It’s another family reunion, and your niece greets you with a big hug. She is a registered dental hygienist who works for a general dentist in a neighboring town. You cannot help but notice the stunning necklace she is wearing and ask if it is a gift from her husband. She informs you that it was purchased with a gift certificate from the orthodontist to whom her practice refers. You believe that she is joking and you smile, but she tells you that the orthodontist promises a substantial gift certificate to any staff member who refers 5 or more patients to him per year. You are incredulous but merely smile at her as you take another sip of your lemonade.
The AAO Principles of Ethics and Code of Professional Conduct, Section IV, C, advises, “Members should not give or receive ‘rebates’ or ‘split fees’ in relation to the referral or acceptance of patients. The term ‘rebates’ and/or ‘split fees’ refers to any substantial remuneration paid or received… in exchange for referring or accepting a patient for orthodontic or other healthcare services.” The ethical code clearly states that the orthodontist’s offer to give gifts to strong referrers is inappropriate and unethical.
Consider the next scenario, which is another authentic situation. When I opened a satellite office, I sent modest announcements to local health professionals to communicate my new location. I received a warm welcome from most of these people, but 1 response impressed me. A local prosthodontist responded to my announcement as follows: “Received notice of your new practice address. My policy in referring to neighboring practitioners is clear-cut. For every patient you refer to me, I will refer one to you. It’s that simple.” I was astounded.
Does this violate the AAO principle from an ethical perspective? Although neither the AAO’s nor the American Dental Association’s ethical code specifically forbids reciprocal referrals, other ethical codes are more directive. For example, the code of the American Academy of Facial Plastic and Reconstructive Surgery states, “The patient relies upon the advice of the physician on matters of referrals. All referrals and prescriptions must be based on the skill and quality of the physician to whom the patient has been referred, or the quality and efficiency of the drug or product prescribed.”
It is unethical to use patients as “currency” in the hope of creating referrals, including offering remuneration or requesting reciprocal referrals. Providing rebates or other forms of reimbursement for referrals is usually prohibited by state law. Finally, if a treatment misadventure occurs at the hands of a referral, the orthodontist could be named as a defendant even though he did not participate in the procedure. Discretion in referrals is therefore critical from both ethical and legal perspectives.
Despite the financial remunerations that dentistry and orthodontics provide, among the most cherished aspects of our practice is achieving and sustaining the trust that our patients place in us. It is our responsibility to nourish that trust without reservation. Appropriate referrals based on the quality of care and an understanding of the unique needs of each patient should be the prime justifications for referral.