Professional conflicts may arise when dental principals and dental associates disagree about processes in the dental clinic. These conflicts may have regulatory implications before the Royal College of Dental Surgeons of Ontario (RCDSO).
In ideal circumstances, dental principals and dental associates will have excellent and mutually supportive relationships that benefit both parties. Associate dentists can gain much knowledge and insight from the mentorship that may be provided by experienced principal dentists. Even in the most positive environment, however, it is possible that professional conflict may arise at some point. Principal dentists generally provide their associates with facilities, resources, patients, and remuneration, and assume the attendant risks. As a result, principal dentists may have specific expectations pertaining to certain procedures, whether clinical, administrative, or otherwise.
Although associate dentists may not have total autonomy over their practice, they remain responsible to their patients, the public interest, and the RCDSO, and are expected to maintain the reputation of the dental profession. Below we have identified a few subjects that may lead to professional conflicts, and on which it would be prudent for associates to reflect.
COVID-19 protocols
Infection prevention and control (IPAC) has always been of vital importance in the dental context. As a result of the constant developments and implications of the COVID-19 pandemic, IPAC measures have recently gained increased attention in the media and from patients.
In relation to a principal dentist and/or clinic owner, an associate dentist will have limited control over the practice environment. However, this will not excuse the associate dentist for any lapses with respect to personal protective equipment (PPE), fallow time, and/or any other requirements.
The RCDSO has regularly reviewed and updated the guidance document “COVID-19: Managing Infection Risks During In-Person Dental Care.” It is prudent for all dentists, associates and principals alike, to ensure that they are familiar with the most up-to-date version of this document and are implementing its protocols. Associates may consider reviewing this document, as well as the RCDSO’s Self-Audit Review Form COVID-19 Guidance Document, with their principals as a possible means of bringing potential lapses to their attention.
Administrative staff
On occasion, a patient may have no issue with their dental treatment but may nevertheless complain to the RCDSO because of their interactions with front desk staff. As administrative staff are not regulated by the RCDSO, these kinds of complaints may only name the treating dentist. For example, a patient may file a complaint against an associate dentist alleging that front desk staff was rude.
Associate dentists will likely have no or very limited involvement in staffing. They may find that their tenure at the clinic is exceeded by that of a longtime administrative employee involved in reception and front desk duties, over whom they have little authority. In addition to communication issues, billing concerns may also arise, for example, if front desk staff have improperly written-off a copayment.
Dentists bear responsibility for the conduct of their staff. While principal dentists have the most control over their clinic and accordingly bear the most responsibility, associates may, depending on the specific context, also face some form of regulatory consequences. Even if a panel of the Inquiries, Complaints, and Reports Committee (ICRC) takes no further action on an allegation pertaining to the conduct of an administrative staff member, the formal complaint process itself will still have been a stressful and expensive process. Whenever possible, it may be prudent to proactively discuss potential concerns with the staff member in question and the principal dentist.
Referrals to specialists
Associate general dentists may find that different principal dentists will have varying approaches to more complex care and referrals. Some clinics may have dentists on staff who are registered with the RCDSO as endodontists, orthodontists, and/or other specialties, in which case internal referrals will likely be expected. The principal’s approach may otherwise be implicit in the language of the associate agreement signed at the outset of the professional relationship.
Where the principal has expressed an expectation that as much work as possible should be performed within the clinic, it will nevertheless remain prudent for associates to consider whether the indicated dental treatment is within their skillset, scope of practice, and comfort level. If a complaint should arise, a panel of the ICRC may be critical if timely referrals were not made. When in doubt, associate dentists should consider discussing referrals with their principals on a proactive basis. Maintaining fulsome progress notes that identify the rationale for referrals, as well as all other treatment decisions, will also be prudent.
Continuity of care
Dental philosophies will differ and there may be a prevailing style at a clinic that does not align with an associate dentist’s own preferred practices. For example, an associate pediatric dentist may have a professional conflict with their principal dentist regarding treatment and management of early childhood caries, and the extent to which stainless steel crowns should be implemented. It would be inadvisable to criticize another dentist’s approach in front of patients, as this can undermine both the colleague and trust in the profession as a whole.
Potential issues could also arise where there is a lack of consistency with respect to which dentist regularly treats a patient, and/or if planned treatment is implemented by someone other than the dentist who formulated the treatment plan. An associate dentist may not have control over whether they are a patient’s regular dental provider, as the clinic’s treatment coordinator may have other reasons for scheduling treatment with a different dentist.
If Dentist A formulates a treatment plan and Dentist B subsequently implements the treatment, a patient may only be critical of Dentist B if any aspect of the treatment is not to their satisfaction. Upon performing their own independent assessment, Dentist B may have identified a new dental issue, or may have determined intraoperatively that an adjustment to the treatment plan was warranted based on a change in circumstances. Regardless of the reason for a change and/or the appropriateness of the care, a patient could potentially perceive that Dentist B’s conduct fell below the standards of the profession. It may be prudent for associate dentists to proactively discuss logistics of treatment planning and implementation with their principal dentists.
Knowledge is power
Becoming familiar with relevant RCDSO guidelines and governing legislation may assist dental associates in identifying and implementing best practices in their own work as early as possible. Having awareness of professional requirements may also be helpful in navigating potential disagreements with principal dentists. Communicating with principal dentists in a thoughtful, respectful, open, and non-judgmental manner, and framing issues in a constructive way that links regulatory compliance to practice enhancement and success may be of some assistance. Where professional conflicts cannot be resolved, it may be prudent for associate dentists to consider whether they are able to adequately address their professional and regulatory obligations in their current circumstances.
About the Author
Josh Koziebrocki, LLB, BA (Hons), is the principal lawyer and founder of Koziebrocki Law. He represents numerous dentists and has extensive experience dealing with regulatory issues. Josh is certified by the Law Society of Ontario as a Specialist in Health law. He can be reached at 416-925-5445. josh@koziebrockilaw.com, www.koziebrockilaw.com
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