. Enrolled as a provider for a dental insurance company, a dentist benefits from the steady source of patients and cash flow. As insurance companies are thought of as large, faceless companies, it may be tempting to take advantage of the p ­ erceived lack of oversight associated with a private practice especially with insurance billing. The reality is, now with the electronic filing of claims, countless statistics are collected and being maintained by insurance company computers for billing records, claims submitted, and a multitude of demographic information concerning your practice history. Outliers are easily identified. Computers are programmed to spot billing trends and changes such that a large deviation from a dental office’s usual billing practices will signal a red flag. For example, if a practice that traditionally codes extraction of teeth as simple extraction (D7210), now suddenly has an increase in claims filed with the procedure code of removal of tooth, soft tissue impaction (D77220), the trend will be noted by the computer. Overcoding of ­dental procedures may provide increased revenues, yet it can also elicit an audit by a dental insurance company, the defense of which may not be covered by your malpractice insurance. Computers have streamlined the process of the acquisition and purchasing of dental supplies. Ordering online from the company increases the ease of purchasing process for you and your staff. Yet it should come as no surprise that your order history is tracked by the Dental Supply Company. Consequently, online ordering of dental supplies results in countless practice demographics generated from your order history being evaluated. This information can be relayed back to the local sales representative to assist them in their marketing strategies. However, order tracking can also identify outliers. In one case, a sudden increase in the frequency of an office’s ordering of nitrous oxide tanks caused alarm and referral of that information to the state dental board for review. Conversely, the sudden drop in orders maybe an indication that an office is switching vendors or even ordering “gray market products.” Actions do not go unnoticed. It can be tempting to use gray-market products in an effort to reduce costs and help the bottom line. However, you may be spending dollars to save pennies and jeopardizing relationships with sales ­people whose assistance may be needed in the future.

Leadership Style and Tools for Success

No two people are alike and thus no two practices are alike. The tone of the p ­ ractice is set by the practice leader, the dentist. It is valuable to self-examine one’s leadership style. Are you a delegator? Are you hands on? Do you micromanage? Do you avoid confrontation? Do you like to be on the cutting edge of technology?

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How do you spend money? All of these attributes can be both strengths as well as ­weaknesses. Knowing your particular style of leadership is very important to ­business success as you can utilize your strengths and build on your weaknesses by surrounding yourself with staff that compliments your business style. The most valuable asset of any dental practice is not only the dentists’ skill in their “hands,” but also the dentists’ interaction with the patients. Dentistry differs from any other business in that our patients cannot “take back” treatment once it has been rendered. This concept of finality associated with the removal of diseased tooth structure and then the subsequent reconstruction of the site combined with the assumption that the dentist is, as a professional, an expert in these techniques lays the foundation for the dentist–patient relationship and serves as the driving force of dentistry as a business. The potential for deviation from this truth and ­standard is the basis of ethical decision making in the business of dentistry. Developing a business plan is crucial. A business plan identifies the goals of the practice and thus the vision and direction of the practice. The business plan should be specific enough such that goals and milestones can be set. In turn, using the business plan will allow you to make business decisions with purpose and not based on emotion. Recalling your business plan can help at the times when one’s moral fortitude is tested, giving perspective to a tough situation. Implement an office protocol. The office protocol should address all aspects of how you run your business, from hiring and performance evaluations to patient interactions. This need not be extensive, yet having a guideline that is applied to all will allow you and your team to make dispassionate decisions as well as to serve as a reference and benchmark when making those difficult moral and ethical decisions.

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Chapter

14

Ethics and Advertising Richard J. Simonsen, DDS, MS

Protect and defend your name above all else.

Chuck Schwartz, CEM Chairman, CONVEXX

Ethics and Advertising

On its face, advertising serves a useful purpose for consumers. It is beneficial because it provides information about individual businesses offering services that the public may wish to purchase. In any purchasing choice, decisions are made based upon the information that is available. The more information available to patients, for example, the better prepared they will be to make a decision on what is in reality a purchasing decision about their health. So why should they not have information about the training and skill level of the clinician they are considering to treat their vital body parts? Why should they not have as much information as possible about which treatment option they should choose and who will render that treatment? Certainly our legal system has recognized that advertising can play a large role in providing the information that patients may need to make an informed choice of treatment and treater. The problem of course comes when advertising becomes deceptive or unfair such that the consumer is faced with a false choice. This is where the ethics of advertising must be considered. Ever since the Federal Trade Commission (FTC) started to break down the selfimposed (by state boards of dentistry) restrictions on advertising by dentists, the role of advertising in the profession has been fraught with emotional and political charges and decisions. On the one side you have state boards of dentistry trying to protect the interests of their constituency, which is practicing dentists (state boards are generally made up largely of practicing dentists), and on the other side you have the FTC and the courts trying to make sure that the public is protected from the potential self-interested actions of some state boards, and some dentists who 119

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may choose to walk the fine line between ethical and ­unethical advertising. The promotion of competition is also a goal of advertising and of the FTC, while the profession of dentistry prides itself on collegiality rather than competition. Of course, one hopes that all parties are working with the best interests of the public and the consumer (patients) at heart, but that is not always the case, as we shall see. In a writing under the title of “Advertising: for good or evil,” Geoffrey Klempner wrote that there are 3 charges that can be leveled against advertisers:1 •  They sell us dreams, entice us into confusing dreams with reality. •  They pander to our desires for things that are bad for us. •  They manipulate us into wanting things that we do not really need. Are these the characteristics that we would wish to be associated with the noble profession of dentistry? I think the answer is very clearly, “No!” However, at the peak of the recent cosmetic revolution through the 1990s and 2000s, and even today, I think one could argue that some of those charges could have been leveled against a certain segment of our practicing community engaged in exaggeration and hyperbole in attempting to present themselves as experts (if not specialists) in the area of cosmetic dentistry (not a recognized specialty area of course). At the time, some in this segment of the profession put profits before health. It was a segment that saw self-interest being placed squarely before patients’ interests in many cases, which put short-term profit before long-term benefit. The fight over advertising was fought and lost by the opponents to advertising in the United States when the FTC ruled that dentists can advertise, provided the advertisement is not false or deceptive. State boards then tried to regulate advertising but found that the bar was placed quite low at “false or deceptive” and thus many dentists got away with advertisements at which most in the profession would cringe. Advertisements can be self-aggrandizing and unprofessional, yet legal. They lure in consumers by preying on their vanity and then manipulating them to want something that they do not need, and that in fact in many cases is harmful to their long-term oral health, and thus to their overall health and well-being. In the early days of dentistry, advertising had been a historical artifact of harmless self-promotion on business cards and free giveaways from the dental office imprinted with the name of the practice or the dentist. Then we went through a long period from essentially minimal advertising of practices to the point now where most dentists carry out some form of practice information delivery, for example on the World Wide Web, if not all-out advertising ranging from the professionally-endorsed to the tacky, and from the informational to the dishonest and/or self-promotional. Examples of Victorian era advertising trade cards (courtesy Dr. Theodore P. Croll, Doylestown, PA) can be seen in Figures 14.1 and 14.2. These cards are from circa 1885–1895 and depict some claims that would be called deceptive and unethical today. Claims such as “perfect crowning system” or “painless dentistry” could p ­ robably not stand up to scrutiny. Another card talks with apparent hope

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(false in many cases no doubt) of “painless extracting” while it gets closer to the truth with, “Decay removed and fillings inserted with the least pain possible.” Along with word of mouth, “tradesman’s cards” were the only way to advertise one’s services in seventeenth and eighteenth century England.2 Although dentists do not use trade cards any more, I  have seen advertisements for dentists that are of questionable ­professional standards in use today, such as on the back of grocery store receipts and on the sides of an advertising van that drives around town (I  have seen one in San Diego, CA) with moving screens that promote certain busiFigure 14.1 A typical Victorian Era dentistry trade card for a well known dental business (circa 1885). Claims of nesses, including densuperiority, “painless” extracting, and “perfect Crowning tal offices. Today, the most popular form of System” are highly suspect. advertising is surely a well-designed and well-managed Web site. Such a site, with truthful statements about the dentist and his/her team, with perhaps some educational materials available, can be a very positive advertisement for the dentist and the practice. However, it can also be misused as can be seen with a very quick look online where many Web sites for dentists can be seen that exaggerate a dentist’s credentials and are misleading and deceptive in an attempt to get the patient in the door. It seems that here there is a graying of the f­ormerly sharp line between a profession and a trade, at least in terms of a ­ dvertising standards.

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The core of ethical advertising for the dental professional surrounds three issues, the first of which is the issue of trust. Trust is the most fundamental building block of a practice and of the relationship between a dentist and his/ her patients. Without trust, an adversarial relationship, such as seen during the purchase of an automobile for example, is set up and there can rarely be a satisfactory outcome of the relationship as each side tries to gain an advantage over the other. There is a complete lack of trust on both sides of this arrangement; both sides being fully aware that the self-interests of both sides are in opposition to each other. The buyer wants the best possible car for the lowest possible price. While the seller, particularly in the case of a used (or “previously owned” as the new term has it) car, is trying to sell the Figure 14.2 This 1880s card claimed TAFT’S vehicle for more than it is worth. DENTAL ROOMS to be the “finest” office in the It is trust that leads to the dentist state of New York, and the crowns and bridges being able to complete the best “THE BEST MADE/THERE ARE NO BETTER.” treatment plan for the patient, Again, maybe, maybe not, but they are ethically who, in turn, is happy to receive questionable claims for a healthcare practice. such treatment trusting that it has been delivered with his best ­interests (the patient’s) in mind. But the adversarial relationship is also entering the dental practice as office managers and staff are encouraged to “sell” additional treatments to the patient, or the patient tries to bargain for additional services to be included. This is the inevitable outcome of additional advertising (for example, “free teeth whitening with examination”) and it has been going on since the early trade cards (“No charge for extracting when teeth are ordered,” Figure 14.1). It is unfortunate that it appears the trust factor is decreasing in the dentist–patient relationship today. It can only lead to an erosion of the autonomy of the profession over time. After trust comes the the wish to refrain from making claims that could mislead patients. As we shall see, this is an extremely problematic area in dental advertising today. We see many examples where the intent seems to be to mislead the patient (deceptive advertising) into believing that Dr. X is better than any other dentist, at a

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particular procedure or in a particular community. This gets into a grey area where the FTC would probably say it is acceptable to say one is good, but not acceptable to draw comparisons to colleagues, like claiming to be the best for example, as it is almost impossible to prove. From a professional standard, any attempt to claim superiority is fraught with collegial issues and is certainly unprofessional if not illegal or unethical. The third core component for advertising is to stay within one’s area of professional competence and abilities and not stray into claims of inference for being a specialist if one is not so qualified. Unfortunately, in the rush to follow business principles that really should not relate to a health care profession, many colleagues stray over the ethical boundary in this area. For example, taking a weekend course in implants does not qualify a dentist to call himself a “qualified implantologist” or even just an “implantologist” when no such specialty exists. The ethical boundary lies at leaving the inference with the unsuspecting public that Dr. X is a “specialist.” The public does not know the accredited specialty areas and it is easy to deceive by exaggeration. Calling one’s practice “[Your town’s name] Dental Implants Specialists” or “Specialists Implant Center,” especially when there is no implant specialty and the dentists involved are not, therefore, implant specialists as the name of the practice implies, is deceptive and is inappropriate, if not illegal. It may be technically correct if the owners of ‘Specialists Implant Center’ are, say, periodontists, but the right or wrong of this issue should be determined by how the average member of the public would interpret the meaning behind the name. A statement can be legal, but unethical. The key to interpreting such names is to ask the following question: Is a member of the public likely to be misled into thinking that the dentist in question is a specialist in the area advertised? If so, the advertisement in the form of the practice name is unethical. The onus is on the dentist to truthfully and honestly present his or her skills and qualifications in a forthright manner and no matter how tempting, to not even hint at any sort of claim that may put one in shaky territory. Subjective claims concerning the quality of the services provided, or the relative quality of the treatment provided, should be avoided. For example, there are many practices that try to set themselves apart by calling the practice, for example, “Advanced Dentistry.” One has only to enter a Google search under “advanced dentistry” to find general practitioners who call themselves the “best cosmetic dentists.” How do we know that they are the best? And what is your colleague down the road, also a general dentist, going to call her practice? Super-Advanced Dentistry? Where does it stop? Although it may be true that the level and quality of care provided in this office is of a higher standard, how can that be proved without evidence? The American College of Dentistry in its Policy on Advertising notes in a list of points defining deceptive advertising that an advertisement is deceptive if it: contain[s] a representation or implication regarding the quality of dental services which would suggest unique or general superiority to other practitioners which are not susceptible to reasonable-verification by the public.3

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The ADA Principles of Ethics and Code of Professional Conduct4 make it quite clear in the section on Veracity (truthfulness) where it states: In order to properly serve the public, dentists should represent themselves in a manner that contributes to the esteem of the profession. Dentists should not misrepresent their training and competence in any way that would be false or misleading in any material respect.

The ADA Code goes on to state: Although any dentist may advertise, no dentist shall advertise or solicit patients in any form of communication in a manner that is false or misleading in any material respect.

The use of unearned or non-health degrees is an area where dentists sometimes stray into using letters after their name that could potentially mislead the public. Dentists may use the title doctor or dentist or either of the commonly awarded degrees, DDS, DMD (but not doctor and the doctoral degree together, as that would be redundant) plus any advanced degree such as MS or PhD, provided the degree in question is awarded in a health service area. Thus MD is acceptable, but MA would only be acceptable if dentally or medically related and not if it is in English or some area unrelated to health care. Similarly, one could use a PhD in oral biology, but not if it was awarded in theology. The reasons are obvious in terms of the potential for misleading the public into thinking the individual has advanced training leading to some kind of specialty or advanced status in dentistry. The use of a nonhealth degree in an announcement to the public may be a representation which is misleading because the public is likely to assume that any degree announced is related to the qualifications of the dentist as a practitioner.4

Of course it goes without saying that one must only professionally utilize legitimate degrees awarded in health care in a health care business. Obviously, using degrees from diploma mills is worse than using degrees properly earned, but in a non-health field. Some years ago, a regular contributor to the Journal of the American Dental Association listed a master’s degree after his dental degree every month after the author’s name on the title page. This MBA degree suddenly disappeared when the degree’s legitimacy was questioned. It had been granted by a southern state diploma mill and was used simply to bolster the author’s ego and qualifications. Advertisements have also appeared in the dental press, even in the ADA News,5 showing an individual using what would appear to the public to be an advanced degree. When a member of the public sees, DDS, LVIM after a dentist’s name, it would naturally be assumed that LVIM is a degree on a par with DDS or MS, or, because order usually designates order of achievement and thus rank of degree, a more advanced degree. But what is LVIM? In my opinion, it is four letters designed to confuse and mislead the public into thinking a holder of this designation is a better dentist than one without the designation. Yet one has to really dig on the

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internet to find out what “degree” this is. It turns out to be some sort of certification in “aesthetic neuromuscular fellowship” given out by an institute and primarily to its own teachers (called “faculty,” a term generally used for university professors). When individuals lacking advanced specialty training or master’s degrees or the PhD degree wish to separate themselves from the pack, they should not do it with self-awarded letters from an unaccredited institute. This is exactly the sort of example the ADA Principles of Ethics and Code of Professional Conduct is referring to when discussing the inappropriate use of unaccredited and unearned degrees and how the public can be misled and confused by the use of this deception. A dentist may use the title Doctor or Dentist, DDS, DMD or any additional earned, advanced academic degrees in health service areas in an announcement to the public. The announcement of an unearned academic degree may be misleading because of the likelihood that it will indicate to the public the attainment of specialty or diplomate status… an unearned academic degree is one which is awarded by an educational institution not accredited by a generally recognized accrediting body or is an honorary degree.4

Similarly, fellowships that are based in association should be used most carefully and state dental practice acts or state laws may vary in different areas of the country. In general, a fellowship that involves attainment rather than simply association can be used more frequently than the other. Of course it is open to interpretation as some would argue that fellowship of association infers attainment to a certain degree. Although that may be true, one risks getting on shaky ground by highlighting to the public fellowships, even though gained with some sort of unaccredited “board” examination. Such fellowships may be used in one’s curriculum vitae, or mentioned in a published paper, provided its usage falls within the editorial policies of the ­journal. Some organizations grant dentists fellowship status as a token of membership in the organization or some other form of voluntary association. The use of such fellowships in advertising to the general public may be misleading because of the likelihood that it will indicate to the public attainment of education or skill in the field of dentistry.4

The American College of Dentists (ACD), a highly respected fellowship organization in dentistry, has been at the forefront of promoting ethical standards in the profession, and the organization takes a firm stand on ethical standards. The college’s position on advertising is straightforward as follows: While recognizing that advertising is legal, the ACD “does not encourage or support advertising by dentists and feels that any form of advertising by dentists is demeaning to the profession, is not in the best interests of the profession, and is not in keeping with its perception of professionalism.”6 The college does however recognize that advertising, “when properly done, … may help people to better understand the dental care available to them and how to obtain that care.”5 The ACD recognizes that advertising by dentists should be designed to increase public confidence in the profession and the individual

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­ ractitioner and should not be misleading or false in any way. In particular, advertisp ing should avoid creating any false expectations for a favorable treatment outcome and should not be designed primarily to appeal to a lay person’s fears.5 The American Dental Association Principles of Ethics and Code of Professional Conduct discusses 5 principles of a dentist’s duties.4 •  The first is the principle of patient autonomy. Here the dentist has a duty to respect the patient’s rights to self-determination and confidentiality. This duty has emerged from the days when the health care professionals, including dentists, often exhibited a paternalistic attitude toward patients. When discussing treatment, it was always that “the dentist knows best” and patients often felt unable or unwilling to question the dentist about treatment. Patients generally just accepted what the dentist chose to do for treatment. The situation today is very different with patients who are much more educated about treatment (many have researched much of the information online) and they expect, and in most cases receive, the options to choose the treatment of their choice as laid out by the dentist in an open and honest discussion of informed consent. There are, however, clear examples in the published literature, primarily found in the nonpeer-reviewed, free publications, of case presentations that I would describe as “induced consent” rather than informed consent. By induced consent, I mean that it is just not feasible that the operator has been honest in the discussion of patient options as the treatment “chosen” is clearly what the dentist wanted generally for economic reasons, or for reasons of area of expertise, rather than what a well-informed patient, of even simple intelligence, would have chosen. Guiding the patients “choice” to what the dentist wants, for whatever reason other than a genuine concern for what is in the best long-term interests of the patient, is in violation of the first principle of patient autonomy. As Ozar and Sokol put it so well, “A dentist can make his/her explanation of alternative treatment options persuasive in any direction he/she chooses.”7 •  The second principle is of nonmaleficence, to do no harm. The dentist has a clear duty to heal, not harm, the patient. In this principle, there is a clear duty to recognize the scope of one’s expertise and to refer the patient, or to seek advice if outside one’s area of expertise, to guard the welfare of the patient. As in the first principle of patient autonomy, if a patient is denied appropriate informed consent in, say, an elective cosmetic procedure, and significant tooth structure removal has taken place in an effort to improve the patient’s “smile” rather than some other less-invasive procedure, the patient can be harmed, particularly for the long term. As Bader and Shugars put it so well, “An implicit, if not explicit, assumption covering any treatment is that the benefits of the treatment will, or at least are likely to, outweigh any negative consequences of the treatment … in short, that treatment is better than no treatment.”8 •  The third principle is one of beneficence, to do “good.” Professionals have a duty to act for the benefit of others. All three of the principles discussed so far are of course closely interconnected. One should always ask oneself as a treating dentist, will the patient be better after treatment than if nothing had been

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done? One can appear to be doing “good” in obtaining a short-term appearance benefit to an elective cosmetic treatment, but if the result is significant reduction of tooth structure that results later in the need for endodontic care and/or extensive restorative treatment, the patient has not been well served. Again, the nonpeer-reviewed magazines are replete with examples of the violation of the principle of beneficence. The British author Martin Kelleher has written eloquently about this serious problem from the European perspective.9 He, tongue-in-cheek, invented the terminology “hyperenamelosis” to describe the imaginary condition of a patient with too much enamel (to justify the gross overremoval of enamel seen in many “cosmetic” treatments today) and the term “porcelain deficiency disease” to describe again the imaginary patient who may be deficient in porcelain and thus requires the brutal removal of natural enamel so that it can be replaced with porcelain. •  The fourth principle is justice or “fairness.” Professionals have the duty to be fair in their discussions and actions with patients. While this is self-explanatory, if the dentist does not put the patient’s self-interest first, he is not fulfilling this obligation. This principle is most frequently violated in the form of advertising and treatment planning where the dentist’s willingness to push ethical boundaries of propriety can lead to advertisements that are designed for short-term profit rather than for the patient’s best interests of long-term health. •  The fifth and final principle is one of veracity or “truthfulness.” This principle strikes right at the heart of the ethics of advertising as it demands that the dentist be honest and trustworthy and thus not advertise, for example, in a false or misleading manner. Violations can be found online on dentists’ Web sites of this principle. In the most common examples I have seen, dentists have tried to justify unproven “science” such as that of neuromuscular dentistry or argued against the use of amalgam for restorative dentistry, in an effort to persuade patients to have all their old alloy restorations replaced. Such statements are in direct violation of the ADA position statement on the use of dental amalgam. These 5 principles are all intertwined or overlapped to some degree and make up a code that dentists practicing ethical dentistry and ethical advertising must follow. Advertising in dentistry has its positive and negative sides. On the positive side, dentists can get their message out and patients can benefit from the extra information concerning the dentist’s education, training, and interests. On the negative side, advertisements can make the profession look like a trade by advertising in a nonprofessional manner. False, misleading, or overtly deceptive advertising becomes a stain not only on the individual dentist but on everyone in the profession. Advertising in the dental profession should be professional, honest, informational, and accurate so as to convey the sense of a profession communicating its goals of service to the public. Anything else chips away the unwritten laws of trust and autonomy that the profession has gained on the backs of the generations of colleagues who went before us and built dentistry into the trusted and respected profession as we know it today.

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References 1.  http://klempner.freeshell.org/articles/advertising.html. Accessed January 11, 2013. 2.  Croll TP, Swanson BZ. Victorian era esthetic and restorative dentistry: An advertising trade card gallery. J Esthet Rest Dent. 2006; 18:235–255. 3.  ACD Policy on Advertising. http://acd.org/policy1.htm. Accessed January 11, 2013. 4.  ADA Principles of Ethics and Professional Conduct. http://www.ada.org/194.aspx. Accessed January 11, 2013. 5.  ADA News. September 20, 2004. 6.  American College of Dentists, Policy and Guidelines, Code of Conduct. http://www. acd.org/policy1.htm. Accessed January 11, 2013. 7.  Ozar DT, Sokol DJ. Dental Ethics at Chairside: Professional Principles and Practical Applications. 2nd ed. Washington, DC: Georgetown University Press; 2007. 8.  Bader JD, Shugars DA. Variation, treatment outcomes and practice guidelines in dental practice. J Dent Educ. 1995; 59(1):61–65. 9.  Kelleher, MGD. The “daughter” test in aesthetic (esthetic) or cosmetic dentistry. Dent Update. Jan/Feb 2010; 37(1):5–11.

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Chapter

Informed Consent

15

James Q. Swift, DDS

People will forget what you said to them, but they will always remember how you made them feel.

Nelson Mandella In order for people to undergo treatment to optimize oral health, they must present to oral health care providers. By doing so, the dental patient places confidence and trust in the individual who is willing to offer and provide his or her knowledge, skills, and experience to do so. A great privilege extended to dentists, dental hygienists, dental assistants, and dental therapists is that the patient surrenders self and puts self in a vulnerable position as they submit to oral health care treatment. Think about it. The dental patient endures fear and anxiety due to anticipated discomfort, many times unjustly associated with a visit to the dentist. The dental patients allow the provider to ask pertinent questions about their health, habits, family, and relationships. They recline in a dental chair, allow the dentist to place hands on their head and neck, and open their mouths and by doing so limit their ability to communicate. They allow the dentist to place sharp objects in their mouths, insert needles into very highly sensory enervated body parts, administer local anesthesia that takes away the stimulus generated by the procedure to be provided, and then succumb surgical manipulation of oral hard and soft tissues. They anticipate that once the local anesthesia is metabolized and sensation returns, they may suffer residual pain and discomfort, which is expected for many dental procedures. They may have facial edema and ecchymosis, which is difficult to hide from public scrutiny. They may have alterations in their speech and inability to have normal oral function for a brief or perhaps extended time. It is an extreme example of trust and faith.

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It is the responsibility of the oral health care provider to inform patients of their health and disease and to describe the options that exist for that disease to be treated. Because dental patients place trust and faith in their dentist, they expect that the dentist will be honest, fair, and ethical and make decisions in the best interest of the patients and not in the best interest of themselves. But it can be difficult, if not impossible, for the dental patients to determine that is the case. Many dental disease processes do not have definitive symptoms. Inflammatory disease associated with oral microflora infections in many situations creates minimal pain or discomfort, yet the disease progresses. Many men and women have ­sustained significant periodontal disease to the point significant loss of periodontal support, tooth mobility, and finally tooth loss without significant pain, discomfort, or awareness that the disease was present. Dental caries can create significant loss of enamel and dentin before there is pain as the process progresses toward the dental pulp. Partially erupted impacted third molars can contribute to periodontal support loss on the distal aspect of second molars without ever sustaining a clinical case of pericoronitis. Jaw cyst and tumors can develop in the maxilla or mandible without any tumescence, thereby making the dental patient oblivious to its presence. It is not uncommon that many men and women are surprised when extensive and ­comprehensive treatment plan is offered in the absence of any symptomatology. Oral health care procedures are routinely rendered after administration of some type of local anesthesia with implementation of additional techniques of pain and anxiety control. This may include minimal or moderate sedation techniques or in some situations general anesthesia. The oral health care patients may be unaware of the complexity or severity of procedures being performed. They cannot see what is being done due to anatomic location. They cannot feel what is being done when they are anesthetized. Outcomes of appropriate and effective dental treatment may not be fully appreciated, as the dental patient cannot determine whether a dental surgical ­treatment procedure is acceptable or unacceptable. Dental restorations are miniscule and placed in areas that are difficult if not impossible to visualize. There are many dental patients who submit to treatment and accept the word of the dentist who informs them that the treatment they received was acceptable and in concert with the accepted standard of care. If the dental patients are without any symptoms, especially pain, they may perceive that the care rendered was acceptable or even exceptional. Often however, the absence of pain may not indicate that successful or acceptable treatment was rendered. The onus of providing informed consent becomes even more demanding due to these facts associated with providing dental care and maintaining dental health. The dental patient must place complete trust and confidence in the oral health care provider to be honest and ethical. In the health care environment, the ­expectation of ethical behavior is elevated beyond that in other professions or situations, because a dental patient surrenders himself or herself to the provider and is subjected to the

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care provided without having knowledge as to whether the procedure is performed effectively or correctly. Informed consent mandates that the patient is responsible for decision making regarding dental treatment. There are always at least two options from which the patient can select. They include the dentist’s recommended treatment and no treatment. Both options have risks and potential benefits. The dentist has an inherent responsibility to make sure that his or her patient has been given all of the pertinent information necessary or requested so that the dental patient can make the ­decision as to how to proceed. When presenting treatment options to patients, the dentist should not be “selling dentistry.” It is important to provide information regarding the benefits of dental care. The idea that the dentist should convince the patient to undergo care only then compensation will be gained is unethical. The informed consent process, if properly conducted, limits such unethical behavior. Because oral health care providers are trained to provide a broad range of ­procedures and treatments and are not dependent on other providers to deliver comprehensive care for the dental patient, the informed consent process is controlled and rendered individually. The responsibility rests almost entirely with the person who will be performing the procedures.

Elements of Informed Consent

There must be a doctor–patient relationship. The dental patient gives the doctor or oral health care provider implied consent by presenting to the dental office, requesting care, completing demographic and medical history paperwork, and then submitting themselves for a clinical examination. Once the examination is conducted and disease is diagnosed, it is the responsibility of the oral health care provider to formulate a treatment plan that is comprehensive and properly sequenced to address the most significant or important treatment needs to benefit the overall general health and specifically the dental health of the patient. The treatment plan must address the most serious pathology first. Any condition or disease that may be progressive to cause a greater harm if left undiagnosed or unmanaged must be given priority consideration, regardless of the desires of the patient or the oral health care provider. For example, a patient may present with dental neglect, poor oral hygiene, and advanced periodontal disease resulting in tooth mobility, inflammation, and chronic infection, which may not be symptomatic. The reason for the visit may be to consider options for smile beautification with veneers or tooth whitening, without concerns regarding the more insidious indolent periodontal disease. The oral health care provider has a duty to direct the patient toward care that will result in the control or elimination of the disease that is threatening the overall well-being of the patient.

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After the development and implementation of a definitive treatment plan, the comprehensive restoration to optimum oral health begins. Because oral health care is generally procedure based, it is the obligation of the oral health care provider to explain to the patient the procedures involved and the elements of informed ­consent are mandatory. First, the oral health care provider must explain the planned procedures in sequence. With significant or advanced disease, it is unlikely that the average oral health care patient would be able to comprehend all of the features of informed consent. An overall acceptance of the treatment plan should be obtained before initiating care. In some dental practices, this may be a case presentation to the patient with a listing of the anticipated procedures, the sequencing of the care, anticipated timing of the rendering of care, and last but not least, the expected cost of care. It is also important to relate to the patient that the plan may change at any time due to a change in the dental disease, overall changes in health, success or failure of procedures, and other factors. It is impossible to predict outcomes 100% of the time. As the procedures are scheduled, the specifics of informed consent for the ­upcoming procedure should be explained. Those specific include the following: •  diagnosis and procedure •  potential complications •  special situations •  situation that may put the patient at increased risk for a complication when compared to the “average” patient •  expected postoperative course •  alternative procedures, the cost of those procedures, and potential success or failure compared to the recommended procedure •  expectations if no treatment is rendered

Diagnosis and Procedure

It is the responsibility of the oral health care provider to make the diagnosis and determine the procedure that is most likely to treat the disease and the patient. The terminology used must be understandable to the patient. The specifics of the procedures including duration, discomfort, appearance, function, and recovery must also be explained. If the dental patient has been referred to another provider for consultation, the subsequent provider is responsible to establish diagnosis and project procedure independent of the referring provider’s diagnosis and treatment plan. It is frequent that there is agreement between the referring oral health care provider and the subsequent provider, but there is no obligation on the part of the subsequent provider to agree with the previously established diagnosis and ­treatment plan.

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Potential Complications

Frequency and severity of potential complications must be considered as the oral health care provider provides the listing of complications, as frequent ­complication may be expected by the patient or a particularly serious complication requiring significant ancillary care and procedure may result in the patient declining the offered treatment. For example, alveolar osteitis or dry socket is a frequent postoperative occurrence after third molar removal. Although uncomfortable if it does occur and many times the treatment of dry socket requires additional visits to the oral health care provider, long-term disability is unlikely. Persistent paresthesia of the lingual nerve after third molar removal resulting in partial to complete “numbness” of the involved side is very infrequent; however, it is generally more disabling to the patient and therefore may be of more concern to the patient when he or she is selecting the treatment plan.

Special Situations

Some patients have clinical situations or diseases that will put them at greater risk than the average patient. For example, surgical removal of a large third molar with the apices of the teeth touching the inferior border of the mandible may be more often associated with iatrogenic mandible fracture or inferior alveolar nerve paresthesia. One may expect that the risk of dental implant failure is higher with patient who smokes cigarettes. The oral health care provider has an obligation to determine potential adverse situations and potential outcomes and inform the patient during the informed consent discussions.

Expected Postoperative Course

Many dental surgeries are associated with postoperative challenges in some situations that are fully expected to occur and of which the patient must be informed. For example, tooth extractions may be associated with facial and cervical edema, ecchymosis, trismus, and other temporary short-term disabilities with varying and generally unpredictable duration. There is an obligation to inform the patient that these expectations may interfere with the responsibilities with their employment or being in the public eye.

Alternative Procedures, Cost of Those Procedures, and Potential Success or Failure Compared to the Recommended Procedure

There are many acceptable alternative treatments provided by oral health care providers. Patients may make treatment decisions based upon cost, insurance coverage, expected disability, appearance, convenience, and relative importance to o ­ verall

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well-being. It is the ethical obligation of the oral health care provider to present these alternatives, even though he or she may not be able to provide them. For example, a patient may present to the dental practice missing a mandibular second premolar. The periodontal health of the remaining full dentition is acceptable. There is no evidence of dental caries, other oral and maxillofacial pathology, or other dental treatment needs. Oral hygiene is acceptable and periodontal health is present. The patient wishes to have the missing tooth replaced. The adjacent mandibular first premolar and mandibular molar are healthy and unrestored with acceptable periodontal health. Treatment options may be no treatment, a removable partial denture, a fixed partial denture or dental bridge utilizing the first premolar and the molar as full covered abutments, or a dental implant in the site of missing the missing tooth. However, dental implant therapy is not rendered by the dental practice. The oral health care provider still has the responsibility to be aware of contemporary dental procedures and to list the potential treatments, even if the treatment that the patient selects is not a treatment that he or she is able to provide. The oral health care provider also has the responsibility to fairly and objectively make treatment suggestions and recommendations, even if it requires that the potential dental procedure patient must be sent to a colleague or competitor to have the treatment provided. Many oral health care patients select treatment on the basis of what they may be able to afford or they may select treatment that is covered by dental insurance or a dental benefits plan. If there is no dental insurance or the insurance has specific or limited benefits (for example, dental implant treatment is a policy exclusion), the patient may choose not to proceed with the treatment or he or she may decide to use discretionary income to pursue the treatment they desire. The oral health care provider must provide a cost estimate as a part of informed consent as cost drives decision making. The cost of the dental care may be weighed with the desired care, recommended treatment plan, the oral health care provider’s recommendation, the time needed for care to be provided, and other factors. Various dental treatment procedures have varying rates of success and failure. Evidence-based procedure and outcomes must be a component of informed consent. However, many treatments and procedures in both medicine and dentistry do not have substantial or acceptable published evidence basis. The absence of evidence basis however is not a reason to deny dental care or a dental p ­ rocedure. Experience and generally accepted community standards at the time treatment is rendered can be used as a basis for decisions made in the formulation of ­treatment plans or sequences.

Expectations if No Treatment Is Rendered/Informed Refusal

The oral health care provider also has a responsibility to inform the patient that no treatment procedure may be an option in making decisions regarding oral health  care. The provider is obligated to disclose the risks and benefits of no

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t­ reatment. In many situations, it is difficult to be accurate as the provider is asked to predict the progress of disease, which is impacted by many factors. These factors include the patient’s overall general health, his or her interest in being involved with their health, compliance with recommended oral health measures, the impact of other comorbidities that may effect oral health, the severity and prevalence of her or his oral disease, the patient’s financial ability to pay for oral health care, and other factors. The impact of no treatment must clearly be explained and delineated on the chart. If the patient elects no treatment, the provider must explain the impact and consequences of that decision, especially in the presence of progressive disease. In some situations, informed refusal of care or election of no treatment may be documented by asking the patient to sign a document testifying that they refuse to be treated as recommended for their overall benefit by the oral health care provider. Signed informed refusal may be difficult to obtain if the patient has elected not to be treated as per the oral health care providers recommendation; there may be no reason to continue the doctor–patient relationship. Also, the refusal to accept the treatment recommendations may be viewed as a lack of confidence in the oral health care provider who delineated the treatment plan.

New Developments in Oral Health Care

As new techniques and procedures are developed and new innovations, ­equipment, medications, and devices become available, the oral health care provider has a responsibility to become familiar with such discoveries. The provider is obligated to evaluate any scientific papers or articles that are available regarding the new technology. Many times, various vendors or product representatives extol the virtues of their product to enhance sales. The vendors have the obligation to be truthful regarding their wares. But it is the oral health care provider who must have the final decision as to whether he or she will employ the technique or product to provide the care to the patient. This is a responsibility of informed consent. There has to be a first time that any oral health care provider executes a procedure or utilizes a device or product. The dental patient is entitled to be informed that this is the case. If the patient refuses the treatment because it is the first time but indicates that they would like to proceed with the treatment recommended, the oral health care provider should refer the patient to the provider who has experience with the material or technique.

Infrequently Performed Procedures Demanding Significant Clinical Expertise

The same is true regarding procedures that are infrequently performed but may require significant expertise to execute. If there is a provider who performs a procedure demanding significant skill on a frequent basis and obtains an appropriate successful outcome, the oral health care provider is obligated to inform the oral

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health care patient that this situation exists and that successful outcomes may be more frequent or likely because of the frequency at which it is executed by another provider. Many patients will accept treatment from a provider who is not performing a certain procedure with regular frequency on the basis of geography and an unwillingness to travel for care, or perhaps because he or she is favorable to a particular doctor’s “bedside manner,” or because of familiarity. It is the obligation of the oral health care provider to assure that the patient is aware of this situation for appropriate informed consent. If the patient elects to proceed and the provider agrees to perform the procedure, the decision has been made with appropriate informed consent.

Informed Consent for Minors/Individuals Unable to Make Own Health Care Decisions

Any dental patient consenting to treatment must be of legal age of majority or 18 years old. Any minors presenting for oral health care cannot have irreversible dental treatment procedures without informed consent given by their parent and/or legal guardian. The same is true for adults who are of legal age but unable to make their own health care decisions. Evidence of informed consent discussions with the appropriate individuals must be documented in the dental chart.

Conclusions

Most dental licensing boards and state agencies mandate informed consent. ­Evidence of informed consent must exist in the dental chart of the patient receiving oral health care. In some situations, written informed consent is desirable as there is objective evidence that an informed consent process took place. Dental patients are entitled to self-determination of their overall oral health.

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Chapter

16

The Itinerant Practice in Dentistry

It’s not what you say, it’s what they hear Frank Luntz, PhD

Roger P. Byrne, DDS, MS, MD

Introduction

The purpose of this chapter is to introduce and discuss the ethics associated with itinerancy in dentistry. Members of the profession questioned on this topic would most likely focus on a specialist performing care in a generalist office. While this method of care is not uncommon, another model of care delivery seems to have an increasing incidence. This involves a practitioner who performs dental services, and for whatever reason, elects to work for remuneration without a motivation to achieve ownership in a practice.

Principles of Ethics and Code of Professional Conduct As dentistry moved up the evolutionary trail from a trade to a profession, emphasis on higher education, state licensure, defined standards of care, and ethics were promoted by both the public and members of the profession. In effect, the public expected a “professional” to have the patient’s best interest considered while peer associations were formed to address ethical standards of care and continuing education in the practice of dentistry. To be a member of a professional association (e.g., American Dental Association), one is required to acknowledge and abide by that associations Principles of Ethics and Code of Professional Conduct. A failure to do so may result in minor to serious punishment by the association (e.g., letter of counsel or expulsion from membership). When an association issues a serious punishment

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to a member, they are required to send the information to the National Practitioner Databank, which may impact state licensure, purchase of liability insurance, or membership in other peer associations. Note: The practice of dentistry in each State is governed by a Dental Practice Act Statute which is regulated by an agency of the state (e.g., state board of dental examiners), which enhances the statute by codifying rules and regulations. This is the legal aspect for the practice of dentistry in a state. The ethical standards of practice are developed by the dental profession itself and are administered by the association in which a dentist is a member. Therefore, all violations of a dental practice act and associated rules and regulations of a state are not only illegal, but are unethical acts as well, but the reverse is not true in that not all unethical acts are illegal.

Definition and History of Itinerant Healthcare The term itself refers to one who travels from place to place to perform his or her work. In the earliest healthcare, the provider would travel from location to location because of a deficiency of providers in underserved areas. As provider volume and competition increased, fewer generalists found the need to travel and thus settled in one community. As medical specialization increased, some (e.g., surgeons) would travel to perform surgery and then leave follow-up care to the general practitioner in the area. This trend caused the American College of Surgeons to address the itinerant practice of surgery in 1974, with revisions in 1997. Arguments to benefit patient care promoted the premise that the most qualified and best trained practitioner in a specialty area should not delegate certain care to a lesser trained practitioner. This core principle of ethics survives today. Note: While there are associations under the umbrella of dentistry that have addressed the “itinerant practice” of its members, The Principles of Ethics and Code of Professional Conduct of the American Dental Association does not specifically address the term.

Itinerant Practice for the Dental Specialist History

The proven treatment delivery model for specialty care in dentistry today remains the same as it has been for decades. Upon completion of residency training, graduates commonly enter an existing practice as associates, with the future plan of a buy-in or buy-out or they open their own office in a chosen community. Historically, as relationships were developed with referral practitioners, patients were sent to the specialist’s office for care. On occasion the specialist may travel to an underserved area, but the majority of his productive time was spent in his/her own facility. Advantages to both the practitioner and patient would be: 1) an office specifically designed and utilized daily to meet practice requirements 2) availability of special equipment 3) a staff with very specific training in the limited procedures of the practice and 4) post treatment care rendered by the specialist. Patient disadvantages may include travel to an unfamiliar office location that may be farther from their home.

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Itinerancy As competition and costs increased in the general dental practice, business consultants began promoting that delivery of certain specialty care could be performed in the generalist office rather than a referral to the specialist office to increase income. Because “fee-splitting” or “referral fees” are illegal, the specialist would ideally pay a “rent” to the generalist for the use of their office space or have the generalist provide other services such as fee collection. The obvious advantages are: 1) the general dentist has an increase in income by keeping some portion of the fee inhouse 2) the patient is able to be treated in a familiar facility and 3) the specialist makes a portion of a fee rather than a total loss and does not have to offer routine post treatment care. The disadvantages are: 1) the generalist may have increased liability for licensure and/or medical malpractice 2) the specialist has to work in a non-­specialized facility, has to transport specialty equipment or utilize non-specialty equipment, has to transport staff from his/her office or utilize possibly non-trained staff and 3) the patients deserve the optimum care of a well designed facility, specialty equipment, trained staff, and post treatment care by a specialist but experience a “compromise.” It should also be noted the federal drug enforcement agency (DEA) requires a provider who administers medication have a separate DEA license for each facility in which this is performed (e.g., intravenous sedation).

Examples of Unethical Decisions by the Itinerant Specialist 1.  T  he specialist completes residency and goes to a community of interest with the intent of not owning a practice. Instead, she or he develops 50–100 referral offices that allow the specialist to render care in their practice. The specialist’s remuneration consists of 50% of the fee billed by the general dentist. The dentist selects the patients, does a diagnosis, does a patient evaluation including the physical status and clearance for general anesthesia or sedation, recommends care, does the treatment consent, bills for the procedure(s) under the name of the generalist practice, and renders all post treatment care. 2.  The specialist completes residency and goes to a community of interest with the intent of owing a practice. However, after years of practice the specialist sees a declining patient base and a relative increase in office overhead. To supplement income, the specialist develops several general dental offices in neighboring communities, which will provide the similar services as described in example 1 above and allow the specialist to simply come in to perform services. The specialist shows up to perform a procedure under anesthesia without having seen the patient before and fails to perform a current health history or limited physical evaluation. During the procedure, the patient has a cardiac arrest and dies. 3.  The specialist completes residency and goes to a community of interest with the intent of owing a practice. However, the practice is slow to meet his or her income needs, so the specialist finds a large dental clinic approximately 100 miles from the specialist’s primary office that is willing to allow the s­ pecialist

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to perform procedures for remuneration in the clinic two days per month. After a dental procedure and after the specialist had returned home, a ­patient emergency develops. The patient contacts the dental clinic for care but the generalist was unable to appropriately treat the patient who ultimately ­required hospitalization and emergency surgery.

Discussion

1.  A  s a student, are the failures of the itinerant generalists and specialists in the above examples easy to identify? 2.  I s the specialist who has no interest in practice ownership more or less likely to have a deep concern about ethical practice and performing to the accepted standards of care? 3.  Is it important for both parties to understand the legal and ethical standards for an itinerant arrangement? 4.  A  s a student, do you feel the generalist can be held liable for the care rendered by a specialist with an itinerant agreement?

Appropriate Standards for Itinerant Specialists Itinerancy, in and of itself, is not the unethical practice of dentistry, but is dependent on published standards. For example, in 2012, the American Association of Oral and Maxillofacial Surgeons modified and adopted new ethical standards for itinerant surgery. These standards include the following principles: 1.  D  iscourage membership from making itinerant surgery a major part of their practice. 2.  Encourage the patient to meet the surgeon before the procedure. 3.  P  rovide the patient with the surgeon’s name, office address, 24 hour telephone number, and state license number. 4.  T  he surgeon shall perform a patient assessment consisting of a medical history and limited physical examination, a recorded physical status classification, and a diagnosis justifying surgical care. 5.  T  he surgeon shall only perform surgery in a suitably equipped facility meeting the same standards as required for their primary office as noted in the AAOMS Office Evaluation Manual and the state laws regulating office anesthesia. 6.  T  he surgeon shall provide an affidavit certifying the criteria in #5 are met in each location where itinerant surgery is performed. 7.  T  he surgeon shall not perform surgery in an unsuitably staffed facility. They shall abide by state law and utilize a minimum of two operating room assistants in sedation/anesthesia cases.

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8.  T  he surgeon cannot delegate post-operative care to any person not of similar training and qualification trained to recognize, treat, and manage surgical complications including the right to hospital admission. This section hopefully provides the student with a thought provoking look at the itinerant practice of dentistry by a specialist and the current standards that are available.

Itinerant Practice in General Dentistry History

For generations, dentistry was perceived as a “cottage industry” where a dentist would have full ownership as a solo practitioner until they retired and sold the practice to a new graduate. As more dentists entered the workforce, associateships, partnerships, and group practices flourished with the majority of dentists still seeking a position of ownership in the practice. However, more recent events in the marketplace, as noted below, have altered this traditional path and some graduates are choosing to seek itinerant or “non-ownership” employment. For the purpose of this section, non-ownership is referred to as an itinerant practice but does not mean, nor preclude, the dentist who travels from office to office as discussed in the specialist section.

Economic Impairment Recent dental graduates have witnessed the most severe recession in our economy since the Great Depression and banks are really not motivated to make practice loans to a dentist. This reality is coupled with the fact that these same graduates have borrowed more from the student loan programs than those of previous generations and enter the workforce with significant debt.

The Corporate Practice of Dentistry Since the 1920s, states have prohibited a corporation from owning a dental practice, employing practitioners, or collecting patient fees. The legal basis for the above argues that only a “person” can obtain a license and the ”corporation” cannot have the education, skill, or ethics to practice dentistry. The intent was to prevent interference by the corporation with the dentist–patient relationship and to ensure that dental decisions were made by a licensed dentist. Currently, all states still support the latter statement but some (6) have altered their statutes to allow a business corporation to have ownership by non-licensees and/or hire dental licensees. Four other states either have no law that addresses the business corporation in the practice of dentistry or have statutes that are ambiguous or conflicting. There are also entities (e.g., practice management companies) that own certain clinic brands with hundreds of employed dentists. Note: A business corporation in dentistry is not to be confused with a “professional” corporation.

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Business and Ethics In this section, there are two issues that influence the ethics of dental practice. One is the itinerant dentist and the other is the business corporation in the practice of dentistry.

Discussion

1.  W  ould one anticipate a different ethical approach to patient care between the following: •  A licensed dentist who owns a practice and an itinerant dentist. •  A licensed dentist who owns a practice and a business corporation that owns a dental practice. •  A business corporation that owns a dental practice and an itinerant dentist. 2.  Is there a natural conflict in the ethical practice of dentistry found in the ­following circumstances: •  Choosing between a more or less expensive dental procedure for a patient if you are an itinerant dentist being paid on a percentage of production versus one that is paid a fixed day rate. •  A business corporation offering a bonus to an itinerant dentist for performing the more expensive patient care. In the experience of the author, the majority of practitioners still desire ownership in a personal practice where they may control the quality of patient care delivery while building a favorable reputation and long-term repeat business. This care model is preferable to one that includes only a full itinerant practice. For those who choose to make itinerant practice a part of your career, please do not lose sight of your legal and ethical obligation to practice the standards set forth by your profession.

About the Author

Roger Byrne has been a practicing oral & maxillofacial surgeon since 1973. He served on the Texas State Board of Dental Examiners from 1987 to1993 and as president of the board in 1991–1992. Byrne has served on the American Association of Oral and Maxillofacial Surgeons Commission on Professional Conduct since 2007 and currently is Chairman.

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Chapter

Ethics in Transition

17

Boyd Tomasetti, DMD

Whenever the daily routine tries to tear you down, look at the brightness of the sun and the sparkling, colorful reflection of the light in nature. That will bring you up instantly.

Gabriele Milessi, MD, DDS In the world of Frank Sinatra you have now “entered the autumn of your years.” By this time, the vast majority of dentists in the United States (and the world) have transitioned from dental school to private practice. Others have gone into a hospitalbased practice or the federal services. Thankfully, some practitioners have remained in academics and are helping a new generation of dentists become educated at both the undergraduate and specialty levels. Hopefully, by this time, the practitioner has been involved in an “ethical practice.” Patients and colleagues have been approached and treated with the utmost respect and professionalism. This is not to say that every act is considered and questioned as to its ethical nature. But, subconsciously, practitioners keep the principles of ethics in the back of their minds. This is the transition period where we move from one aspect of our professional lives to another. Perhaps, we are going from full-time practice to a part-time position. We may be transitioning from practice to academics or looking into a totally different career such as consulting. We may be bringing a new, younger dentist into our practice with the plan for them to take over the practice. Just as ethics play a continuing role in the everyday practice of dentistry, it will also come into play as the dentist transitions at the end of their career. Earlier in this book, the American Dental Association (ADA) Code of Ethics was discussed, and this same code, which assisted in our daily practice of dentistry, and will now serve as a guide to our transition. Our ethical obligations to the patients and colleagues will remain the same. Also coming into play, more so than in our daily practice, will be legal issues that may at times appear to conflict with ethical dilemmas. 143

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In the United States, the dentist is governed by the Dental Practice Acts of the various states. The dentist must also take into consideration additional laws, rules, and regulations that are there primarily to protect the public. In a similar manner, other countries or regions, the European Union for example, will have laws and rules that will regulate the practice of dentistry within their own purview. As each state or entity establishes its own laws and rules, what is legal in one may not be legal in another. In addition, the practitioner and the law will also be guided by “the standard of care.” For the most part, the Dental Practice Acts and similar laws do not address the transition of a professional career other than ensuring protection of the patients. The laws of contracts may play a larger role. Although it is important and critical that we follow the legal guidelines, we must also ensure that this is an ethical transition. As we begin this transition period, it is imperative that we continue to be ethically involved. The ADA Code of Ethics includes 5 fundamental principles: patient autonomy, no malfeasance, beneficence, justice, and veracity. In addition, the American College of Dentists (ACD) publishes an ethics handbook that incorporates and expands upon the ADA Code. The ACD handbook discusses citizenship, scientific literature, research, and licensure. The safety and welfare of our patients are the prime concerns during this transition period. Not only are we as professionals about to experience a major life change, whether in private practice or another treatment setting, but our patients are s­ ubject to major change in their lives as well. It is not uncommon, particularly in the U.S. private practice setting, for a patient to have been with one dentist throughout their life. As mentioned earlier, 1 of the 5 basic tenets of the ADA Code is patient autonomy. Autonomy is the right of the patient to make his/her own decisions regarding treatment. The patient has the final decision with regards to their treatment. This obviously includes the patient’s right to determine from whom they will receive their treatment, and this can create a major stumbling block in the transition from one practitioner to another. One of the prime factors in the sale of a dental practice is the transfer of patient records. The practice buyer wants the names and addresses of all patients of record. The retention of these patients within the new practice will be a major factor if the incoming practitioner is to be successful. At the same time, the retiring practitioner wants the patient list to be as large as possible, thus increasing the practice value. The retiring dentist cannot force his or her patients to remain with the incoming dentist. At the same time, it is not ethical to “pad the list” of active patients who may potentially remain with the practice. It would be highly unusual for a single practitioner to have 3000 active patients—to artificially inflate this number would be highly unethical and quite possibly result in potential contract violations.

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This transition of patient records from one dentist to another can result in multiple ethical dilemmas for both parties. It is imperative that the retiring/selling dentist be honest when representing the number of active patients in the practice. The number of patient charts rarely, if ever, equals the number of active patients. The incoming dentist is not going to be able to review every chart. At best, a random r­eview may be done of a small percentage of patient records. Hopefully, the incoming dentist is going to rely on the ethical representation of the retiring/selling dentist. In addition, the demographics of the active patients are important. A practice with an unusually high percentage of geriatric patients may not be as valuable as one with a more evenly distributed age range. Again, the transition is going to be dependent on an ethical representation of the patient mix. Dental staff retention will also play a major role in practice transition. Just as we must respect patient autonomy, the staff also has a voice regarding their allegiance to the practice. The retiring/selling dentist cannot ethically “guarantee” that the staff personnel will remain during and after the transition. The staff will often have intense loyalty to the original dentist. It is not uncommon to see a complete staff turnover within a year of practice transition. This staff change may result in significant patient loss particularly in the hygiene department. One of the most common practice transitions in the United States is the hiring of an “associate” dentist who will eventually take over the dental practice. The associate dentist must be treated ethically throughout this transition period. Ethics demand that, if the associate is to take over the practice, he/she has full access to the practice finances. This can be a very difficult thing for the practice owner to relinquish. One of the big debates is exactly when the “associate” becomes the anointed one and receives access to the practice’s inner workings. This is a critical moment in the transition period for both the purchasing and selling dentist. Unfortunately, in a number of instances, the associate stays in that position for an inordinate amount of time and neither the staff nor the patients ever sees him/her as the future practice owner. The selling dentist certainly does not want to reveal sensitive financial information only to see the associate leave the practice and become affiliated with a competing practice or open his/her own practice down the street. The associate is certainly entitled to see all financial information prior to making a commitment to purchasing the practice. This may necessitate the signing of nondisclosure papers but will certainly require that each dentist deals with the other in an ethical manner. Full disclosure is of paramount importance in the practice transition. We have now come full circle in our dental career and it should be clear that ethics have played a critical role in our development as a dentist. From those initial days in the anatomy class to the final walk out the door, all of us, for the most part, strived to treat our staff, patients, and colleagues in both a professional and ethical manner.

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Epilogue Steve Afriat Not the motivation to make money, but joy and curiosity are the best premises for a satisfactory life in dentistry.

Dr. Konrad Wangerin DDS, MS This book has been an exciting journey to allow thoughtful perspectives of ­healthcare professions, in this case, dentistry. Sharing professional and life experiences with the future providers of this important medical profession is the key to a successful career in dentistry. As one of the few public members of the California State Dental Board, I have been privileged to work side by side with dental professionals in recommending legislation, creating policy and protocols for dental professionals, as well as hearing, reviewing, and opining about disciplinary actions against licensed professionals. As a public member, I take my charge that I am there on behalf of the consumer very seriously. However, I do collaborate with the more experienced dental professionals to do the best decision making we collectively can on behalf of the people of the State of California. It is my good fortune that by having this perspective, ethical decision making is a high priority. I have always said that you cannot teach ethics. Either people have ethics or they do not. And although I believe that to be essentially true, the fact is that you can teach questions about ethics as this book has done and help dental care professionals ask themselves the right questions so that they can learn decision making and best practices and protect the interests of the consumer. While it is easy to default to the tried and true philosophy of first and foremost “do no harm,” it is not always that simple. Dentistry affects humanity in a very unique way. Other than the occasional trip to the pediatrician, where a child might receive a shot and have to stick out their tongue and say, “ahh,” dentistry is quite often the most impressionable part of a child’s early experience with medicine. Those early experiences with dentistry often set the tone for a lifetime of attitudes that the child, who eventually becomes an adult, will have not only toward visiting the dentist but also in dealing with their healthcare needs. Modern dentistry has become a gateway to dealing with medical problems. It’s no secret that recent studies show that life expectancy can be increased by many years as a result of doing something as simple as flossing every day. Heart disease, HIV, 147

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certain forms of cancer, and various cardiopulmonary deficiencies can be discovered by a sharp dentist during a routine examination. Prevention of heart disease, certain forms of cancer and certain infections can be taught through proper home dental care and proper examinations. So the world of dentistry has evolved over the last few decades to include more patient education and sensitizing patients to the importance of oral healthcare as it relates to overall healthcare. So perhaps you can teach someone ethics. You can encourage the knowledge and attitudes that lead most individuals to choose healthcare professions. To use that opportunity to raise consumer awareness, to encourage and support patients to ­become more responsible for their own healthcare, and to encourage children to enjoy and if not enjoy, appreciate those early experiences with healthcare professionals. And to make sure that the credo of “do no harm” actually means to do some good … to encourage patients to walk out of the office and say they are glad they went, they learned something about increasing their life expectancy and quality by taking better care of themselves. And finally, through certain procedures whether it is orthodontics, reconstructive surgery, implants, whitening, and a whole variety of other procedures, the role of dentistry is to lift a person’s self-esteem. Yes, ethical decision making in dentistry can be something as simple as playing a gentle and supportive role in helping someone find their smile and in helping a child to feel confident to open his or her mouth and laugh; to give an adult more confidence in their relationships or in their professional careers. So in my view, as a person who wears the hat of protecting consumers, ethical ­decision making is simple. What did you do today to improve not only the oral healthcare, but also the very lives of those people you touch when they walk into your offices? This book has gone a long way to answering that question.

148 Ethical Decision Making in Dentistry

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Index A Academy of General Dentistry (AGD), 41, 105–107 Access to care, 49 ACD. See American College of Dentists (ACD) Acetaminophen, 87 ACGME. See American council on Graduate Medical Education (ACGME) Actual referrals, 44 ADA. See American Dental Association (ADA) Advanced dentistry, 123 Advertising ethics and ADA Principles of Ethics and Code of Professional Conduct, 124–127 claims, 122–123 core component for, 123 deceptive/unfair, 119 definition, 123 for dental professional, 122 fellowships in, 125 for good/evil, 120 restrictions on, 119 in United States, 120 in Victorian era advertising trade cards, 120–121 in Web sites, 120, 121, 127 unethical, 120, 123 AGD. See Academy of General Dentistry (AGD) Alveolar osteitis, 133 American Academy of Cosmetic Dentistry, 70–71 American Association of Oral and Maxillofacial Surgeons, 140

American Association of Women Dentists, 21, 41 American College of Dentistry, 123 American College of Dentists (ACD), 125, 144 American council on Graduate Medical Education (ACGME), 6–7 American Dental Association (ADA), 21, 105–107 Code of Ethics, 143, 144 coding, 4 Principles of Ethics and Code of Professional Conduct, 124 dentist’s duties, principles of, 126–127 Survey of Dental Practice, 48 American Dental Education Association, 21 American Student Dental Association’s (ASDA), 19, 21 Code of Ethics, 22 Andrews KG, 15, 16 Anesthesia, 55, 130 Anti-Kickback Act, 46 Applicant evaluation, 25 ASDA. See American Student Dental Association (ASDA) ASDA White Paper on Ethics and Professionalism in Dental Education, 22 Aspirin, 86, 87 Autonomy patient, 144 perception of, 116 sense of, 116 B Beemsterboer PL, 18 Behaviors, unethical, during patientfocused education, 14

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Beneficence, dentist’s duties, 126–127 Billing insurance, 116 for patients, 95–101 systems, ethical, 101 Bisphosphonate-related osteonecrosis of the jaw (BRONJ), 8 Board of Examiners, 91, 92 Bonded porcelain, 68, 71, 75 Bowers study, 15 Brain dumping schemes, 26 Bridge, importance-performance analysis for, 63–65 BRONJ. See Bisphosphonate-related osteonecrosis of the jaw (BRONJ) Business interaction, 115–116 plan, 112, 113 developing, 110, 117 Business 101, 110–111 C California Board examination, 30 California Dental Association’s (CDA) Code of Ethics, 105 California State Dental Board, 147 Candidates anonymity, 30 brain dumping for, 26 demonstrating clinical skill, 29 examinations paying for, 35 preparation for, 26 require of, 36 failing, 28, 29 irregularity, 27 misunderstanding, 27 performance, 36 Care delivery environments innovative, 5 patient, 2–3 Cavity, 82 CDA. See California Dental Association’s (CDA) CE. See Continuing education (CE) Certification programs, CE, 106 Cheating in medical school, 15–22 methods, 17–18

Claims and advertising, 120–123 electronic filings of, 116 Class II amalgam restoration, 31 Class II gold foil restoration, 31, 32 Class V gold foil restoration, 31 Clinical care environment, 5 Clinical certification, fail in, 29 Clinical decision making, 114 Clinical education dental students, ethical behavior, 1 ethics, 2 Clinical examination in Portland, 33 Clinical indications for care, 114 Clinical licensure examination, 18, 19 Clinical sciences, NBDE, 26 Clinical situations, 133 Clinical skills, 106 Clinical training, 17–18 Clinic, complaints in, 34 Clinician, needs of, 30 CODA. See Commission on Dental Education (CODA) Codeine, 87 Colgate pledge, 84 Commission on Dental Education (CODA), 27 Communication, 115 skills to patients, 114 Community dentist in, 114 service, 41 Compensation for group practice, 49 Competencies, 6–7 Comprehensive treatment plan, 33–34, 114 Concept of finality, 117 Consumers, advertising, 119 Contemporary dental procedures, 134 Continuing education (CE) certification programs, 106 courses, 106 for dental professionals, 104 effectiveness, 107 ethical aspect of, 107 formal forms, 104 quality, 105–106 regulations, 105 relevance, 106

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Continuity of care, 7–8 Coronal restoration, 56 Corporate practice of dentistry, 141 Cosmetic dentistry, 120 Courses, CE, 106 Cracked filling, 86 D Decision making dental treatment, 131 ethical, 37, 91–94 in dentistry, 68, 147–148 for patient billing, 95–101 human tendency for, 112 oral health care, 134 tree, 114 Definitive treatment plan, development and implementation of, 132 Degrees, dentists, 124–125 Dental benefits, 98 companies, 96, 97 supporting information, 101 options of, 98 third-party payers, 97 Dental board, 91 allegations, 93 complaint process, 92 primary mission of, 92 violations discovered by, 93 Dental business model, 114 Dental care benefits of, 131 cost of, 134 Dental cleaning, routine, 114 Dental clinical education, academic health center care environment, 8 Dental consultants, 100 Dental coverage, 97, 100 Dental disease process, 130 Dental education competition of, 16 ethical problems in, 1 ethics in, 22 impropriety within, 15 program, 25–30 Dental fees, 97 Dental Health Maintenance Organizations (DHMO), 98–99

Dental health of patient, 131 Dental hygiene, 26, 82, 86, 87 Dental implant risk of, 133 therapy, 134 Dental Implants Specialists, 123 Dental information systems, 10 Dental instruments, 85 Dental insurance, 98 company, 100, 116 consultant, 101 Dental license, 91, 92 Dental patient, 129–131, 135–136 Dental plans, 40 types of, 98, 99 Dental practice autonomy, sense of, 116 business, 110 and consumers in, 115 entity, 112 cash flow of, 111 employee salary of, 110 failure of, 110 fee structure, 111 group. See Group dental practice interesting things in, 73 practice consultants of, 111–113 setting fees, act of, 111 Dental Practice Act, 46, 111, 144 advice/techniques, 112 Dental practice management, 48 Dental practitioners, 101 Dental professionals, 22 CE for, 104, 105, 107 to decision making, 147 Dental restorations, 130 Dental schools, 41, 91, 109 candidate for, 112 CE, 105–106 clinical care environment, 5 clinical practicum requirements, 4 curriculum, 104–105 ethics in, 13 clinical training, 17–18 competition in, 21–22 didactic training, 15–16 hidden curriculum, 19–20 licensure examinations, 18–19

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Dental schools (Continued ) organized dentistry, 21 patient-focused education, 14 preclinical training, 16–17 repercussions of impropriety during, 18 SPEA, 20–21 student-delivered care ethics, 8–9 traditional view of ethics, 1 Dental Service Organizations (DSO), 48 Dental society meetings, 113 Dental specialist itinerant practice for, 138–141 appropriate standards for, 140–141 history, 138 itinerancy, 139 unethical decisions by, 139–140 Dental staff retention, 145 Dental students cheating, 15 didactic and clinical education, 1 duty, 22 Dental Supply Company, 116 Dental testing agencies, 28, 30, 36 Dental training program, 105 Dental treatment, 130 decision making, 131 procedures, 134 for minors, 136 Dentistry advertising in, 120, 127 affects humanity, 147 clinical care pod, 9 comfortable living and ethical patient care relationships, 54 corporate practice of, 141 description, 53–54 diagnostic phase adjunctive diagnostic examinations and testing, 59 chief complaint, 58 clinical examination, 59 medical history, 58 present illness history, 58 social history, 58 ethical challenges in fast-paced community dental clinic, 56 full mouth reconstruction, 55 language barrier, 55 maximizing cash flow, 57

nitrous oxide, 56–57 patient flow moving, 55–56 ethical decision making in, 147–148 importance-performance analysis tool case study, 60–64 description, 60 information systems, 8 itinerant practice in, 137–142 business and ethics, 142 economic impairment, 141 profession of, 120 scope of, 110 state boards of, 119 treatment planning phase, 59 Dentists, 51, 68, 92, 110, 131, 144 advertising by, 119, 120, 125 benefits from patients, 116 bill procedures, 98 with clean practice record, 36 in community, 114 degrees, 124–125 as dental students, 1–2 DHMO, 100 duties, 77 principles of, 126–127 emergency care, 49 employee favoritism of, 39 fees of, 78 focus of, 68 graduating from, 109 in group practice, 47 incentive for, 48 initial oral examination for, 97 key decision by, 112 knowledge and skills, 105 licensure of, 91 patient, 114, 115, 117 conversation between, 68–70 pledge, 11–12 PPO, 98–100 practice models of, 48 predoctoral dental education programs, 28 in private practice, 39–41 procedures, 75 requirements-based environment, 4 responsibility of, 111 rights of, 105 skill level, 73–74 transitions, ethics in, 143–145 Web sites for, 121, 127

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Department of Insurance (DOI), 100 DHMO. See Dental Health Maintenance Organizations (DHMO) Diagnostic phase in dentistry adjunctive diagnostic examinations and testing, 59 chief complaint, 58 clinical examination, 59 medical history, 58 social history, 58 Didactic education dental students, ethical behavior, 1 ethical dilemma in, 5–6 Didactic test in discipline-based course, 5–6 Didactic training, 15–16 Dilemma, ethical, 143 burden of clinical requirements, 3–4 clinical competencies, 6–7 continuity of care, 7–8 dentist’s pledge, 11–12 description, 1–2 in didactic education, 5–6 live patient examination, 10 medically and dentally complex patients rejection, 8 orthodontic graduate program case presentation, 10 patient care delivery environment, 2–3 student-delivered care ethics, 8–9 treatment plan cost, 4–5 Discipline-based course, didactic test, 5–6 Discrimination, dentist, 49 Doctor, and patient interaction, 85 Documentation, excellent communication and, 115 DOI. See Department of Insurance (DOI) Do it my way approach, 6 Dry socket, 133 DSO. See Dental Service Organizations (DSO) E Easy Maintenance characteristics, 62–64 Education time, extension of, 27 Electronic claims payment, 97 Electronic filings of claims, 116 Emergency care, 49 Emotion, decision based on, 112 Employees, salary offered to, 110 Employment of family members, 50

E & M services. See Evaluation and management (E & M) services Endodontics, 98 Enforcement arm, 92 Esthetic dentistry concern, 68 definition of, 68 fair fee, 77–79 fun application to, 75 issue of, 72 principles of, 70–72 purpose of, 67–68 result of, 74–77 Ethical behavior, 37 dental students, 1 expectation of, 130 Ethical billing systems, 101 Ethical challenges in dentistry fast-paced community dental clinic, 56 full mouth reconstruction, 55 language barrier, 55 maximizing cash flow, 57 nitrous oxide, 56–57 patient flow moving, 55–56 Ethical decision making, 37, 91–94, 110, 117 in dentistry, 147–148 in esthetic dentistry, 68 for patient billing, 95–101 Ethical dilemmas in dentists education burden of clinical requirements, 3–4 clinical competencies, 6–7 continuity of care, 7–8 dentist’s pledge, 11–12 description, 1–2 in didactic education, 5–6 live patient examination, 10 medically and dentally complex patients rejection, 8 orthodontic graduate program case presentation, 10 patient care delivery environment, 2–3 student-delivered care ethics, 8–9 treatment plan cost, 4–5 Ethical obligation of oral health care provider, 134 to patients, 143 Ethical practice, 143 Ethical problems in dental education, 1 Index 153

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Ethics and advertising. See Advertising, ethics and of career-long learning, 103–107 in clinical education and practice, 2 in dental school, 13 clinical training, 17–18 competition in, 21–22 didactic training, 15–16 hidden curriculum, 19–20 impropriety within dental education, 15 licensure examinations, 18–19 organized dentistry, 21 patient-focused education, 14 preclinical training, 16–17 repercussions of impropriety, 18 SPEA, 20–21 traditional view of, 1 in dentistry. See Dentistry guiding principles in, 12 medical. See Medical ethics principles of, 143 of professional group dental practice. See Group dental practice of referrals, 43–46 student-delivered care, 8–9 in transition, 143–145 Evaluation and management (E & M) services, 4 Evidence-based care, 6 Evidence-based concepts, 107 Evidence-based procedure, 134 Examinations administer practical clinical, 34 candidates, 35 definition, 29 failing in, 28 guidelines for, 30 licensure and licensing, 25–27 preparation, 30 Examiner manuals, 30 F Fair Credit Billing Act, 95 Fairness, dentist’s duties, 127 Fast-paced community dental clinic, 56 Federal Trade Commission (FTC), 119–120 Fee schedules, 110 Fee structure for dental practice, 111 Financial management, 51

Fixed partial denture, 63–64 FTC. See Federal Trade Commission (FTC) Full mouth bonded restorations, 74 provisional restoration, 75 reconstruction, 55 restorations, 68 effect of, 72 series of radiographs, 98 G Gingival margins, 76–77 Give Back a Smile program, 70–71 Grading criteria, 30 Gray market products, 116 Group dental practice ethics of professional access to care, 49 aspect of, 49 compensation, 49 dentist in, 48 emergency care, 49 financial management, 51 motivating factor, 48 practice management responsibilities, 50 principles of, 48 professional development, 51 staff management, 50–51 participants in, 48 H Harassment, sexual, 51 Health care environment, 130–131 Healthcare professions, perspectives of, 147 Health-care providers, 82 Health insurance, 88 Health Insurance Portability and Accountability Act (HIPAA), 95 Health Policy Resource Center, 48 Hidden curriculum, 19–20 within dental education, 16 High Chewing Comfort, 62 performance for, 63–64 HIPAA. See Health Insurance Portability and Accountability Act (HIPAA) Hispanic Dental Association, 41 Hispanic Student Dental Association, 21 Human tendency, 112 Hygiene, dental, 82 Hygienist, 70

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I Iatrogenic mandible fracture, 133 Immediacy, decision based on, 112 Implant, importance-performance analysis for, 64, 65 Implantologist, 123 Importance-Performance analysis for bridge option, 63–64 for implant, 64 method of, 66 for nontreatment option, 62, 63 for RPD, 62–63 tool, 60–62 INBDE. See Integrated National Board Dental Examination (INBDE) Incentive for dentists, 48 Indemnity plan, 98 Induced consent, 126 Inferior alveolar nerve paresthesia, 133 Inflammatory disease, 130 Information systems, medicine and dentistry, 8 Informed consent alternative procedures, 133–134 clinical situations, 133 cost of procedures, 134 diagnosis and procedure, 132 elements of, 131–132 expected postoperative course, 133 features of, 132 infrequently performed procedures, 135–136 introduction of, 129–131 for minors, 136 no treatment procedure, 134–135 potential complications, 133 success and failure procedure, 134 Informed refusal, 135 Innovative care delivery environments, 5 Instruments, medical aura of, 85 Insurance billing, 116 companies and vendors, 115–116 patients and, 114 Integrated National Board Dental Examination (INBDE), 26 Item remembering schemes, 26 Itinerant healthcare, 138

J Jaw cyst, 130 Joint Commission on National Dental Examinations (JCNDE), 18, 19, 26, 27 Journal of the American Dental Association, 124 Jurisdictional complaints, 92 Justice, dentist’s duties, 127 K Kelleher M, 127 Klempner G, 120 Koerber A, 16 L Language barrier, ethical challenges, 55 Laser gingivoplasty, 68, 77 Laws of contracts, 144 Leadership styles, 116–117 Learning career-long, ethics of, 103–107 problem-based, 15 Lecture, practice management, 112 License, 111 holders, 93–94 Licensure, 91–94 examinations, 18–19 and licensing examinations, 25 NBDE, 26–27 practical clinical. See Practical clinical examinations Live patient examination, 10, 19, 20 Loftis B, 19 Long-term stability, 62 performance for, 63–64 Low-cost dental clinics, 33 LVIM, definition, 124 M Malocclusion, 75 Managed care plans, 98, 99 Mandibular molar, 134 Mandibular premolar, 134 McCabe, DL, 15 Medical education, 6–7 Medical ethics, oath to profession, 82–89 Medical school, cheating in, 15–22 methods, 17–18 Medication, internet and researched online, 114 Index 155

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Mid procedure, 88 Minimally invasive dentistry, concept of, 75 Minimal Tooth Preparation, characteristic of treatment, 62–64 Modern dentistry, 147 Monumental audit, 110 N National Board Dental Examination (NBDE), 18, 26–27 National Board Dental Hygiene Examination (NBNHE), 26 National dental meeting, vendor portion of, 113 NBDE. See National Board Dental Examination (NBDE) NBNHE. See National Board Dental Hygiene Examination (NBNHE) Nicholas J, 43 Nitrous oxide, ethical challenges, 56–57 Non-health degrees, dentists, 124 Nonmaleficence, dentist’s duties, 126 Nonparticipating practices, 97 Nonpatient-based examination, 19 Nontreatment, importance-performance analysis for, 62–63, 65 No-prep porcelain veneers, 75–77 O Oath to profession, medical ethics, 82–89 Odontogenic diseases, 109 Office management business 101, 110–111 insurance companies and vendors, 115–117 new technologies, 113–114 patients, 114–115 practice consultants, 111–113 Office protocol, implement of, 117 Office staff, size of, 110 Oral clinical findings, 73 Oral health care developments in, 135 ethical obligation of, 134 patients, 130, 132, 134, 135 provider, 129–131 alternative procedures, 133–134 clinical situations, 133 cost of procedures, 134 diagnosis and procedure, 132

infrequently performed procedures, 135–136 for minors, 136 no treatment procedure, 134–135 potential complications, 133 recommended procedure, 134 success and failure procedures, 134 systems-based practice in, 4–5, 7 Oral health care system, 34 Oral hygiene, 73, 134 Organized dentistry, 21 P Pain, 86 duration of, 58 persuasive embrace of, 87 postoperative, 88 Pain killers, 82 Painless dentistry, 121 extracting, 121 Pankey LD, 69, 78 Patient care delivery environment, 2–3 relationships, comfortable living and ethical, 54 Patients acceptance of treatment plan, 114–115 autonomy, 144 dentist’s duties, 126 billing and dental benefit, 95–101 care cheating in, 18 implications for, 50 pro bono for, 51 clinical examinations, 19, 29 communication skills to, 114 dental. See Dental patient dentist and, 114, 115, 117 and doctor interaction, 85 encourage and support, 148 esthetic, 75 circumstances of, 70, 71 result of, 75–77 ethical obligations to, 143 finding services, 30, 35 focused education, 14 insurance and, 114 misleading, 122 in Oregon, 34

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pedodontic practice in, 115 perspective as, 86–89 referral, 41 submission and treatment decisions, 35 technology/techniques, 114 top 5 reasons for, 93 trafficking in, 35 Payroll taxes, 110 Peace officer authority, 92 Pedodontic practice, patient in, 115 Perfect crowning system, 121 Pericoronitis, 130 Periodontal diseases, adjunctive treatment of, 114 Periodontal health, 134 Persistent paresthesia of lingual nerve, 133 Postoperative course, dental surgeries, 133 Potential complications, 133 PPO. See Preferred Provider Organizations (PPO) Practical clinical examinations, 27 challenging, 28 dental and dental hygiene, 29 ethical issues, 30–37 guidelines for, 30 imperfect, 28 licensing jurisdictions rely on, 29 regional, 25 Practice consultants, 111–113 Practice management, 114 advisor, 112 courses on, 106, 112 lecture, 112 responsibilities, 50 Practice philosophy, 40 Preclinical training, 16–17 Predoctoral dental education programs, 28 Preferred Provider Organizations (PPO), 98–99 Principles of Ethics and Code of Professional Conduct, 137 Private dental practice, 115 Private practice, dentist advantage of, 40 location, 39–40 PRN. See Professional Recovery Network (PRN) Problem-based learning, 15 Pro bono care for patients, 51 Procedure-based dental practice, 4

Professional development, 51 Professionalism, 7 Professional Recovery Network (PRN), 93 voluntary participation in, 94 Protection and Affordable Care Act, 46 Q Quality assurance procedures, 106 R Radiographs, 44 Referrals actual, 44 ethics of, 43–46 Referring dentist, 44–46 Remedial education, 27 Removable partial denture (RPD), importance-performance analysis for, 62–63, 65 Requirements-based environment, 4 Restaurant industry, axiom of, 114 Retiring dentist, 144, 145 Return on investment (ROI), 113 Root canal procedures, 87 treatment, 55–57 Routine dental cleaning, 114 RPD. See Removable partial denture (RPD) Rule of thumb, 96 S Scoring rubrics, 30 Self-insured plans, 98 Selling dentist, 145 Selling dentistry, 131 Settlement conferences, 92 78th Legislature, 2003, 92 Sexual harassment, 51 Sharp HM, 19 Short-term monetary gain, 114 Sierles F, 18 Sinatra F, 143 Social security, 110 Solo practitioner, 51, 97 Solo private practice advantage of, 40 description, 39 disadvantage of, 40–41 Index 157

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SPEA. See Student Professionalism and Ethics Association (SPEA) Specialists Implant Center, 123 Staff hiring, simple act of, 110 Staff management, 50–51 Standard of care, 113 State dental meeting, vendor portion of, 113 Student-delivered care ethics, 8–9 Student National Dental Association, 21 Student Professionalism and Ethics Association (SPEA), 20–21 Student, responsibility of, 28 Study club meetings, 112 Symptom-reactive practices, 58 Systems-based practice, in oral health care, 4–5, 7 T Tax identification number, 111 Technology, 113–114 promotion of, 114 purchase of, 113 Testing agencies, dental, 28, 30, 36 Texas State Board of Dental Examiners (TSBDE), 91 divisions of, 92 Third-party payers, 97 Tooth extraction, 84 Toxic personality, 112 Trade cards, advertising, 120–122 Traditional group private practices, 48 Transition, ethics in, 143–145 Treatment evaluation of, 37 financial arrangement, 97 financial discussions, 96 free of charge, 34 options, importance-performance analysis for, 62–66 plan, 36, 74, 131–132 communication and documentation of, 115 conversation, 78 costs, ethical dilemma, 4–5 formulation of, 134 patient acceptance of, 114–115 presentation of, 115 planning phase in dentistry, 59 restorative/reconstructive, 101

sequencing, 34 unforeseen gap in, 97 Trust between dentist and patients, 122 Truthfulness, dentist’s duties, 127 TSBDE. See Texas State Board of Dental Examiners (TSBDE) Tumors, 130 U Unearned degrees, dentists, 124 Unemployment taxes, 110 Unethical advertising, 120, 123 Unethical behaviors, during patientfocused education, 14 University of Southern California (USC), SPEA, 20 Unprofessional behaviors during patientfocused education, 14 URC amounts. See Usual, reasonable, and customary (URC) amounts USC. See University of Southern California (USC) U.S. licensing jurisdictions, 25 requiring NBDE, 26 US News & World Report, 15 Usual, reasonable, and customary (URC) amounts, 98 V Vendors insurance companies, 115–116 portion, dental meeting, 113 Veneers, 68, 75, 76 Veracity, dentist’s duties, 127 Violations on dentists’ Web sites, 127 W Web sites for dentists, 121, 127 Western Regional Examining Board’s (WREB) dental examination, 31 WREB dental examination. See Western Regional Examining Board’s (WREB) dental examination Written employment agreement, 48 X Xerostomia, 66 X-rays, 88, 111

158 Index

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