ETHICS

 

From Pandemic, to Panic to 'Pendemic'

 

 

LM Sykes^I; E Crafford^II; C Bradfield^III

^IBSc, BDS, MDent, IRENSA, Dip Forensic Path, Dip ESMEA, Head of Department of Prosthodontics, University of Pretoria, South Africa. ORCID Number: 0000-0002-2002-6238
^IIBChD, BChD Hons, Oral Medicine, MChD OMP, Senior Specialist Department of Oral Medicine and Periodontics, University of Pretoria, South Africa
^IIIB Tech, BChD, Dip Aesthetics, Registrar Department of Prosthodontics, University of Pretoria, South Africa

Correspondence

 

 

ACRONYM

C19: Covid-19

 

INTRODUCTION

Medical doctors and dentists working in private practice are generally faced with the situation of "no work, no pay". Although most have some form of indemnity cover to ensure they will receive and income if they are injured or incapacitated, this will be of no benefit if they are unable to work due to non-medical conditions, or for other extraneous reasons such as a lack of patients.

 

 

In light of the current C19 pandemic and government restrictions on human contact, it is going to be extremely difficult for dental practitioners who have closed their rooms or scaled down their practices to treating only emergency patients to earn an income. They may have to explore other avenues of staying financially solvent in these difficult and unpredictable times, and leads to the question:

Is Covid-19 (C19) going to be an excuse to justify the indiscriminate and potentially irresponsible issuing of sick letters and prescriptions by healthcare professionals?

 

SURVEY DESIGN

At a recent dental congress, practitioners were asked to complete a questionnaire in which a number of practice-related ethical scenarios and questions were posed.

One question related to the issuing of medical certificates and sick letters and the writing of prescriptions for family members. Over 50 dentists completed the questionnaire, and the results are presented in the Tables below.

 

RESULTS

In responses to the question "Would you issue a sick certificates for family members? Almost half of the dentists said yes, one fifth a definite no and 34% said it would depend.

 

 

When asked to elaborate on their answers, many of the comments and opinions were similar thematically and thus not repeated below. All others are presented verbatim.

Comments in the 'Yes' category included:

• If it's true then yes (but you have to be ethical).

• Yes they are all still patients with problems.

• It's practical. Why should I go and pay someone else for something that I can do myself.

• Yes. You will not go and prescribe incorrect medication deliberately!

• You act professionally towards all patients and family in the same manner.

• Yes if you follow the Hippocratic Oath.

• If you have integrity and can be sure of non-attachment.

• Patients are patients and I treat them all the same.

Those who said 'No' gave reasons such as:

• No, it's unethical!

• It's difficult to monitor proper compliance, and human factors must not be discounted.

• No, you can easily become biased.

• They will take advantage. (Especially relatives)

• It sets a precedent and can lead them to expect you to bail them out in the future.

The 'It depends' group generally said 'Yes', but had added provisos like:

• In emergency situations only, otherwise it's better to consult with a colleague or medical practitioner.

• It depends, are you honest and will not abuse the system?

• Only if you also treat those family members then it's OK.

• Also they must have been treated on the day that you issue the letters.

• It depends on the situation. They must have come for treatment, and the treatment should justify a sick note.

• As long as it's not over treatment or over medication.

• As long as I am not prescribing out of my field or for non-dental conditions.

• Only in emergency situations or if you are the most qualified person, or if a referral would be impractical (such as if services are far away).

• As long as treatment was actually performed.

In responses to the question "Would you write prescriptions for medication for family members?, there were more 'Yes' responses with over two thirds saying they would and less than 6% who said a definite 'No'. Just under one third (28%) said it would depend.

 

 

Many of the comments were similar to those for writing sick certificates, with most of the added opinions being in the "It depends" category.

Under the definite 'Yes' replies were statements such as:

• You have a medical qualification, so why not.

• I'm a doctor and capable so definitely 'Yes'.

• Patients are patients regardless of their relation.

• I see no problem if you are honest and ethical.

The only strong NO's felt that the possibility of bias and abuse was too great (Author comment: they didn't specify if they meant abusing your favours or abusing the drugs!)

The remaining comments all fell under the 'It depends' category

There was a strong emphasis that it must be within the scope of dentistry and be needed for some actual dental treatment or condition. They include:

• As long as it's within your scope of practice and necessary for the diagnosis.

• It depends on the severity of the condition. If it involves any scheduled medication then I will rather send to a colleague.

• Only if the family member is also your patient and the prescription is for the actual treatment you are performing, not for other conditions.

• Only if I'm allowed to prescribe that drugs and I know the pharmacological effects and side effects.

• It must be restricted to your scope of practice but it's OK for emergencies of chronic medication.

• If they are not my patients but I am the only qualified health care professional around and it's an emergency then I will.

• The medicine must be needed and not done as a favour.

 

DISCUSSION

This survey question asked dentists about writing sick certificates and scripts for family members. However, in light of the current C19 pandemic, it can be anticipated that more and more patients as well as the broader public will be approaching practitioners with requests for letters to justify their absenteeism from work, as well as for a variety of drugs and medicinal products.

At the same time, most clinicians have limited their practices to treating only patients in serious pain or with dental emergencies. This is going to place a huge financial burden on them as these procedures are not common and generally not well re-imbursed. Dental specialist could be more affected as they do not see walk in patients and generally perform fewer emergency procedures.

Furthermore, clinicians may also want to restrict their contact with people, and could be very tempted to write letters and issue scripts to anyone asking for these, both as a means of generating income and without needing to see or consult with them in person.

 

 

They may manipulate Code 8104 which makes provision for limited oral examinations, consultation for a specific problem not requiring full mouth examination, and the issuing of prescriptions.¹

The problem is that the dentist may never actually see the patient clinically, and thus cannot carry out a comprehensive clinical and oral examination, may not elicit a full medical history and cannot make use of confirmatory radiographs. Their diagnosis will be based on patient - reported signs and symptoms which are bound to be subjective, maybe grossly misleading, and could lead to a completely erroneous diagnosis.

Of more concern is the likelihood that clinicians may over-prescribe antibiotics. This goes against current trends to manage disease and infection conservatively wherever possible, especially when one considers the universal problem of ever-increasing numbers and types of drug-resistant bacteria.

In the United States, not only are over one third of antibiotics prescribed unnecessary, often the selection and duration of treatment are also inappropriate.² However, patients often expect and demand scripts for medication, and may place undue pressure on the dentist to comply.

Antibiotic prescribing may also be influenced by psychological factors, perceived or genuine patient expectations, clinical workload, habit, or in some instances, blatant lack of accountability.²

It may now become very tempting for practitioners, faced with the uncertainties of the C19 virus and its associated co-morbidities, to think along the lines of "rather be safe than sorry" and prescribe antibiotics "just in case".

Considering the current situation, this may seem like a "win-win" situation for all. However, the Centres for Disease Control and Prevention recommend that clinicians consider the condition carefully before writing scripts for antibiotics, as in many instances delayed prescribing, active monitoring, and the use of relevant diagnostic aids may be more prudent.²

Antibiotic stewardship is a term developed to monitor and promote optimization of antibiotic use in order to ensure patient safety and outcomes. It includes "ensuring that antibiotics are only given when necessary and beneficial, that the right agent, dose and duration of treatment are used, and that when needed they should be started promptly.²

Remember, the responsibility for potential side effects of a prescription remains with the issuing doctor. Thus if they have not carried out a full consultation, they may be unaware of possible contraindications or drug interactions, especially amongst patients who self-prescribe or are on polypharmacy.

 

CONCLUSIONS

Now more than ever clinicians are going to be called upon to be calm and rational, to make educated decisions, and to act with honesty and integrity despite the temptation to try and fill their rapidly emptying rooms and pockets.

To quote Roy T Bennett:

"Do what is right - Not what is easy or popular"³

 

References

1. SADA Dental Codes Diagnostics. 2016; 5. Accessed at: https://www.sada.co.za/clinical-resources/codes/        [ Links ]

2. King LM, Fleming-Dutra KE, Hicks LA. Advances in optimizing the prescription of antibiotics in outpatient settings. BMJ. 2018; 12; 363-75.         [ Links ]

3. Bennett, RT. The light in the heart. Accessed at: https://www.goodreads.com/author/quotes/15042371.Roy_ T_Bennett.         [ Links ]

 

 

Correspondence:
Leanne M Sykes
Head of Department of Prosthodontics, University of Pretoria
South Africa
Email: leanne.sykes@up.ac.za

 

 

Author contributions:
1 . Leanne M Sykes: Primary author - 60%
2 . Elmine Crafford: Secondary author - 20%
3 . Charles Bradfield: Registrar - 20%