ETHICS

 

Special-IST versus Special inter-IST

 

 

LM Sykes^I; TI Mmutlana^II

^IBSc, BDS, MDent, IRENSA, Dip Forensic Path, Dip ESMEA; Head of Department of Prosthodontics, University of Pretoria. ORCID: https://orcid.org/0000-0002-2002-6238
^IIBChD, MDS, MDent, Specialist-Lecturer, Department of Prosthodontics, University of Pretoria

Correspondence

 

 

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ABSTRACT

Dentists who wish to specialize in a specific discipline have to undergo and complete a rigorous, structured and extensive postgraduate academic and practical training programme, and pass all the requisite exams. Only then can they be registered with a regulating professional body and be recognized as such in that field. Thereafter their scope of practice becomes limited to that specialty alone. This differs from general dentists, who are not restricted in their scope of practice, but may have limitations to the extent of their capabilities. They may choose to upskill themselves through attendance at short courses, hands-on training workshops, informal study groups, dental company workshops or even YouTube videos. Unlike the trainee in a formal institution, this is unstructured and outcomes are unspecified, yet some of these practitioners then market themselves as specialists in these fields. While the Health Professions Council of South Africa (HPCSA) has set out a list of core ethical values and standards for good practice, there are no regulations enforcing the need for these practitioners to undergo and pass HPCSA recognized examinations to assess their capabilities, knowledge and skill in these modalities. This opens the profession up to risks of practitioners contravening a number of core values and standards expected of trusted professionals and can mislead and put the general public at risk. This paper aims to explore if regulation of this type of practice is required, who should be allowed to offer additional training to dentists, and who should be regulating the trainers.

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INTRODUCTION

Having successfully completed one's studies, graduated, and being registered as a healthcare professional confers on a practitioner the right and privilege to practice their profession¹. However, with this right, comes a number of legal and ethical obligations and duties. In reality, it is impossible to create a definitive set of prescriptions to follow that will encompass all clinical situations, and the onus often remains on the clinicians to decide for themselves which actions or treatment decisions could be defended if challenged. This will require them to engage in a process of reasoning and rationalisation, based on their training and expertise; and grounded in core moral values and standards of good practice. Their final decision should always be in the best interest of their patients and society, bearing in mind that it may also impact on their reputation.¹ In order to help practitioners with this process, the Health Professions Council of South Africa (HPCSA) has set out a list of core ethical values and standards for good practice.¹

Core ethical values and standards

There are eleven basic core ethical values, however not all may apply to each individual case scenario. Furthermore, there may be times when adherence to some standards may clash, making it all the more crucial for the practitioner to apply ethical reasoning in coming to a final decision. These values are listed below as several of them will be used to discuss the main theme of this paper, which revolves around practitioners' skills, expertise, and training, and how they present themselves to the public in this regard:

1. Respect for persons, and acknowledgement of their worth, dignity and sense of value.

2. Best interest or well being (non-maleficence) wherein the practitioner should not harm or act against the patient's best interest even if this is in conflict with their own interests

3. Best interest or well being (beneficence) wherein the practitioner should act in the patient's best interest.

4. Human rights of all should be recognised.

5. Autonomy, which gives each patient the right to self-determination and to make their own, informed decisions based on their own beliefs, values, and preferences.

6. Integrity of the practitioner as evidenced by them being responsible and adhering to the core values.

7. Truthfulness, which forms the basis of the trust between the practitioner and their patients.

8. Confidentiality and treating of all personal or private patient information as confidential unless there are overwhelming moral or legal reasons for disclosure.

9. Compassion, sensitivity and empathy with individuals as well as societal needs and the striving to provide comfort and support where ever appropriate or possible.

10. Tolerance of patient's different ethical beliefs and desires.

11. Justice and treatment of all individuals and groups in an impartial, fair and just manner.¹

Specialist, special interest and expertise

A specialist is a practitioner who has completed an extensive period of postgraduate academic and practical training with specialization in a specific and limited area of dentistry; and should have passed all the requisite examination processes needed to be recognised and registered in that field. Thereafter they will restrict their scope of practice to that area alone, and no longer carry out general dentistry.² This differs vastly from general dentists, who are not restricted by their scope of practice, and can undertake work in any aspect of dentistry they choose. They may have a keen interest in a certain field, and develop their skills and expertise in that area. They may undertake various short training courses offered by recognised teaching institutions, informal study groups, dental companies or even YouTube videos.³ They do not necessarily complete any structured training programmes nor do they have to undergo and pass HPCSA recognised examinations, to validly assess how capable they are of carrying out these specialised procedures. They are then free to continue practicing routine dentistry, or to devote a major portion, or all of their time to this single domain.⁴ Some even advertise themselves using terms such as "dentist with special interest in...", "expert in...", "cosmetologist", "authority in..", "trained.." etc. While not illegal, such testimonials can be misleading to the general public who interpret these titles as an indication of specialised training. Some even charge substantially higher fees for this service. They may argue that they are even more specialised than the specialists and as such feel legitimately and ethically entitled to their designation and remuneration. After all they are fulfilling the main aim of treatment, which is "the management and care of a patient by provision of therapy focused on combating a disease or disorder, or with interventions aimed at improving health".⁵ The question is how and/or should this practice be regulated?

Issues to consider

There is no doubt that there are general dental practitioners who have spent time, effort and expenses upskilling their knowledge and technical skills in certain specific areas of dentistry. Some may have even limited their practices to this field and earned themselves a trustworthy reputation within the dental community. While they remain general practitioners, they seldom carry out the various other treatment modalities within the scope of general dentistry. Technically, they are not specialists and so cannot "legally" advertise themselves as such or charge specialist fees. However, they certainly do carry out specialist type and quality of work. Why then can they not present themselves as experts and charge accordingly? Clearly if one considers this in terms of the core ethical values and standards, they could fully justify their actions.

The concern is more with dentists who have completed short training courses, attended basic workshops or online programmes, or worse, been taught about products and techniques by company representatives. They then promote themselves on public platforms and social media as specialists. They may even augment their "adverts" with questionable testimonials, show "before and after" patient photographs, or in extreme cases, offer limited deals and discounts. Those in the know may realise the illegitimacy of this, and thus twist the terminology used to describe themselves as mentioned above in order to avoid litigation. To the unsuspecting public, specialist and expert sound the same and they accept the authenticity of the clinician who labels themselves as such. These same dentists may continue doing both general and the more complex work, yet charge substantially higher fees for the latter even at specialist rates or higher. From an ethical perspective this runs the risk of contravening a number of core values and standards expected of trusted professionals. There is clearly no respect for persons, as it may not be in their best interest or well-being, and can potentially lead to more harm than good (maleficence). Untruthful self-promotion shows no respect for human rights or compassion for unsuspecting patients. In addition, autonomy will be compromised in that clinicians have not been truthful about their expertise and limitations when offering these modalities to their patients. Their actions cannot be justified and undermine their own integrity as well as that of the entire profession.

 

CONCLUSION

In conclusion, one final point of consideration with regard to clinicians performing specialised dentistry is the question of who trained them? Can a professional be taught by a company representative or manufacturer? Are short courses and internet videos able to impart practical skills? Who assesses the quality or monitors accreditation of privately arranged education courses? How much participation and training in a field is needed to justify charging higher fees? Can a clinician be trained by someone who has a lesser degree than their own? Can general dentists teach specialists? These questions remain in most part unanswered and unmonitored, and perhaps need to be taken up with controlling bodies.

 

REFERENCES

1. HPCSA, Ethical guidelines for good practice in the health care professions. Accessed at: https://www.hpcsa.co.za; www.google.com/search?q=hpcsa+booklets+-+specialist+qualitifcations&rlz        [ Links ]

2. American Dental Association. Section 5. Principle of veracity (truthfulness). Accessed at: https://wwwada.org/en/about-the-ada/principles-of-ethics-code-of-professional-conduct/veracity. Accessed on : 24-10-2016        [ Links ]

3. Sykes LM, Vally Z, Evans WG. Practicing beyond your expertise - Part 10. Who's to blame, who's to name? SADJ 2017, 12; 5. 230-233        [ Links ]

4. Dental specialties and subspecialties. Accessed at: https://www.britannica.com/specialties//dentistry/ancillary-dental-fields. Accessed on: 13-03-2022.         [ Links ]

5. Online Medical Dictionary. The definition of treatment. Accessed at: medical-dictionary.thefreedictionary.com/ treatment. Accessed on: 01-03-2022-03-21        [ Links ]

 

 

Correspondence:
Leanne Sykes
Head of Department of Prosthodontics
University of Pretoria
E-mail: Leanne.sykes@up.ac.za

 

 

Author Contribution:
1 . LM Sykes: 70%
2 . TI Mmutlana: 30%