ETHICS CASE

Request for records by demanding patient

P Govan

BA LLB (Wits) Dip Co Law (Wits). Head, Legal and Corporate, SADA. E-mail: pgovan@sada.co.za

From the first encounter and at the first consultation, the practitioner knew that the patient would be demanding. The patient continually interrupted the dentist and offered diagnoses based on what she had obtained from Internet searches. Practitioner and patient tolerated each other.

Despite this, the dentist completed the initial phases and when it was time for the final treatment, the dentist collected laboratory costs in advance as the patient had no medical scheme cover or insurance. On the day of fitting and delivery of the prosthesis, the patient informed the practitioner that she had forgotten her chequebook and cards and was unable to make payment. The patient made some complaints about the appearance and fit of the prosthesis and the practitioner made detailed notes about this interaction.

Some weeks later the patient had made no effort to pay the bill or to call the office. The practice then received a fax from another dentist accompanied by a signed consent by patient with a request for the patient's records. The letter from the dentist explained that as this was a patient new to his practice, early receipt of previous records would be appreciated. The first dentist then faced a dilemma... should the new dentist be informed about the 'problem' patient and that the bill had not been paid? Should the new dentist be warned?

Does the first dentist add a "bad debt" entry to the notes, send the copy of the records and write off the balance? Or does the practitioner send a copy of the records with a letter of caution about how difficult the patient has been and detailing the unpaid bill. Or does the practitioner send over the records and hand over the bill for collection?

RELEASE OF RECORDS

On the issue of release of records there is really no question. The HPCSA Ethical Rules stipulate that practitioners shall provide patients with their records on request. Dentists may furnish copies and charge a nominal fee for that service. However, dentists may not withhold records because accounts are overdue. The Promotion of Access to Information Act, 2000, permits a person to request records to exercise or protect their rights.

Another issue for consideration is that to whom is it that the dentist owes a duty.... to the new dentist (professional colleague) or to the ex-patient who the practitioner dislikes? The ethical obligation to the patient is more compelling than the obligation to colleagues. The Ethical Rules provide that the first and primary duty of practitioners is to benefit the patient and business obligations do not obviate the professional duty of putting the welfare of the patient first.

Some practitioners also believe it is improper to mix financial information with the clinical information. Sending financial information is not normal practice when patient records are requested.

INFORMED CONSENT

The patient often interrupted the practitioner during consultation and treatment and expressed dissatisfaction with the dental services provided. The patient held firm views on treatment outcomes, some of which conflicted with the practitioner's recommendations. The moral foundation for informed consent is respect for patient autonomy. Patients have a right to make informed choices about what will be done to their bodies.

The patient severed the professional relationship with the original practitioner and is entitled to request that her records be sent to the new dentist. The practitioner is justified in handing over the unpaid account for collection.