ETHICS CASE

 

Referrals - practitioner, patient & specialist obligations

 

 

S Naidoo

BDS (Lon), LDS.RCS (Eng), MDPH (Lon), DDPH.RCS (Eng), MChD (Comm Dent), PhD (US), PG Dipl Int Research Ethics (UCT), DSc (UWC). Senior Professor and Principal Specialist, Faculty of Dentistry, University of the Western Cape, Department of Community Dentistry, Private Bag X1, Tygerberg 7505. E-mail: suenaidoo@uwc.ac.za

 

 

The profession of dentistry has both benevolent and protective aspects with regards to duty of care to patients, to always try to do the best for the patients and to fulfill the principle of non-maleficence -to do no harm. This principle expresses the concept that professionals have a duty to protect the patient from harm. Under this principle, the dentist's primary obligations include keeping knowledge and skills current, knowing one's own limitations and when to refer to a specialist or other professional. All dentists, whether generalists or specialists, have both legal and ethical responsibilities to their patients - legally they need to exercise reasonable skill and care and ethically they are obligated to always put the best interests of the patients first (above personal or professional interests) and to carry out treatment to the standard of care set by the profession.

General dentists are usually the first professional patients visit, seeking an evaluation of their oral and dental needs. The general dentist may then treat the patient or may refer the patient for specialty care depending on the conditions which have been assessed and diagnosed. This is because amongst general dentists there are differing levels of expertise, exposure to post-graduate training, and confidence in undertaking the treatment of more complicated and advanced dental conditions. When necessary, timely and appropriate referral is an ethical imperative which fulfils a professional duty to a patient. Failure to inform a patient of the need for specialist consultation and/or referral could result in violation of the ethical principles.

General dental practitioners are obliged to seek consultation whenever the welfare of a patient will be protected or may benefit by utilising those who have special skills, knowledge, and experience. Patients are referred to a specialist for many reasons including the complexity of the case, definitive diagnosis, behavioural problems, the patient's medical history, the need for specialised investigations and tests. The general dentist is expected to recognize when specialist care is more appropriate for the patient's needs and completion of the treatment plan and should then refer appropriately. This is stated in the Health Professions Council General Ethical Guidelines for the Health Care Professions¹ as follows:

5.7 Access to Care

Health care practitioners should:

5.7.1 Promote access to health care. If they are unable to provide a service, they should refer the patient to another health care practitioner or to a health care facility where the required service can be obtained.

6.1 Referrals to Colleagues

6.1.1 Act in their patients' best interests when making referrals and providing or arranging treatment or care. They should not ask for, or accept, any undue inducement or incentive, from colleagues to whom they refer patients because it may affect or be seen to affect the health care practitioner's judgement.

6.1.2 Treat patients referred to them in the same manner in which they would treat their own patients.

On occasion, patients may decline the offer of the general dentist's referral to a specialist. Provided that the treatment is within the limits of the dentist's competence, and that the patient understands that a higher standard of care might be obtained from a specialist, one would still be satisfying the requirement of duty of care. However, if one acquiesces to the patient's request, in circumstances where the treatment falls beyond the skills, training and expertise required, and one fails to make sure that the patient understands this, then it would become much more difficult to refute any allegation of a dereliction of duty of care.² Therefore when a patient is referred for specialist care both the referring practitioner and the receiving specialist need to ensure that they arrange a smooth transfer.

All referrals should always be conducted in a professional manner, respecting the usual professional courtesies which one would expect between two healthcare professionals. Clear and effective communication between all parties is essential in the referral process. The referring general dentist should be cognisant of the following guidelines and responsibilities to ensure the patient is provided with the required level of professional care.

 

COMMUNICATION BETWEEN THE REFERRING DENTIST AND THE PATIENT

• The patient should be informed of the rationale for the referral and the procedures and protocols involved. These include the reason and purpose of the referral, the expected nature and scope of the procedures involved, and the anticipated outcome of the referral and treatment.
• The choice of a specific specialist should take into account any patient preference.
• Referral correspondence should be written in the expectation that the contents could be read by the patient, or by any professional colleague who is referred to in the text.
• The patient should be informed that all relevant information will be sent to the specialist in advance of the consultation appointment.
• The patient should be given information that will assist in the introduction to the specialist, educational material, contact details and directions to the specialist's practice.

 

COMMUNICATION BETWEEN THE REFERRING DENTIST AND THE SPECIALIST

It is preferable that the referring dentist conveys, in advance, all information that will assist the specialist in providing a complete consultation to the patient. Referrals letters should include, but are not limited to:

• The patient's name, age and contact information (address & telephone numbers)
• Clear instructions on the nature, scope and reason of the referral and expectations of the referring dentist.
• Relevant treatment and background information;
• Relevant medical history that may necessitate prophylactic antibiotic coverage or any other precautions prior to the consultation.
• Projected treatment needs following the referral.
• In addition, relevant records and materials such as radiographs, laboratory reports, models and other medical or dental information that would assist the specialist in the assessment of the patient should be included. The normal professional courtesy which is adopted when a patient is referred to a second dentist, is for it to be made clear at the outset what the scope of the referral is, and whether or not it is anticipated that the patient will be referred back to the original dentist when the relevant episode of treatment has been completed.³ Problems can sometimes arise when the second dentist accepts the patient for their future care, when the original dentist was expecting the patient to be referred back. This may be on account of the patient's stated wishes -but this process must be transparent, and the patient's decision should be communicated back to the original dentist so as to avoid the perception that the patient may have been unfairly influenced to change dentists - an action that is widely considered to be unethical.³

 

COMMUNICATION BETWEEN THE SPECIALIST AND THE PATIENT

The patient would need to be informed by the specialist's practice details of the appointment time, date and the practice location. The specialist has the responsibility to provide a consultation and treatment for patients while ensuring that the procedures performed are in compliance with the overall treatment plans and goals established by the GDP and patient. The following protocol should be considered to achieve delivery of optimal treatment and to provide continuity of care for the patient while maintaining professional etiquette between the health professionals who share the responsibility for the patient's care:

• Treatment provided by the specialist should be limited to the nature, scope and reason outlined in the referral. If the specialist determines that additional or alternative treatment is recommended or required, she/he should discuss these issues with the patient and the referring dentist before proceeding with treatment.
• Alternatively, if the specialist, upon reviewing the referral letter and after consulting with the patient, deems that the treatment suggested by the referring dentist is not in the patient's overall best interest, then she/he should communicate with the referring dentist and the patient to come to a mutual agreement regarding the management of the patient.
• The specialist should not duplicate and charge for procedures already performed adequately by the referring dentist.

After the consultation, the specialist should provide the patient with information to enable an informed decision regarding management of the problem'. This information should include:

• A diagnosis, recommended treatment and possible prognosis
• Discussion of risks, benefits, advantages and disadvantages and costs of treatment alternatives
• The need for any future treatment, follow-up and maintenance; and
• The expectation that the patient will return to the referring dentist for on-going dental care.

 

COMMUNICATION BETWEEN THE SPECIALIST AND THE REFERRING DENTIST

• The specialist's practice should confirm to the referring dentist receipt of the patient referral and the timing of the scheduled consultation appointment . The referring dentist should be informed if the patient fails to keep the consultation appointment.
• If the specialist believes that continued treatment over the longer term is necessary or desirable, the general dentist should be consulted about this decision and should the receive regular treatment updates and reports. The specialist should also discuss with the referring dentist when the patient is expected to return to the generalist's practice for continued treatment or maintenance.
• If treatment had been delayed or interrupted or significantly modified, the referring dentist should receive a progress report in this regard
• If the specialist deems the need for care outside his/ her specialty, the general dentist should be consulted to determine whether the patient's need will be met by the general dentist or by another specialist and, if the latter, the general dentist should be involved in the choice of the specialist to whom onward referral will be made. If there are inter-specialty referrals, the general dentist should receive detailed consultation reports and a record of all treatment rendered or recommended by the specialists.
• After the consultation, the specialist should provide the referring dentist with a detailed consultation report, including a diagnosis, treatment options, and an account of all treatment rendered or recommended. Reports should be provided in a timely manner.
• The specialist should provide the referring dentist with relevant diagnostic quality copies or duplicates of radiographs or digital images taken by the specialist.
• The specialist should provide the referring dentist with relevant copies of any diagnostic test results, consultation letters or other information obtained.
• When the requested treatment has been completed the specialist should ensure there is provision for the patient to return to the referring general dentist, unless the patient expressly requests differently without prompting or persuasion from the specialist.
• A final report should be sent to the referring dentist at the end of treatment when the patient is returned to his/her care.
• Self-referrals by patients to specialists may occur without the knowledge of a general dentist. When this occurs, the specialist should take reasonable steps to ensure that the patient is aware of the pitfalls of not having a general dentist oversee their comprehensive dental care and try to advise the patient accordingly.
• When a consultation is provided on the basis of a self-referral by the patient, the patient's general dentist should, with the patient's permission, be sent a report in order to keep the patient's records current.
• In some instances, patients may not wish to return to the referring dentist, and request referral to a new general dentist. It is prudent for the specialist to inform the patient that professional ethics prevent further referral until the patient has discontinued the existing professional relationship with the original dentist. Further, it is also prudent for the specialist to not recommend a particular practitioner but to provide a list of dentists practicing in the area convenient to the patient.

 

CONCLUDING REMARKS

Interestingly, while general dental practitioners are entitled to carry out all dental procedures including those falling within the scope of specialists (provided that they have necessary education and training), specialists are restricted to practicing only within the ambit of the specialty or category in which they are registered. General dentists should recognise that there are many circumstances when patient needs, convenience and resources must be taken into account as part of the referral process. The relationship between general dentists and specialists should be governed by mutual respect, trust and professional etiquette.

 

References

1. Health Professions Council of South Africa. Guidelines for Good Practice in the Health Professions. Booklet 1: General Ethical Guidelines for the Health Professions. Pretoria, 2009.         [ Links ]

2. Ethics, values and the law. DPL Dental Ethics Module 4: Duty of Care. 2009        [ Links ]

3. Ethics, values and the law. DPL Dental Ethics Module 11: Relating to colleagues. 2009        [ Links ]