Risk management assessment: dentists' ethical duty to provide emergency after-hours care.

Patients' after-hours emergency needs are a concern for dentists. The issue of providing or arranging for emergency services is an ethical obligation, according to the ADA Principles of Ethics and Code of Professional Conduct, section 4.8, which states:

Dentists shall be obliged to make reasonable arrangements for the emergency care of their patients of record. Dentists shall be obliged when consulted in an emergency by patients not of record to make reasonable arrangements for emergency care. If treatment is provided, the dentist, upon completion of treatment, is obligated to return the patient to his or her regular dentist unless the patient expressly reveals a different preference.

Theoretically, every dentist wants to ensure that his or her patients can access the services of a competent dentist in an emergency situation. However, the ADA code does not fully address some of the other circumstances that may occur when patients seek emergency care during off-hours.

Emergency care planning may include any of the following:

* Dr. Smith goes on vacation and Dr. Jones, a colleague down the street, agrees to provide emergency care for Dr. Smith's patients. Perhaps they formalize this arrangement so that each covers for the other whenever the need arises. This might include illnesses, family emergencies, vacations, etc. The only disadvantage to this arrangement might be that the two of them would need to plan out their families' vacation schedules in advance and that they probably could not both attend the same educational seminars. Minor challenges, easily addressed.

The major advantage to this type of arrangement is that Dr. Jones has the additional benefit of knowing in advance which patients have had invasive procedures during the several days before Dr. Smith leaves town. Dr. Jones may also have access to these patients' records and he will have a better chance of providing them seamless care because of his knowledge of the treatment provided. Hopefully, these two dentists know each other well enough to feel comfortable with each other's clinical abilities and communication skills. There should be no reason to assume that one would criticize the work of the other to a patient and, unless a particular patient chose to make a change (and patients have a right to do so), neither doctor would "recruit" the patients of the other.

In some areas, several doctors formalize this type of coverage arrangement. When more dentists participate in this coverage plan, the doctors have greater flexibility in scheduling their out-of-office time while still knowing that their patients' emergency needs will be promptly addressed. Formalizing this agreement ensures that one participant doesn't take advantage of the system. Formalizing also ensures that patients are promptly referred back to their dentist of record. Finally, written agreements should specify collegial discussions about patients' clinical problems, availability of records when feasible, and refusal to engage in "criticism" of the work done by other doctors.

* Dr. Smith is ill or on vacation and leaves a voice message on his answering system telling patients when he will return to the office and that, in the meantime, they should go to the local Emergency Department if they have an emergency or they should call again. Perhaps the sole benefit to this approach is that Dr. Smith has let his patients know that he will be unable to treat them for a specific time period. Assuming that his answering system doesn't develop some type of glitch, a patient who has a significant problem may follow these instructions and proceed to the ED where a physician is likely to assess the patient's problem. Depending on the results of this examination, the patient may be sent home with pain medication and an antibiotic. Or, the physician may provide clinical care on the spot. An additional scenario may emerge if the patient is referred to another dentist for immediate treatment. The disadvantage to this arrangement is that neither the physician nor another dentist is likely to have access to Dr. Smith's records. The treating doctor must rely on the patient's recounting of the problem and the current state of the treatment--which may or may not be accurate. If Dr. Smith is unavailable by phone, he may be blindsided by treatment decisions he may not agree are in the patient's best interest.

The ADA statement on emergency care addresses the needs of patients who are already under the care of a dentist. The document refers, for example, to the situation in which Dr. Jones treats Dr. Smith's patient in an emergency situation and then refers the patient back to Dr. Smith. However, another scenario is just as likely to occur--and this is not addressed by the Code of Professional Conduct.

* Dr. Smith is called at home by a person who is not a patient of record and who is not a patient of a dentist with whom Dr. Smith has an after-hours treatment agreement. This individual tells Dr. Smith that he has a dental emergency; he wants Dr. Smith to open his office and provide emergency care. On the basis of the ADA statement, Dr. Smith might feel obliged to provide this service. In fact, some significant risk issues may be attached to this scenario. Ultimately, Dr. Smith will determine the best policy to use when addressing this kind of request. But when devising this policy, Dr. Smith should consider the following questions:

** Opening an office after hours may expose the dentist to security risks. This unknown person may have a legitimate dental emergency; he may also have a gun and be intent on robbing Dr. Smith. In order to address this situation, Dr. Smith may prefer to offer to meet the patient at a nearby Emergency Department where the basics of emergency care can be implemented and follow-up treatment scheduled.

** Most dentists agree that patients who do not have a personal dentist are at higher risk for oral health problems. Many of these individuals are sporadic in their oral hygiene, rarely have their teeth cleaned or their dental status assessed, and often have significant problems before they seek dental care. Dr. Smith will have greater difficulty achieving a satisfactory outcome for this patient. His efforts may be further hampered by the necessity to provide aggressive care for a patient whose health history and whose ability/willingness to be compliant may be problematic.

* An individual calls or visits Dr. Smith's office. He is not Dr. Smith's patient. Neither is he a patient of one of Dr. Smith's colleagues. The individual reports that he has a dental emergency and that, although he does not currently have the time/money/ insurance approval to initiate care, nonetheless he would like to obtain pain relief and then schedule the actual treatment for a later date. Risk issues that Dr. Smith should consider include:

** This person may be a perfectly innocent individual, but this scenario is often reported by law enforcement officials as indicative of drug-seeking activity. Scam artists are often "new to town," currently not under the care of a dentist, unwilling to authorize treatment (other than pain medication), and they promise to return in a day or two to commence the actual treatment. Police and drug enforcement officers note that these persons often name a particular drug that "works best" for them and they may become belligerent and threatening if the doctor offers emergency treatment, but will not write a prescription for a painkiller.

** Dentists are frequently advised by law enforcement experts to refuse to treat unknown persons without an up-front agreement that treatment will be initiated before prescriptions (in very limited amounts) will be given to unknown parties. In general, dentists who implement this type of policy soon discover that the "walk-in emergency" or the "late at night" emergency trade has suddenly disappeared.

While it is true that dentists do have an obligation to try to provide emergency care for patients, this is an instance in which charity begins at home. Individuals who have the greatest right to a dentist's concern and emergency intervention are that doctor's own patients. When dentists agree to provide emergency coverage for each other's patients, it would be best if these arrangements are made within a formal context so that each participant is laboring under the same set of expectations and promises.

Kentucky has been reported as a state that has a high risk for drug-seeking activity from individuals ostensibly trying to obtain health care services. The prevalence of drug theft and related crime (especially related to oxycontin) increases the risk of physical injury to health care workers who have access to high value street drugs. The mere possession of a DEA number and a prescription pad dictates that dentists should not allow themselves to be duped because of their ethical concern for patients.

State or local dental associations and study groups may be able to provide guidance for dentists who want to ensure that patients do indeed have access to after-hours emergency care--but who also don't want to be put into the awkward position of having to provide care for a person who will not comply with standard treatment protocols, who may be engaging in unlawful activities, and who will either inadvertently or intentionally place the dentist at risk. Cooperative efforts with DEA officials, hospital Emergency Departments, physicians who treat drug addicts, and a consistent local approach to the design of after-hours emergency services policies will help dentists: a) ensure that legitimate and compliant patients access needed care; b) restrict the emergency care for some individual to environments that are safe for the doctor as well as for the patient; and c) make it more difficult for persons with hidden agendas to engage in illegal activity.

Reprinted with permission from Kathleen M. Roman, GE Medical Protective, copyright [c] 2003.

Kathleen M. Roman is Assistant Vice President, Clinical Risk Management Education Services, GE Medical Protective.