David Croser advises a cautious approach to ‘blowing the whistle’ on standards of dental treatment.
Consider the situation of Myra, a young dentist who recently joined a new practice to take over some of the patients formerly treated by Salim, one of the partners now working part-time in the practice. As part of a structured retirement plan due to failing eye-sight. Myra also sees the emergency cases for Salim when he is away from the practice.
After six months or so Myra has begun to acquire a nucleus of patients; the appointment book is starting to fill up, but she is still worried about the number of gaps during the day, which won't easily be filled until Salim finally retires in nine months time. This transfer of Salim's patients has also been worrying here because there have been a number of cases she has seen where Salim's recent treatment has failed. There have been root-filled teeth that have re-infected, crowns that have fallen out, heavily filled teeth that have only been patched and a significant amount of untreated periodontal disease.
Inheriting problems
Myra is worried that she will soon be inheriting many of Salim's patients who seem to have a mass of problems and she will face an ethical dilemma of what to say to patients if she considers there has been supervised neglect. Does she need to 'blow the whistle'?
Myra is inhibited about confronting Salim about these disturbing cases and all the more so because she realises that he is extremely popular with patients and has been in the practice for many years. Salim's appointments tend to last no more than a few minutes after which the patient emerges laughing at the consoling news that everything is fine. With increasing frequency they return a few weeks later with an acute problem to be treated on a day when Salim is away from the practice.
As the problem becomes increasingly significant the young dentist, Myra, feels that she needs to resolve the matter soon. Indeed she feels the problem is getting her down; what should he do? Should she call the GDC? Contact Dental Protection? Speak to the other partners or steel herself to have a word with Salim?
Before doing anything in this situation it is important to take a moment to collect and document all the facts.
The obligations
The above scenario is not uncommon and doesn't only happen when a young dentist takes over the practice of a retiring dentist. It can occur at all stages of one's career - particularly when a dentist has had a blind spot to certain types of treatment or is perhaps unwell or distracted by other pressures in their personal life. These situations carry certain obligations as defined in the General Dental Council's booklet Principles of Raising Concerns (see box 1)
The ethical obligation is to act to protect patients at all times when you believe that a colleague's conduct, performance or health puts patients at risk. This ethical duty over-rides personal and professional loyalties and the obligation is on the dentist to discuss the matter with a senior colleague, or appropriate professional body. There is no obligation to immediately 'whistle blow' to the authorities, but it does mean that you cannot simply sit back and allow things to happen.
One of the dilemmas of course is deciding just what standard of dentistry puts the patient at risk? Is it a single crown that does not fit or is it a prolonged series? Great care should be taken therefore by any dentist in this situation to avoid being excessively judgmental about a small sample of patients. There are two sides to every story and you have no guarantee that the impression you obtain from examining the patient is the same as talking to the dentist who carried out the treatment.
The key is to take advice from a senior colleague and to talk through the issues before deciding upon what course of action to take. If possible and the inter-professional relationship permits, the matter should be brought to the notice of other dentist as soon as possible. Below is a checklist to consider in the event of concerns about whistle blowing.
1. Document all the cases thoroughly, with comprehensive clinical notes, X-rays and photographs if necessary. Detailed records can be of great assistance in validating any concerns that you may have and indeed in demonstrating to the poorly performing dentist that there is a problem.
2. Consider carefully whether the patients that you are seeing are a representative sample of this dentist's work. For example, if the only patients seen are those who present as an emergency they may not be representative of the entire list. Beware of making assumptions.
3. Don't jump to conclusions. Remember you were not present when the treatment was carried out and there may be other factors to explain the condition of a patient's mouth.
4. Arrange if possible to speak with the dentist whose work requires replacement and involve them in the decision to do so. Be prepared to make records, radiographs etc accessible to the dentist, particularly if the dentist has left the practice.
5. Consider involving others in the practice if you feel intimidated in discussing the matter with the poorly performing dentist.
6. Consider involving others such as your employer or your manager, senior colleagues on the Local Dental Committee or the Dental Health Support Group. Confidentiality is important but patient safety comes first. We would suggest that you always take advice on such issues from Dental Protection.
7. Be prepared to justify your own treatment plans for the patient as frequently the new treatment plan throws the patient into a state of confusion. Do not resist the patient seeking a second opinion and it is a good idea to be willing to put your treatment plan in writing.
8. Remain objective. Answer questions honestly and do not make gratuitous criticism.
9. Treat all situations with care and sensitivity. Patients may be very reticent to challenge their old dentist that they have seen and trusted for many years. Dentists are very proud about their professional practice and it may be very difficult to accept that one's performance is poor. When raising these issues it is always important to do so with care and sensitivity.
10. If a patient wishes to take the issue further then it is good to try and encourage the patient to raise that issue in the first instance with the dentist who provided the treatment. This, at the very least, gives the poorly performing dentist an opportunity to resolve the issue directly with the patient. This is a separate consideration as to whether the matter should be referred elsewhere.
11. If you do decide to whistle blow then be prepared to follow it through by providing evidence and being challenged on that evidence if necessary.
Principles of Raising Concerns
2.1 You have a responsibility to raise any concern you have
that patients might be at risk because:
of the health, behaviour or professional performance
of an employer or colleague;
You can download the full document from www.gdc-uk.org