Whistle Blowing in
Dentistry
When Does the Dentist
Have the Obligation To
‘Blow the Whistle’ On A
Colleague Who Is Treating
A Patient Unjustly?
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.
Case Scenario
“Hygienist Troubled
By Employer’s
Attitude and
Behavior”
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?
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.
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?
Scenario
“Periodontist
Frustrated With
Referring Dentist’s
Treatment”
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?
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?
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.
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.)
Scenario
“UK Graduate
Launches Practice
As Associate”
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?
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?
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.
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 welldocumented are my facts?
– What is the standard of care?
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?
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.
Accusation
• What are one’s motives in
‘blowing the whistle?’
• Careful attention must be given
to separating an urge of selfaggrandizement, 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.
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.