- Email: [email protected]
Patient care and responsibilities of the itinerant provider
FEATURES
ETHICAL MOMENT
Patient care and responsibilities of the itinerant provider Kennedy W. Merritt, DDS; Kristi Soileau, DDS, MEd
Q
I practice dentistry in a remote part of my state only 3 days per month. A few days after 1 of my clinic days, a patient who underwent a difficult extraction began experiencing swelling, pain, and fever. I prescribed antibiotics and narcotics over the phone, but they did not manage her issues, and she needed someone to look at the extraction site to assess the problem. No other dentist’s practice is within 30 miles. The patient cannot drive that far, and she is not comfortable making the trip while taking “pain pills.” The emergency department physician is comfortable giving her stronger antibiotics in hopes of helping her but is not capable of diagnosing whether the extraction site is healing as it should. I will not return to town for another 2 weeks and do not have access to digital records. Is it ethical to maintain a practice model of itinerant dentistry that provides care irregularly to patients without having reasonable emergency care arrangements in place?
A
The profession of dentistry struggles with providing care to all who need it. In this scenario, you are offering care to a population that likely would not receive such care under any existing typical practice models. Presuming quality of care is not in question, the inability to provide timely or
adequate follow-up care certainly may be an ethical concern in comparison with the care available from more settled providers in the community. Although the American Dental Association Principles of Ethics and Code of Professional Conduct1 (ADA Code) had been in effect for many years before such alternative practice models came to be, it was drafted to be adaptable and, thus, successfully provides helpful guidance in assessing the ethical ramifications of this activity. Each of the ADA Code’s 5 ethical principles—Patient Autonomy, Nonmaleficence, Beneficence, Justice, and Veracity—apply. Section 1, Autonomy (“selfgovernance”) obligates dentists “to safeguard the confidentiality of patient records.”1 This, however, does not mean simply that the dentist should protect patient information. Of further consideration is the fact that relevant information in the patient’s records must be released to another practitioner, on request, if that information “will be beneficial for the future treatment of that patient.”1 In your case, you are considered the patient’s current and primary dental caregiver; however, the medical professional providing emergency care may not have timely access to the patient’s treatment record. Making arrangements in advance to ensure accessibility of the patient’s records to other providers who may need to provide care to the patient between visits to you would be 1 way to “maintain patient records in a manner consistent with the protection of the welfare of the
patient.”1 To act in the best interest of the patient, you should provide some mechanism through which a health care professional who is providing emergency care can gain access to the patient’s record. The patient should be informed about how and when this may occur. Another ethical consideration addressed by the principle of Autonomy is informed consent. Before initiating treatment, a patient must be informed of the risks, benefits, and alternatives to procedures that have been recommended. Another important piece of information for the patient also might include who will provide emergency care in your absence, as well as where that care can be accessed. The ADA Code supports that the patient must be informed about the possibility that seeing another practitioner may be necessary in the event that followup care is required before the primary dentist returns and is able to provide care again. The ADA Code obligates dentists to involve “patients in treatment decisions in a meaningful way,”1 which would suggest that you must inform patients of the foreseen limitations of the care being provided. This would be the only way to ensure that “due consideration [is] being given to the patient’s needs, desires and abilities .”1 Section 2, Nonmaleficence (“do no harm”) also applies to your situation. Nonmaleficence means that the dentist must “do no harm.”1 Under this principle, the dentist has an obligation to know his or her own limitations. Once
JADA 148(9) http://jada.ada.org
September 2017 695
FEATURES
such limitations are known, it is an itinerant dentist’s responsibility to assess his or her ability to be physically present in the event of an emergency. The awareness of such a limitation may affect the types of procedures that the dentist is able to provide. For example, it may not be feasible for an itinerant dentist to perform surgical procedures if he or she does not have an established mechanism for providing postoperative care. The itinerant dentist may need to have an established relationship with other providers to whom referrals will be made under circumstances such as those of your patient or when procedures are necessary and the itinerant dentist is unable to follow through. Related to this is Section 3, Beneficence (“do good”). Beneficence refers to doing good for the patient—in other words, the dentist has a “duty to promote the patient’s welfare.”1 According to the ADA Code, 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.1
Thus, in this situation, the providing dentist is offering care to an underserved population, which fits squarely within the goals of Beneficence and takes into account that the circumstances under which the patient is seeking care may not be ideal. However, the dentist should recognize and attempt to take into account circumstances that are less than ideal, such as the dentist’s limited presence in the community, by making advance arrangements with other providers, as well as considering other means of being in communication with existing patients, including by phone or e-mail, as long as privacy and confidentiality are not
696 JADA 148(9) http://jada.ada.org
jeopardized. One type of arrangement might include teledentistry.2 Section 4 of the ADA Code, Justice (“fairness”) is also applicable. This principle “expresses the concept that the dental profession should actively seek allies throughout society on specific activities that will help improve access to care for all.”1 It also refers to fairness, such that if a dentist is unable to provide posttreatment emergency care, the dentist nonetheless is “obliged to make reasonable arrangements for the emergency care of their patients of record.”1 Because of your schedule, you should address the need for possible emergency followup care. You should consider this issue carefully before embarking on the provision of itinerant dental treatment in remote areas. As part of the consideration of providing itinerant dental services in a remote location, you should identify possible sources of follow-up care in emergent situations. Likely sources are hospital and medical center emergency departments, urgent care clinics, and other health care and medical professionals. You can discuss your plans for providing needed dental care to residents of the region on an itinerant basis with the potential providers of follow-up care, noting the best sources for follow-up care for issues arising from the different treatments that you are likely to provide. A dentist considering providing itinerant dental care may wish to consider other sources of ethical advice about the provision of health care by an itinerant health care provider. Because leaving the patient to find emergency care on his or her own is not ethical practice, you should make special note of any treatment areas where follow-up care is not available. In these cases, before commencing treatment, you should discuss the possible need for follow-up care with the patient and arrive at a mutually acceptable arrangement
September 2017
for providing posttreatment care, should such be needed. Possible alternatives are transporting the patient to the most convenient provider of qualified follow-up care via a social service agency providing that transport, transport being arranged by the patient at the patient’s expense, or transportation that the dentist subsidizes. Consider in particular situations whether a convenient local health care provider or the local hospital emergency department can transfer intraoral images electronically to you, who then could consult collaboratively with a secondary care provider to provide adequate follow-up care. Another alternative in instances in which no adequate follow-up care exists is for you to commit to being available to provide that care in the event of an emergent situation. In the event that no source of adequate follow-up care is identified, you have no alternative but to forgo providing that required treatment and refer the patient to the best available alternative source of care where the appropriate level of any follow-up that may be necessary is available. Only in this way is the patient’s welfare protected.3 Finally, in Section 5, Veracity (“truthfulness”), the fifth principle “expresses the concept that professionals have a duty to be honest and trustworthy in their dealings with people.”1 When care is provided to a patient by an itinerant dentist in an office that is not his or her usual or primary practice setting, being forthcoming with the patient about the potential need for follow-up or emergency care in the hands of another adequately trained and informed professional is an ethical course of action. The itinerant dentist must be honest with the patient regarding any limitations of the care being provided. Dentistry performed by an itinerant dentist can be a welcome solution to the problem of access to
FEATURES
care; however, it must be provided in an ethical manner. The well-being of the patient must be of the utmost importance, and the itinerant dentist must consider how to ensure that the patient is cared for appropriately between visits. n http://dx.doi.org/10.1016/j.adaj.2017.06.033 Copyright ª 2017 American Dental Association. All rights reserved.
Dr. Merritt is a clinical assistant professor at Midwestern Dental Institute, Glendale, AZ, and is a member of the American Dental Association Council on Ethics, Bylaws and Judicial Affairs. Dr. Soileau practices periodontics in New Orleans, LA, and is a member of the American Dental Association Council on Ethics, Bylaws and Judicial Affairs.
Address correspondence to the American Dental Association Council on Ethics, Bylaws and Judicial Affairs, 211 E. Chicago Ave., Chicago, IL 60611. Disclosure. Drs. Merritt and Soileau did not report any disclosures. Ethical Moment is prepared by individual members of the American Dental Association Council on Ethics, Bylaws and Judicial Affairs (CEBJA), in cooperation with The Journal of the American Dental Association. Its purpose is to promote awareness of the American Dental Association Principles of Ethics and Code of Professional Conduct. Readers are invited to submit questions to CEBJA at 211 E. Chicago Ave., Chicago, IL 60611, e-mail [email protected] or to call the ethics hotline at 1-800-621-8099. The views expressed are those of the authors and do not necessarily reflect the opinions of the American Dental Association Council on Ethics,
Bylaws and Judicial Affairs or official policy of the ADA. 1. American Dental Association. American Dental Association principles of ethics and code of professional conduct, with official advisory opinions revised to November 2016. Available at: http://www.ada.org/w/media/ADA/ Publications/Files/ADA_Code_of_Ethics_2016. pdf?la¼en. Accessed July 20, 2017. 2. Glassman P. Teledentistry: Improving Oral Health Using Telehealth-Connected Teams. San Francisco, CA: University of the Pacific Arthur A. Dugoni School of Dentistry; 2016. Available at: https://comm.ncsl.org/productfiles/83403465/ Teledentistry-Improving-Oral-Health.pdf. Accessed June 29, 2017. 3. American Association of Oral and Maxillofacial Surgeons. Code of professional conduct, October 2016, article V, section C.5. Available at: http://www.aaoms.org/images/uploads/pdfs/ code_of_professional_conduct.pdf. Accessed June 29, 2017.
JADA 148(9) http://jada.ada.org
September 2017 697
ETHICAL MOMENT
Patient care and responsibilities of the itinerant provider Kennedy W. Merritt, DDS; Kristi Soileau, DDS, MEd
Q
I practice dentistry in a remote part of my state only 3 days per month. A few days after 1 of my clinic days, a patient who underwent a difficult extraction began experiencing swelling, pain, and fever. I prescribed antibiotics and narcotics over the phone, but they did not manage her issues, and she needed someone to look at the extraction site to assess the problem. No other dentist’s practice is within 30 miles. The patient cannot drive that far, and she is not comfortable making the trip while taking “pain pills.” The emergency department physician is comfortable giving her stronger antibiotics in hopes of helping her but is not capable of diagnosing whether the extraction site is healing as it should. I will not return to town for another 2 weeks and do not have access to digital records. Is it ethical to maintain a practice model of itinerant dentistry that provides care irregularly to patients without having reasonable emergency care arrangements in place?
A
The profession of dentistry struggles with providing care to all who need it. In this scenario, you are offering care to a population that likely would not receive such care under any existing typical practice models. Presuming quality of care is not in question, the inability to provide timely or
adequate follow-up care certainly may be an ethical concern in comparison with the care available from more settled providers in the community. Although the American Dental Association Principles of Ethics and Code of Professional Conduct1 (ADA Code) had been in effect for many years before such alternative practice models came to be, it was drafted to be adaptable and, thus, successfully provides helpful guidance in assessing the ethical ramifications of this activity. Each of the ADA Code’s 5 ethical principles—Patient Autonomy, Nonmaleficence, Beneficence, Justice, and Veracity—apply. Section 1, Autonomy (“selfgovernance”) obligates dentists “to safeguard the confidentiality of patient records.”1 This, however, does not mean simply that the dentist should protect patient information. Of further consideration is the fact that relevant information in the patient’s records must be released to another practitioner, on request, if that information “will be beneficial for the future treatment of that patient.”1 In your case, you are considered the patient’s current and primary dental caregiver; however, the medical professional providing emergency care may not have timely access to the patient’s treatment record. Making arrangements in advance to ensure accessibility of the patient’s records to other providers who may need to provide care to the patient between visits to you would be 1 way to “maintain patient records in a manner consistent with the protection of the welfare of the
patient.”1 To act in the best interest of the patient, you should provide some mechanism through which a health care professional who is providing emergency care can gain access to the patient’s record. The patient should be informed about how and when this may occur. Another ethical consideration addressed by the principle of Autonomy is informed consent. Before initiating treatment, a patient must be informed of the risks, benefits, and alternatives to procedures that have been recommended. Another important piece of information for the patient also might include who will provide emergency care in your absence, as well as where that care can be accessed. The ADA Code supports that the patient must be informed about the possibility that seeing another practitioner may be necessary in the event that followup care is required before the primary dentist returns and is able to provide care again. The ADA Code obligates dentists to involve “patients in treatment decisions in a meaningful way,”1 which would suggest that you must inform patients of the foreseen limitations of the care being provided. This would be the only way to ensure that “due consideration [is] being given to the patient’s needs, desires and abilities .”1 Section 2, Nonmaleficence (“do no harm”) also applies to your situation. Nonmaleficence means that the dentist must “do no harm.”1 Under this principle, the dentist has an obligation to know his or her own limitations. Once
JADA 148(9) http://jada.ada.org
September 2017 695
FEATURES
such limitations are known, it is an itinerant dentist’s responsibility to assess his or her ability to be physically present in the event of an emergency. The awareness of such a limitation may affect the types of procedures that the dentist is able to provide. For example, it may not be feasible for an itinerant dentist to perform surgical procedures if he or she does not have an established mechanism for providing postoperative care. The itinerant dentist may need to have an established relationship with other providers to whom referrals will be made under circumstances such as those of your patient or when procedures are necessary and the itinerant dentist is unable to follow through. Related to this is Section 3, Beneficence (“do good”). Beneficence refers to doing good for the patient—in other words, the dentist has a “duty to promote the patient’s welfare.”1 According to the ADA Code, 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.1
Thus, in this situation, the providing dentist is offering care to an underserved population, which fits squarely within the goals of Beneficence and takes into account that the circumstances under which the patient is seeking care may not be ideal. However, the dentist should recognize and attempt to take into account circumstances that are less than ideal, such as the dentist’s limited presence in the community, by making advance arrangements with other providers, as well as considering other means of being in communication with existing patients, including by phone or e-mail, as long as privacy and confidentiality are not
696 JADA 148(9) http://jada.ada.org
jeopardized. One type of arrangement might include teledentistry.2 Section 4 of the ADA Code, Justice (“fairness”) is also applicable. This principle “expresses the concept that the dental profession should actively seek allies throughout society on specific activities that will help improve access to care for all.”1 It also refers to fairness, such that if a dentist is unable to provide posttreatment emergency care, the dentist nonetheless is “obliged to make reasonable arrangements for the emergency care of their patients of record.”1 Because of your schedule, you should address the need for possible emergency followup care. You should consider this issue carefully before embarking on the provision of itinerant dental treatment in remote areas. As part of the consideration of providing itinerant dental services in a remote location, you should identify possible sources of follow-up care in emergent situations. Likely sources are hospital and medical center emergency departments, urgent care clinics, and other health care and medical professionals. You can discuss your plans for providing needed dental care to residents of the region on an itinerant basis with the potential providers of follow-up care, noting the best sources for follow-up care for issues arising from the different treatments that you are likely to provide. A dentist considering providing itinerant dental care may wish to consider other sources of ethical advice about the provision of health care by an itinerant health care provider. Because leaving the patient to find emergency care on his or her own is not ethical practice, you should make special note of any treatment areas where follow-up care is not available. In these cases, before commencing treatment, you should discuss the possible need for follow-up care with the patient and arrive at a mutually acceptable arrangement
September 2017
for providing posttreatment care, should such be needed. Possible alternatives are transporting the patient to the most convenient provider of qualified follow-up care via a social service agency providing that transport, transport being arranged by the patient at the patient’s expense, or transportation that the dentist subsidizes. Consider in particular situations whether a convenient local health care provider or the local hospital emergency department can transfer intraoral images electronically to you, who then could consult collaboratively with a secondary care provider to provide adequate follow-up care. Another alternative in instances in which no adequate follow-up care exists is for you to commit to being available to provide that care in the event of an emergent situation. In the event that no source of adequate follow-up care is identified, you have no alternative but to forgo providing that required treatment and refer the patient to the best available alternative source of care where the appropriate level of any follow-up that may be necessary is available. Only in this way is the patient’s welfare protected.3 Finally, in Section 5, Veracity (“truthfulness”), the fifth principle “expresses the concept that professionals have a duty to be honest and trustworthy in their dealings with people.”1 When care is provided to a patient by an itinerant dentist in an office that is not his or her usual or primary practice setting, being forthcoming with the patient about the potential need for follow-up or emergency care in the hands of another adequately trained and informed professional is an ethical course of action. The itinerant dentist must be honest with the patient regarding any limitations of the care being provided. Dentistry performed by an itinerant dentist can be a welcome solution to the problem of access to
FEATURES
care; however, it must be provided in an ethical manner. The well-being of the patient must be of the utmost importance, and the itinerant dentist must consider how to ensure that the patient is cared for appropriately between visits. n http://dx.doi.org/10.1016/j.adaj.2017.06.033 Copyright ª 2017 American Dental Association. All rights reserved.
Dr. Merritt is a clinical assistant professor at Midwestern Dental Institute, Glendale, AZ, and is a member of the American Dental Association Council on Ethics, Bylaws and Judicial Affairs. Dr. Soileau practices periodontics in New Orleans, LA, and is a member of the American Dental Association Council on Ethics, Bylaws and Judicial Affairs.
Address correspondence to the American Dental Association Council on Ethics, Bylaws and Judicial Affairs, 211 E. Chicago Ave., Chicago, IL 60611. Disclosure. Drs. Merritt and Soileau did not report any disclosures. Ethical Moment is prepared by individual members of the American Dental Association Council on Ethics, Bylaws and Judicial Affairs (CEBJA), in cooperation with The Journal of the American Dental Association. Its purpose is to promote awareness of the American Dental Association Principles of Ethics and Code of Professional Conduct. Readers are invited to submit questions to CEBJA at 211 E. Chicago Ave., Chicago, IL 60611, e-mail [email protected] or to call the ethics hotline at 1-800-621-8099. The views expressed are those of the authors and do not necessarily reflect the opinions of the American Dental Association Council on Ethics,
Bylaws and Judicial Affairs or official policy of the ADA. 1. American Dental Association. American Dental Association principles of ethics and code of professional conduct, with official advisory opinions revised to November 2016. Available at: http://www.ada.org/w/media/ADA/ Publications/Files/ADA_Code_of_Ethics_2016. pdf?la¼en. Accessed July 20, 2017. 2. Glassman P. Teledentistry: Improving Oral Health Using Telehealth-Connected Teams. San Francisco, CA: University of the Pacific Arthur A. Dugoni School of Dentistry; 2016. Available at: https://comm.ncsl.org/productfiles/83403465/ Teledentistry-Improving-Oral-Health.pdf. Accessed June 29, 2017. 3. American Association of Oral and Maxillofacial Surgeons. Code of professional conduct, October 2016, article V, section C.5. Available at: http://www.aaoms.org/images/uploads/pdfs/ code_of_professional_conduct.pdf. Accessed June 29, 2017.
JADA 148(9) http://jada.ada.org
September 2017 697