1. Whistle Blowing in Dentistry When Does the Dentist Have the Obligation To ‘Blow the Whistle’ On A Colleague Who Is Treating A Patient Unjustly?

2. Definition of Whistle Blowing The disclosing to an authority of a wrongdoing of another; reporting a wrongdoing to call attention to a practice of another one considers to be harmful, unjust or illegal, including such matters as incompetence and impairment. More broadly, whistle blowing is the sounding of an alarm to highlight potential harm, when all other avenues for change have been exhausted. The metaphor whistle blowing derives from the blowing of the whistle by a referee of a sporting event to indicate a rule has been violated and a penalty must be imposed.

3. Case Scenario “Hygienist Troubled By Employer’s Attitude and Behavior”

4. Ms Bigelow, a dental hygienist, identifies progressive periodontal disease in a patient at a periodic recall visit. Despite Mr. Chafin's (the patient) best efforts the periodontal condition is progressing with notably deeper pocket depth this appointment than 6 months ago. She has documented in the dental record the deepening pockets, the exudate and bleeding on probing, and the radiographically observable bone loss among all the posterior teeth. Ms. Bigelow thinks Mr. Chafin should be referred the local periodontist, as her employer, Dr. Johnson, a general practitioner, only treats mild periodontal problems requiring root planing and curettage. When she informs Dr. Johnson of her findings and recommendation, he dismisses her with a wave of his hand, and enters the operatory where Mr. Chafin is seated. He probes among a few anterior teeth, and dismisses Mr. Johnson in a cordial manner, reconfirming to him the importance of returning again in 6 months for another "cleaning." Ms. Bigelow is distressed by her employer's cavalier attitude regarding Mr. Chafin's serious periodontal disease. She is confident that it is imperative that he receive substantive and definitive periodontal treatment or he will lose his teeth to the condition. What should she do?

5. Conflicts for the Hygienist Hygienists are not permitted by state practice acts to diagnose oral diseases; however, they are educated to recognize them. ADHA Code of Ethics states that the hygienist must “provide oral health care utilizing the highest professional knowledge, judgment and ability.” But, it is silent on duty to follow dentist’s instructions, or on the duty to report poor dental care. Hygienists practice under a state granted license. The hygienist must justify her or her own negligence in choosing not to inform the patient about potential harm.

6. Hygienists Versus Nurses In contrast to the ADHA Code of Ethics, the American Nurses Association’s Code states that “…the nurse acts to safeguard the client and public when health care and safety are affected by incompetent, unethical or illegal practice of any person.” Should the hygienist’s obligation be any less than that of a nurse?

7. Scenario “Periodontist Frustrated With Referring Dentist’s Treatment”

8. Dr. Omer is the only periodontist in a community of 30,000 people. He has a good relationship with the community's 12 general dentists, all of whom refer their patients with periodontal disease to him. One general dentist, Dr. Deringer, regularly sends patients, who he has treated, with treatment so poor as to compromise what Dr. Omer can do to resolve their periodontal problems. Typically the patients will have overhanging amalgam and composite restorations, and crowns with open or overextended margins. Fixed prosthetic appliances are rarely in proper occlusion. Often, Dr. Omer has done what he can within the constraints of his periodontics practice to fix these problems, but there is only so much he can do. He has spoken to his colleague, Dr. Deringer, on several occasions, suggesting ways in which he might improve the outcomes in this treatment. But this has not seemed to help. Today he has had another one of Dr. Deringer's patients and has had to trim a large excess from the gingival margin of a temporary bridge. The patient asked why such was necessary, as Dr. Deringer had just placed the temporary a week ago. This is the third time in less than a week that one of Dr. Deringer's patient's has asked Dr. Omer potentially embarrassing questions about Dr. Deringer's treatment. What should Dr. Omer do?

9. ADA Principles of Ethics and Code of Professional Conduct “Patients should be informed of their present oral health status without disparaging comments about prior services.” How is it possible to tell a patient that his or her oral health is poor without explaining some of the causative factors?

10. ADA Code (continued) “Specialists or consulting dentists, upon completion of their care, shall return the patient to the referring dentist.” If the periodontist tells the patient about the problem and refers him/her to another dentist, s/he seems to be violating this section of the Code. Yet, the principle of beneficence obligates the dentist to work for the patient’s best interests.

11. ADA Code (continued) Whenever the patient’s interests conflict with the professional’s, the Code states that benefit the patient is the primary goal. And, the Code specifies that all dentists are obligated to report gross or continual faulty treatment by other dentists to the appropriate reviewing agency. (Association peer review in a specific case, or to the state board of dentistry.)

12. Scenario “UK Graduate Launches Practice As Associate”

13. Diane Campbell graduated from the University of Kentucky in May, and is now the associate of Dr. Gutz in Northern Kentucky. Dr. Gutz is in his early 60s, and plans to retire within a couple of years. The plan is for Dr. Campbell to purchase his practice at that time. Shortly after arriving in the practice Dr. Campbell notes that the quality of Dr. Gutz's work is not what she anticipated it would be, and certainly is not in keeping with the standard of care that she was taught while at the University. Dr. Gutz never uses a rubber dam. He does not perform endodontic procedures, nor does he refer them to the local endodontist, regularly telling patients that such teeth cannot be saved, and routinely extracting them. He does not do patient consultations and does not know about the issues associated with informed consent. (Once when Dr. Campbell asked him about it, he replied that such was nonsense; that he knew what was best for the patient, and that he had never been sued.) Dr. Gutz does not restore primary teeth, but routinely extracts them, without placing space maintainers. Just recently Dr. Campbell entered Dr. Gutz's operatory and noted that he was condensing a large mesio-occlusal restoration on a mandibular first permanent molar without a matrix band in place. Dr. Campbell is distressed concerning the welfare of patients under Dr. Gutz's care; she believes it just isn't fair that they receive less than adequate dental care. She is also very concerned about the type of practice with which she is associated, and her plan to purchase the practice in the near future. What should Dr. Campbell do?

14. ADA Principles of Ethics and Code of Professional Conduct The Code warns that criticizing comments must be justifiable and “…a difference of opinion as to preferred treatment should not be communicated to the patient in a manner which would imply mistreatment.” Does this preclude comments about or reporting of care that is clearly outside the standard of care, and is harmful to the patient?

15. Three Common Elements in Whistle Blowing Dissent: the whistle blower disagrees with another. Loyalty: typically the whistle blower sounds the alarm about a member of his/her team, in dentistry a member of the profession, By so doing raising the specter of lack of loyalty. Accusation: the whistle blower identifies an individual to an authority who is acting incompetently, immorally, and/or illegally, thus causing harm to another.

16. Dissent Should the incident or person be reported to the peer review committee or the state board of dentistry? Questions to ask: –Who will be harmed and how badly? –Who will benefit and how much? –How accurate and well- documented are my facts? –What is the standard of care?

17. Loyalty Loyalty to the profession does require that an attempt be made to work things out with the offending individual before ‘going public’ and ‘blowing the whistle.’ “Have all the existing and less drastic avenues for change been exhausted?

18. Loyalty (continued) Is excessive loyalty being displayed? Rarely do dentists come before peer review bodies, and rarely do dentists have their licenses sanctioned for incompetence or treating patients unfairly; yet many dentists will affirm privately that they witness examples of incompetent care regularly. William May suggests, in The Physician’s Covenant, that duty to colleagues frequently is more persuasive in the practitioners mind than duty to patients; and suggests this is highly problematic ethically.

19. Accusation What are one’s motives in ‘blowing the whistle?’ Careful attention must be given to separating an urge of self- aggrandizement, gaining a patient, or revenge for perceived wrong-doing by the other, from a genuine desire to serve the patient’s and society’s best interest.

20. Self Regulation in Kentucky The Kentucky Board of Dentistry receives “5 or 6” complaints by dentists of other dentists annually. Typically these relate to advertising, quality of dental care, and impairment. Though all not necessarily ‘whistle blowing,’ the Kentucky Dental Association receives approximately 20 cases for peer review annually.