Your first new patient of the week is a 40-year-old woman referred by a well-established restorative dentist in your town. She is concerned about spacing and proclination of her upper teeth, and your examination reveals a classic case of posterior bite collapse. Full collaboration with the referring dentist will be essential because the final result will depend on optimal restoration of the posterior teeth.
Unfortunately, your experience with this dentist has been far from gratifying. You have treated several of his other referrals who required postorthodontic restorations, and the outcomes have been consistently inadequate, from both functional and esthetic perspectives. The patients have been equally disappointed.
Your ethical concerns are numerous. Do you accept this patient with plans to collaborate with the referring dentist, knowing that future restorative care will be sub-optimal? Do you insinuate that a different restorative dentist would be best? Do you openly communicate your dissatisfaction to the patient? Finally, do you jeopardize a strong referral source by diverting the patient toward a more skilled or more conscientious provider?
From an ethical perspective, your responsibility is clear. Your primary intent should always be to provide optimal advice and care. This is specifically addressed in the Principles of Ethics and Code of Professional Conduct, Section 3 Principle: Beneficence (“do good”), of the American Dental Association (ADA).
The dentist has a duty to promote the patient’s welfare. This principle expresses the concept that professionals have a duty to act for the benefit of others. Under this principle, the dentist’s primary obligation is service to the patient and the public-at-large. The most important aspect of this obligation is the 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. ” (emphasis added)
The code is explicit in stating that the patient’s needs are the salient priority. Yet the same ADA code addresses the issue of making disparaging comments about another dentist. Section 4.C.1. Meaning of “Justifiable” states:
A dentist’s duty to the public imposes a responsibility to report instances of gross or continually faulty treatment. However, the heading of this section is ‘Justifiable Criticism.’ Therefore, when informing a patient of the status of his or her oral health, the dentist should exercise care that the comments made are justifiable. For example, a difference of opinion as to preferred treatment should not be communicated to the patient in a manner that would otherwise imply mistreatment. There will necessarily be cases where it would be difficult to determine whether the comments made are justifiable. Therefore this section is phrased to address the discretion of dentists and advises against disparaging statements against another dentist. However, it should be noted that where comments are made that are obviously not supportable and therefore unjustified, such comments can be the basis for the institution of a disciplinary proceeding against the dentist making such statements.
Hence, a thin line separates acting in the best interest of your patient and making disparaging statements about your referrer. Your desire and your obligation are to uphold the patient’s trust by providing her with advice that is in her best interest. To the patient, a poor result is a collaborative failure. The orthodontic quality might be ideal, but if the restorative result is unacceptable, you and the restorative dentist are implicated, if not legally, at least by reputation.
It is indeed a conundrum. The constructive aspect of the problem is that it might initiate a gentle yet frank form of communication between the orthodontist and the referring dentist—one that is perhaps long overdue. Although it is a difficult solution, open discussion with the dentist regarding an opportunity for improvement, if delivered tactfully, might be the option that benefits all of those involved.