| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Milieu in Dental School and Practice |
Key words: conflict of interest, ethics education, patient trust, guidelines
Submitted for publication 06/04/07; accepted 10/04/07
 |
Abstract |
|---|
 Top Abstract Methods and MaterialsResultsDiscussionConclusionsReferences |
|---|
Dental schools have the responsibility to ensure that their graduates achieve the core competencies expected of a new dentist. In Canada, forty-six core competencies have been identified, and Canadian dentists rated all forty-six as high in importance on a recent validation survey, including the application of ethical principles to professional practice.4 These competencies serve as benchmarks for reviewing, redefining, and restructuring the predoctoral curriculum.5
Organized dentistry does not have standing ethics committees that deal specifically with ethical issues, including conflicts of interest. The Canadian Dental Association disbanded its ethics committee years ago, deferring guidance to the provincial regulatory bodies. Business ethics have been driven by the public’s perception of the corporation as an overall entity as represented by the actions of senior management.6 Dental ethics is differentiated by the fact that relationships are primarily viewed as interactions between individuals in areas of autonomy and informed consent. Currently, there is no formal mechanism to effectively deal with the public’s perception of the profession as a whole. Although the public does not determine professional ethics standards, there is a strong association between public trust and the perception of ethical behavior. A recent Gallup Poll, which asked the public to rate the honesty and ethical standards of various professions, rated dentists fifth behind nurses, pharmacists, veterinarians, and physicians. Only 62 percent of the respondents rated dentists as high or very high.7
Lack of public trust in dentists may well have been kindled by the news media regarding perceived conflict of interest issues. Recent media reports such as "Second Opinion on Dental Ethics,"8 "Dental Boot Kamp,"9 and "Dentists’ Fraud Growing"10 have tarnished dentistry’s reputation as an ethical profession and increased patient awareness of ethical issues related to conflicts of interest. Such mass media programs have challenged the level of trust that patients should have in their dentist. As more patients become aware of innovative marketing strategies, the principle of caveat emptor (buyer beware) could potentially affect the entire trust-based relationship that is currently eroding the position of dentistry as one of the most respected professions.
Very little research has been done concerning what dentists consider a conflict of interest. There are no studies that answer the question of whether dentists feel adequately prepared in ethics and communication to deal with the myriad of difficult issues they face in general practice. This study attempted to identify some of the issues respecting conflicts of interest among practicing dentists in Ontario.
|
Methods and Materials |
|---|
|
TopAbstractMethods and MaterialsResultsDiscussionConclusionsReferences |
|---|
A pilot study was first conducted in Newmarket, Ontario, in 2006. Letters were sent to all sixty-five dentists practicing general dentistry, requesting them to participate in the study. It was felt that the dental practitioners in this community of 65,000 people represented a combination of urban and rural dental practice that fairly reflected dental practice in Ontario as a whole. Twenty-two dentists (33.8 percent) responded to the pilot survey. Follow-up letters and phone calls were unable to increase the response rate appreciably. Thirteen dentists agreed to complete the survey a second time to determine test/retest reliability, but only two actually completed the questionnaire a second time. Eighty-six percent of the responses to the initial and second questionnaires were in agreement for these two respondents. Pilot survey comments and reliability scores were used to refine the Ontario questionnaire. Ethics Review Board approval was obtained from the University of Western Ontario for both the pilot and Ontario-wide surveys.
Following the pilot study, the questionnaire was revised and then sent to 3,000 general dentists randomly selected from the Royal College of Dental Surgeons of Ontario (RCDSO) membership list of 7,623 practicing general dentists. The target number of 3,000 was selected to provide frequency estimates within ±1.8 percent of the target population value with 95 percent confidence. Newmarket dentists, having been surveyed previously, were excluded from the Ontario-wide study. Simple random sampling was used since the pilot study had revealed no statistically significant response differences between urban and rural dentists and other information regarding demographic variables and practice characteristics was not available.
Responses to the Ontario-wide survey were coded and then entered into a computerized database. The data were analyzed using JMP (v.5.2.1) and SAS (v.9.1) statistical software packages. Standard quantitative analyses, such as chi-square tests, were employed to assess the association of attitudes and opinions concerning conflicts of interest with gender, length of practice, prior communications, ethics, and religious training. Where sample size permitted, logistic regression analysis was used to develop multivariate models for predicting attitudes and perceptions related to conflicts of interest in dentistry.
The study was designed to test the following hypotheses:
|
Results |
|---|
|
TopAbstractMethods and MaterialsResultsDiscussionConclusionsReferences |
|---|
presents the characteristics of the study respondents and, where available, those of practicing Ontario dentists. Just over 80 percent of the responding dentists were thirty-one to sixty years of age, 7 percent were under thirty-one years of age, and 10 percent were over sixty-one years of age. Males outnumbered females almost four to one. By contrast, 77 percent of Canadian general dentists are thirty-one to sixty years of age, and males outnumber females three to one.
|
The vast majority of respondents practiced fee-for-service dentistry (91 percent). Close to 7 percent accepted fee-for-service along with another form of remuneration. Less than 1 percent were retired, and 0.5 percent were involved in a capitation payment plan. By comparison, 92 percent of Canadian general practitioners engage in fee-for-service practice.
Two in five respondents (40 percent) reported receiving no formal ethics education in dental school, 58 percent acknowledged one to eight hours of training, and 22 percent reported more than nine hours. Only 21 percent of dentists reported having any formal ethics training since graduation. Formal interpersonal communications training was less prevalent. Forty-one percent of the responding dentists reported having taken no such training, 43 percent had between one and eight hours, and 16 percent reported receiving more than nine hours of instruction. Formal religious training was reported as having been undertaken by just over half (51 percent) of the dentists. Half (49.4 percent) of the respondents were not aware of any conflict of interest guidelines in dentistry.
Table 2 presents the attitudes and perceptions of the responding dentists regarding eight specific conflicts of interest. When asked about selling dental products for profit in their offices, one-third agreed that it was ethically acceptable as long as the patients got a good deal on the product. Almost three out of five of the responding general dentists (59 percent) had ethical concerns regarding the acceptability of paying a $25 bonus/credit for referring a new patient. Sixty-five percent of the respondents felt that referring patients to an oral surgeon who was in the same office as the general practitioner in exchange for a 50 percent facility fee was ethically acceptable. Three-quarters of the respondents had no ethical concerns about receiving gifts from specialists for Christmas or their birthday, which patients might construe as another form of payment. Only 13 percent of dentists had an ethical concern about receiving such gifts. When asked what value of gifts might create an ethical concern for the dentist, 11 percent (n=78) said that all gifts create an ethical concern, while 17 percent (n=112) felt that gifts valued at under $50 did not present a concern, 22 percent felt that $100 was their limit (n=146), 22 percent felt their limit was under $500 (n=147), and 26 percent felt that there was no limit on value that would make a gift an ethical concern (Figure 1). Paying another health provider who is also the dentist’s landlord more than the normal rent for office space in exchange for sending referrals found dentists fairly evenly divided, with 46 percent agreeing and 44 percent disagreeing with the appropriateness of these arrangements. The respondents were also fairly evenly divided (45 percent agreeing and 46 percent disagreeing) regarding the appropriateness of paying another health practitioner (such as an M.D.) who is also the dentist’s landlord more than the normal office rent in exchange for referrals.
|
|
When asked about a situation in which unnecessary treatment might be performed solely to fulfill educational credit requirements in dental school, such as a surgical complex extraction versus a simple extraction, 24 percent saw no reason to inform the patient since a blanket consent form had already been signed. The overwhelming majority of dentist respondents (88 percent) felt that conflict of interest issues need to be discussed more openly.
Dentists were specifically asked about their previous ethics, religious, and interpersonal communications training and whether that training had influenced how they dealt with conflict of interest issues. Forty-four percent of the respondents felt that dealing with these issues comes from experience only, while 53 percent felt that their ethics training heavily influenced their ability to deal with conflicts of interest. Likewise, 40 percent felt that how they dealt with conflict of interest issues was also heavily influenced by their religious training, and 45 percent felt that their communications training was a major factor. There were associations with dentists who felt that learning to deal with conflict of interest issues is heavily influenced by their previous ethics training (p<0.001) and those who felt that their ethics training enabled them to make better decisions (p<0.001), those who read ethics-related articles in journals (p<0.001), and those who had communications training in dental school (p=0.004) (see Table 3).
|
reports the attitudes of dentists towards ethical decision making. Almost half (49.8 percent) of the dentists responding to the survey felt that their ethics training enabled them to make better ethical decisions, and more than half (57 percent) would have liked to receive more ethics training in their undergraduate program. Over three-quarters of the respondents would have liked more communications training. Of the dentists who had religious training (n=353), 68 percent felt that their religious training had enabled them to make better ethical decisions.
|
When asked if "learning to deal with conflict of interest issues is heavily influenced by my previous ethics training," a significant association was established with mode of practice (p=0.044). Those who work only in a fee-for-service practice (n=502) agreed 64 percent of the time, while those who had alternate employment status (n=51) agreed more frequently at 78 percent. Dentists who received formal ethics training in dental school (n=274, 71 percent) were more likely to agree (p=.016) with a statement that ethics training would heavily influence how one dealt with conflict of interest issues than dentists who did not have formal ethics training (n=218, 59 percent). The respondents who indicated that they had received formal ethics training also felt that this training helped them make better ethical decisions.
Mode of practice is a possible determinant of perceptions regarding conflict of interest. In this study, 90.6 percent of the respondents were engaged solely in fee-for-service practice. When dentists were provided with the definition of a manageable conflict of interest and asked whether various modes of practice were, of themselves, a manageable conflict of interest, 68 percent of the respondents felt that all dental treatment is a manageable conflict of interest in fee-for-service practice compared with 37 percent who felt that all dental treatment is a manageable conflict of interest in capitation practice and 48 percent who felt that all dental treatment was a manageable conflict of interest when dentists are salaried. Only 17 percent of the respondents thought that fee-for-service dentists would be inclined to overtreat a case. Conversely, 72 percent felt that dentists remunerated by capitation would undertreat, and 38 percent felt that salaried dentists would compromise quality to maintain their patient quotas (Table 5).
|
|
Discussion |
|---|
|
TopAbstractMethods and MaterialsResultsDiscussionConclusionsReferences |
|---|
There is no consensus among practicing dentists as to what are deemed ethical issues and what are practical business decisions. A previous study by Kress et al. concluded that dentists’ perceptions differ greatly as to what constitutes an ethical problem.13 Our study supports those findings. Furthermore, regulations respecting ethical issues differ according to the region. While, in Ontario, dentists are advised not to sell dental products, the American Dental Association (ADA) advises dentists only to take care that they do not exploit the trust that patients place in them for their own financial gain.14,15
Some of the conflict of interest examples used in this survey, like the selling of dental products for a profit and benefits obtained for referring patients, are clearly outlined in the RCDSO conflict of interest guidelines, which all dentists in Ontario receive. For the other issues, no clear guidelines have been issued. Even though the RCDSO guidelines specifically forbid the selling of dental products for a profit, over half of the respondents felt otherwise. This would indicate that many dentists are not aware of the existing guidelines and would suggest that even those dentists who read the guidelines interpret them differently.
Interestingly, dentists see their current mode of practice as being manageable while commenting on other modes of practice as being less manageable insofar as conflicts of interest are concerned. This supports the notion that dentists enrolled in capitation plans would undertreat and reinforces a study by Brown and Ruesch that concluded that capitation dentists were dissatisfied with their fees and had concerns about being able to provide only the minimum level of care for their patients.16
If a student performs a treatment, with approval by a faculty member, in order to receive a credit or meet a requirement and that treatment is not in that patient’s best interest nor are the reasons disclosed to the patient, the student may wrongly conclude from this situation that there are times when the dentist’s own needs supersede the needs of the patient. Immanuel Kant said that people should not be treated as a means to someone else’s end.17 According to Newsome and Wolfe,18 "Patients’ primary needs are that they be treated respectfully, ethically, and professionally." According to Van Dam and Welie, the moral risk of treating patients for the sake of meeting educational needs creates a serious conflict of interest.19
The results of this survey demonstrate an association between ethics training and the perception of practicing dentists regarding decision making and dealing with conflict of interest issues. These findings also support the hypothesis that dentists feel that dealing with conflicts of interest is assisted through education. Sharp and Stefanac stated that "it is critical for ethics learning to be reinforced through students’ classroom and clinical experience" and that "observation of good ethics technique is the single most powerful learning tool programs can employ."20
Cohn and Lie reported that religion had shaped medical students’ values in developing an approach to codes of ethics.21 The results of our survey support those findings. No significant associations with age, length of practice, or gender were established.
Many patient complaints received by dental regulatory bodies are communications-based.22 According to the RCDSO Risk Management Guide, "establishing good dentist-patient communications will prevent most lawsuits or patient complaints."23 Unfortunately, few dentists, according to our survey results, have had adequate interpersonal communications training. The results of a previous study suggest that practitioners would benefit from more comprehensive training in interpersonal skills.24
The results of our survey indicate that dentists feel that postgraduate courses in ethics would help them make better decisions regarding conflicts of interest in dentistry. Interestingly, the RCDSO currently only offers remedial ethics courses to dentists who must fulfill an undertaking following a disciplinary hearing involving unethical practice. At the time of this writing, no other continuing dental education courses in ethics are offered in Ontario.
What is clearly evident by our survey is that many dentists are not aware of the existing conflict of interest guidelines produced by the RCDSO. The RCDSO guidelines clearly state that dentists should not profit from the sale of dental products, nor should they enter into contractual arrangements, such as a lease, that provide for a fee or income split.25 The results of our study suggest that many dentists are unclear about the meaning of these guidelines.
Licensing bodies, which set out conflict of interest guidelines, must be perceived by the public and dentists to be free of any conflicts of interest themselves. Almost half (44 percent) of the respondents were concerned about a troubling conflict of interest with the regulatory body collecting the malpractice insurance and administering it through their own Professional Liability Program (PLP). The RCDSO reports the combined affairs of the college and the PLP together on the same balance sheet statement of operations, making the workings of each division somewhat blurred.26 Transparency would be improved and this perceived conflict of interest would be eased if dentists in Ontario were able to purchase their malpractice insurance from an arms-length party, such as the Canadian Dental Services Plan, as they do in almost every other province.
|
Conclusions |
|---|
|
TopAbstractMethods and MaterialsResultsDiscussionConclusionsReferences |
|---|
Of those who responded, most dentists agreed that it is important to discuss conflict of interest issues openly and to raise awareness of these issues. Respondents identified many factors that are associated with better ethical decision making and dealing with conflict of interest issues. More research, education, and discussion are therefore required in this important area of dentistry in order to provide dentists with better direction in managing issues patients may view as conflicting and therefore continue to earn and sustain patient trust in the profession.
|
Footnotes |
|---|
|
REFERENCES |
|---|
|
TopAbstractMethods and MaterialsResultsDiscussionConclusionsReferences |
|---|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
