The Compliance Divas Podcast
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The Compliance Divas Podcast
#173 What Happens When Ethical Dilemmas Occur in Dentistry?
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What happens when an ethical dilemma occurs in your practice? In this episode, the Divas highlight ethical and professional responsibility and how to avoid common ethical issues and how to mitigate them if they occur.
Resources:
- ADA Principles of Ethics and Code of Conduct https://bit.ly/3Z9h8IG
- NY Post - Dental officers laugh as they read cancer patient's diary https://bit.ly/476P3Ul
Welcome. I'm Leslie Cannon. I'm Mary Gavoni.
SPEAKER_03I'm Linda Harvey. I'm Olivia Juan, and together we are the Compliance Divas. Welcome to the Compliance Divas podcast. My name is Olivia Wan, and I'll be your moderator today for the subject of ethics in dentistry. Perhaps you heard the disturbing news about the Knoxville, Tennessee video revealing contents of a private journal that belonged to one of the patients. Some people blame such atrocities on COVID. There's a certain air of rudeness that infiltrated our culture. Others blame it on a generational gap caused by people being glued to their phones and social media. Some are saying that we've slipped into the pit of no ethics in society. But what about ethics in dentistry? So in this week's episode, we're going to dive in with the divas and talk about some ethical principles that you can incorporate in your everyday practice. As the compliance divas, we bring clarity and simplicity to compliance by navigating regulatory compliance to keep you on course. Please subscribe to the Compliance Divas podcast through your favorite podcast channel or on our website, thecompliancedeevas.com. Any resources that we mentioned during the episode can be found on the website. You may also submit questions to support at thecompliancedevas.com. Also, we really appreciate if you can give us a like and give us some feedback on how you are enjoying the podcast. The principles of ethics include patient autonomy, non-maleficence, then efficence, justice, and verocity. Just how do we incorporate these ethics into dentistry and understand these principles in line with the code of conduct? I'd like to start with Mary and explore the principle of patient autonomy. Mary, what are your thoughts on this area of ethics and how we can focus on dentistry and helping in maintaining our ethics in today's world?
SPEAKER_02Thanks, Olivia. What I'm going to do first is just read to you from the ADA standard code of ethics and standards of care document that describes what patient autonomy is, and then we'll talk about how this specifically applies. So according to the ADA, this principle expresses the concept that professionals have a duty to treat the patient according to the patient's desires, the way we would want to be treated as a patient, within the bounds of accepted treatment, and to protect the patient's confidentiality. Under this principle, the dentist's primary obligations include involving patients in treatment decisions in a meaningful way, with due consideration being given to the patient's needs, desires, and abilities, and safeguarding the patient's privacy. So, really, what this means is the patient needs to be involved in any kind of treatment explanations, treatment planning, and treatment presentations. So if it's a patient who maybe is an older patient or is perhaps not quite understanding what needs to be done, then we would need to pull in with that patient's permission a family member or someone who can help to interpret or to help them understand. We need to present treatment in layman's terms that patients can understand, not using all the technical jargon, or if we do, then we translate that for the patient. And all of that information needs to be part of the patient record. What did we tell that patient? How did we present that treatment plan? What were the was the patient's feedback? And remember that patients always have a right to a copy of their records. This is covered under the HIPAA privacy rules. It doesn't mean they can have the original records, those belong to the doctors. If there are practices that are still using analog films, then we, if a patient requests a copy of their x-rays, we never give them the originals. We only make copies. And all patients' records remain confidential. We only release copies either to the patient themselves or to someone they designate, maybe a family member, and to a professional, a specialist that we are referring a patient to, or to a government agency if it's mandated, but we don't release it to just anybody. For example, an insurance company wants a comp a copy of a patient record. We need to make sure what it is that they need the copy of that for, why do they, um, what are they going to use it for? So because we are required to only disclose the minimum necessary for whatever we do with our patient records. But this whole concept of autonomy really means that we are treating the patients the way they want to be treated. We have an obligation to present all the necessary treatment to the patient and all the options, but they can pick and choose what they want to do, what they can afford to do. Sometimes practices will only present the treatment that they think the patient will accept, and that is not appropriate under autonomy.
SPEAKER_03That's a great explanation, Mary. And I appreciate how you brought up about confidentiality being a HIPAA law, but as you mentioned, it also violates the code of ethics, and that's exactly what happened in this scenario that I mentioned with this social media incident. I also appreciate that you mentioned about treating the patient according to the patient's desire. And as you were talking, Mary, I was thinking about because I have to do two hours of ethics training every year for my law license. And we're always told repeatedly, who is the client? Because you can have family members come in and they try to take charge of that consultation. Just like in dentistry, maybe the spouse came in with the other spouse present. And the spouse that's not the patient is taking over and maybe more concerned about cost, or they want it handled a certain way. Or it could be the adult child has a parent present and they're trying, you know, the one that's present is railroading the conversation into a treatment plan that may not be what the patient wants. And so in our dental practices, how do we assure that we are treating the patient according to what they desire? And also balancing, I could remember when I worked in a dental office how you give a treatment plan according to a priority of need, and inevitably they would want the smile line completed first. So although we try to educate and inform, you know, if that's what the patient wants, I guess that's where we're going to be starting out, providing that we've given them the information so they fully understand it. What's your thought, Mary?
SPEAKER_02Well, I'm so glad you brought up that point about um someone else kind of taking over that conversation if we're presenting a treatment plan. First and foremost, unless that patient is considered to be incompetent and you have a medical power of attorney, you must have the permission of the patient to include that spouse or that adult child. And sometimes that's a challenge. I dealt with that with my mother at the end of her life that she would not give permission. So I couldn't be part of that treatment plan. So I had to invoke the power of attorney so I knew what was going on. But we have to be very careful about that aspect of confidentiality.
SPEAKER_03You're exactly right, Mary. Thanks for pointing that out. Now we'd like to go to the next principle, and this is of non-maleficence, and talk to our diva Linda on understanding what this principle is and the code of conduct.
SPEAKER_01Yes, Olivia. The principle of non-maleficence has always been a tongue twister to me. So we can describe it as do no harm. Under the ADA Code of Ethics, this is the principle that expresses the concept that professionals have the duty to protect the patient from harm. So when I think and hear the words protect the patient from harm, as a risk manager, always think about preventing medical errors. And that's something that we've all been aware of for the past 25 years when the medical error crisis was brought to our attention around 1999 or 2000. And so some of the more serious things we would see in a dental practice as far as harm could be extracting the wrong tooth or prescribing a medication for a patient when they have a known allergy. But we also have to think about the fact that there's a lot of things that can happen in dental practice that we may or may not be aware of. And that's called a near miss when an error almost occurs, but someone catches that that's the wrong x-ray pulled up on the computer, or it's the wrong information, or if they've given the patient the wrong prescription. So the ADA further states, Olivia, that under this principle, the dentist's primary obligations include keeping knowledge and skills current, knowing one's own limitations and when to refer to a specialist or other professional, and knowing when and under what circumstances delegation of patient care to auxiliaries is appropriate. So when I think about that description, I think about that in two different categories. One is personally doing no harm, and one is professionally doing no harm. So from the personal perspective, that would be if the doctor or a staff member is impaired. They're taking uh medications they shouldn't be taking at work or they shouldn't be working because they are taking medications. And I've known dentists over the years who've been um addicted to nitrous or other drugs, sadly. And this they've actually got in legal trouble as a result of this and lost their license and went to prison. So that's one end of the expect of the spectrum. And also on the personal side, it's avoiding interpersonal relationships in the practice that could impair one's professional judgment to treat the patient properly with all these different principles of ethics that we're talking about today, Olivia. But I'd like to move over to the professional side and say it's about making sure our education is up to date. We know that dentist and hygienist and many times assistants can't renew their licenses or certificates without proper CE and course education. And when a new service is added to a practice, the doctor wants to go start uh placing implants, they have to go and take appropriate training to get to that skills level. When it comes to the consultation and referral, it's important that if you reach that limit of your knowledge and skills, you know when to reach out to that specialist, whether it's the oral surgeon, the endodontist, periodontist, and so forth, and not try to just retain that patient in your practice with to provide the services when to get second opinion. Sometimes the patient wants a second opinion and they think under the principle of autonomy, they have that right to seek a second opinion. And I mentioned the proper use of auxiliary personnel, it's so important that everybody listening to our podcast understand and know what your state dental practice act is says regarding the delegation of duties for every team member, assistants, hygienist. And I know in many states there are different levels of assistance and knowing who can delegate what level of service to what level of assistant, depending on that individual's training. So those are some important pieces. Then a couple other things I'd like to mention briefly, Olivia, are patient abandonment. You know, how do we make sure that we don't abandon the patient by not calling them and getting them back in when the treatment is not completed, especially when that crown prep has been started and the patient doesn't return for the seating of that. And on the flip side of that is how to be sure we do terminate a patient provider relationship properly so we aren't judged guilty of abandoning a patient. And there's a proper protocol for sending the letter and what has to be in the letter. And for the sake of our conversation today, Olivia, I would refer our listeners to speak to their malpractice attorney or malpractice carrier to get advice on how to properly terminate a patient. Then we have legal guidelines to follow when we're notifying patients when the practice has been sold, or even when the doctor goes on vacation, who's going to be filling in and answering calls and taking emergency care. So those are just some areas, Olivia, where we can be careful of not to do harm for the patient.
SPEAKER_03Thank you, Linda, for that great summary. It seems like it's so straightforward when you talk about it, and yet dental practices may slip into an ethical issue. And I'm really concerned, Linda, with the labor shortage in dentistry, that this could trigger some ethical issues with auxiliary personnel functioning beyond their scope of license. Uh, so that that's a concern that we have. Would you agree, Linda?
SPEAKER_01Absolutely, Olivia. So I think that's one of the most important things when they're onboarding. And I think we've covered this in other podcasts, you know, training opportunities for team members, whether they're brand new to dentistry or just, or even if they're veterans, everybody has to stay current of the changes. So I think you bring a valid point. And it's more than just um checking a box and getting annual training when you have new team members on board and hoping that the person doing your annual training is also going to be orienting them to all the other things that a new person to dentistry needs to know. It cannot happen in one annual training session. So good points to keep in mind, Olivia. Thank you.
SPEAKER_03And also you mentioned about that when you provide a referral, it's not admitting defeat that we don't have skill set in every aspect of dentistry. And so we should be comfortable referring at it. Reminds me of this Pinterest picture where they see this bunny cake on Pinterest, and then they try to make the same bunny cake, and it looks like a monster. You've probably been better off just buying the bunny cake. Uh, and never feel pressured by a patient to provide a service because they don't feel like driving to another office to see a specialist. Uh, so these are really good points in avoiding an ethics violation. But now we'd like to turn our attention to our diva leslie and have her discuss with us the principle of beneficence.
SPEAKER_00Well, Olivia, beneficist basically means do good. And according again to the American Dental Association Code of Ethics, the statement is that the principle expresses the concept that professionals have a duty to act for the benefit of others. And under this principle, the dentist's primary obligation is service to the patient and to the public at large. The most important part or aspect of this obligation is competent and timely delivery of dental care within the bounds of clinical circumstances presented by the patient, with due consideration being given to the needs, desires, and values of the patient. And the same ethical considerations apply whether the dentist engages in a fee for service, managed care, or some other practice arrangement. Dentists may choose to enter into contracts governing the provision of care to a group of patients. However, contract obligations do not excuse dentists from their ethical duty to put the patient's welfare first. I'd like to just elaborate a little bit more, Olivia, on community service. Since dentists have an obligation to use their skills, knowledge, and experience for the improvement of dental health of the public, they're also encouraged to be leaders in their community. And dentists in such service shall conduct themselves in a manner as to maintain or elevate the esteem of the profession. There's also a part about this benefits is that requires a dentist to report abuse and neglect. Dentists, as mandated reporters, are obligated to become familiar with the signs and of abuse and neglect and to report suspected cases when to the proper authorities and do this when laws are consistent with that requirement. So, in in a nutshell, when it comes to this particular aspect of ethics, the American College of Dentists' core values are really, I guess, a summation of all of it. So beneath this is often cited as a fundamental principle of ethics. So the obligation is to benefit others or to seek their good while balancing harms and benefits. The dentist actually seeks to minimize the harms to patients and maximize their benefits. And the dentist also should refrain from harming patients by, again, this is another point that was made earlier, referring to those with specialized expertise when the dentist's own skills are insufficient. Another, I think, you know, sort of inner office, not necessarily out of the office part of this particular code of ethics is that dentists have to maintain a professional demeanor in the workplace. So this is supporting a respectful and collaborative relationship for all of those involved in oral health care. Well, Livia, I think that sums it up pretty well.
SPEAKER_03Thank you, Leslie. It reminds me of an episode that we did a while back where we talked about sex trafficking, how to identify signs. And remember, the average person that ends up into sex trafficking is between, I believe it was 12 and 14 years old. And so with this principle, you know, we want to report child abuse if it's suspected, and then be careful. It's if it's an adult, that's not the case. They may not want it reported. We have to be sensitive to what their preference is while providing resources that are available. So uh you did a great job summarizing that. And um I appreciate that you we should be involved with the community. Be you rub shoulders with them at your local grocery store, being involved in local events and um ball game signs and things like that, that they come to our office to ask for support. So good points. And I wanted to summarize the principle of justice that in this area with the code of professional conduct, um, think about patient selection. We want to serve our patients regardless whether they have a disability or a bloodborne pathogen, and never ever refuse a patient based on their race, creed, color, gender, sexual orientation, gender identity, national origin, or disability. I think these are hot topics right now in the political world, but we have to remember we are serving the healthcare needs of patients. Put aside whatever your sensitivities are and serve the people. Uh, be kind and caring. Be available for emergency service. I mean, granted, nobody wants to do uh be called in on the weekend, but if that's your patient of record, there's an obligation that corresponds with this code of professional conduct. And if you're going to be out of town on vacation or away, then make arrangements for your patients of record to see an alternative dentist. So if you're a solo practice, that would involve maybe reaching out to your colleague so someone can be available to serve these patients. We are also subject to justifiable criticism. Accept it and grow and learn from it. But comments should always be truthful, not intended to tear another dentist or dental professional down and never, never uh disparage another person, uh knowingly or unknowingly. And even if you're called on to provide expert testimony. And if a dentist is called on for expert testimony, they should never share in a fee that's contingent on a favorable outcome to maintain that code of ethics. So let's move to this final principle of discussion, Mary, and any of the divas can chime in, and that is a verocity. Mary, what's your thought on that to start?
SPEAKER_02Veracity in simple terms is be honest, tell the truth. And it's probably one of the most important principles of ethics, because if you are telling the truth, you're most likely doing the right thing. So we see some issues that that arise. That if you say you specialize, you either have to prove that you are a specialist, an orthodontist, an oral surgeon, and so forth, or that you say you are a general dentist who provides those types of services. So we need to be, again, truthful in how we represent the treatment that we provide. And also things that have to do with the types of materials that we use. Probably the most common example would be in the early days of the controversy that we started to see about dental amalgam. And there have been a number of dental dentists practicing that would tell patients that they needed to have all of their amalgam restorations removed all at one time and then go through. I remember one dentist in particular was wanting patients to go through a type of chelation therapy to remove any mercury from their system. And unless there are scientific studies, unless the treatment is something that is said to be standard of care, then that could be a violation of veracity. It could be this person's personal opinion about what to do. But there needs to be some scientific basis for doing it because some of the studies have shown that actually removing all of a patient's amalgam restorations at one time could put them at greater risk because we're aerosolizing a lot of mercury and if certain precautions aren't taken. We don't want to make unsubstantiated representations of expertise that we don't necessarily have. And it sort of goes back to that specializing in types of description of practices. But then we also look at things like have we manipulated treatment dates to coincide with an annual maximum on a plan? Have we billed for a service that maybe could command a higher fee, but we've actually done a lesser service like billing for a gold crown when we actually maybe did a semi-precious metal for that crown, use less expensive materials. And also having to do with insurance billing. And this is a big hot topic out there in the dental profession right now of insurance billing. But if you participate in a plan and you have a contract that you will charge a patient a co-payment, you cannot accept the third-party plans payment, which doesn't include the co-payment as payment in full. Then you are not being honest, you are misrepresenting the fee that you have charged for your patients. So the other issue is then are we recommending treatment that isn't really necessary? And many people who really hate all the restrictions that the insurance plans have put on policies about how many radiographs you can have and how often, and how many times, or what's the frequency of replacing restorations? Because back in the early days of the third-party benefits plans, many of them said that restorations could be replaced once a year. And there were some practices who would not necessarily replace all those restorations, but they would bill for replacing all those restorations and whatever the frequency was. So there are a lot of issues in under this particular topic. But the bottom line is if you are honest and truthful about what you bill for, what you um represent yourself as, and how you explain these treatments to your patients, then you should be fine.
SPEAKER_03That's great, Mary. And I think we've all been trapped in that situation before, so we can certainly relate to what you said. Leslie, what can you add to that?
SPEAKER_00Well, I recall being uh dental receptionist insurance biller, and um sometimes the patient would ask us to do something like change the date of service so they could get benefit that they weren't entitled to. It's important to remember that um the patients may be pushing, but we have to always act with a sense of integrity and honesty. And a simple phrase that I used is you know, I don't want to go to jail. I don't want my doctor to go to jail, and I don't want you to have to hire a criminal defense attorney because you're actually the direct beneficiary of the uh of the claim that has uh been uh misstated or materially misrepresented if you're asking us to change a date so that it benefits you.
SPEAKER_03It's so true, Leslie Mary.
SPEAKER_02Leslie, I'm so glad you brought that up because we were or I was sort of um explaining that in terms of the veracity, but it's also the legality that is insurance fraud. Um and so we I love your phrase, I don't want to go to jail. And I would say to a patient, I don't think you would want us to commit insurance fraud on your behalf. So absolutely.
SPEAKER_03Thanks. That's great. And and I wanted to emphasize what's been said that you know, let's say you charge $200 for a fee and you're planning to discount the copay, then that's not what you charged. So you have to disclose it to the insurance plan what you are actually charging, otherwise, it gets into that unethical issue of um potentially fraud. So keep keep those thoughts in mind. And I think you mentioned about the upcoding. And I think one incident that I don't believe the doctor even knew that the upcoding was taking place, it was more of an administrative thing until he had to refund all that money back to the insurance company. So I think this has been a really great review of ethics in dentistry and how we can better serve our practices individually. And we appreciate you tuning into this episode as the compliance divas. We bring clarity and simplicity to compliance by navigating regulatory compliance to keep you on course. Please submit your questions to support at the compliancedeevas.com. And the resources that we mentioned, which is the ADA document, it will be available in the show notes. Thanks again for tuning in, and we'll see you next week.