Are dentists influenced by gifts and incentives, and should professional codes of conduct be updated to provide clearer guidelines for interactions with patients, colleagues and industry so as to avoid conflicts of interest in dentistry? By Angela Tufvesson
Ever accepted a box of chocolates or bottle of wine from a grateful patient or specialist on the receiving end of a referral? Likewise, many dentists receive free samples from visiting pharmaceutical company reps. These practices may seem entirely innocent, but evidence suggests that practitioners may be unaware of their potential influence on professional behaviour, argue two University of Sydney academics in a recent paper published in the Journal of Law and Medicine.
All wrapped up
According to the authors, Dr Alexander Holden and Professor Heiko Spallek, the profession is exposed to influence and incentives from three main sources: patients, professional colleagues and industry, especially the pharmaceutical and medical devices industries.
Dr Holden says many specialists send gifts to referring practices at Christmas and other holiday times, often accompanied by an invitation to a lecture where CPD is offered. “There’s no immediate sense of ‘you sent me a referral therefore I’m going to give you some sort of reward’ but, let’s be honest, you don’t get a hamper unless you’ve sent some sort of referral at some point in the preceding year,” he says.
Similarly, pharmaceutical companies, supply companies and other firms that support dentistry often visit practices and offer ‘lunch and learn’ sessions. “They’ll bring food in exchange for your time over your lunchbreak to talk about their products and perhaps bring some free samples as well,” says Dr Holden. “Again, we can say that’s perfectly innocent but could a patient or outside member of the public look at that and say, ‘Well, does that somehow affect your decision-making ability?’”
Crucially, the paper argues that practitioners are less likely to be aware of these influences courtesy of a phenomenon dubbed ‘bias blind spot’.
“Most people would be very aware of these concepts but would never think it might happen to them,” says Dr Holden. “That’s the definition of bias blind spot—this idea that most people will point out the splinter in someone’s eye while forgetting the splinter in their own. For example, if you ask colleagues if they suffer from professional bias, the answer will probably be no. If you ask them if their colleagues have a problem with bias, they might say that some do.”
So, how does the dental profession instruct practitioners to manage these sorts of potential conflicts? The Dental Board of Australia’s Code of Conduct says practitioners must recognise and resolve conflicts in the best interests of patients, explaining that good practice involves skills such as recognising the influence of pharmaceutical companies, not offering inducements to colleagues and not accepting gifts from patients other than “tokens of minimal value such as flowers or chocolates”.
Dr Hugo Sachs, president of the Australian Dental Association (ADA), says the organisation is a signatory to a consensus statement supported by the Asia Pacific Economic Forum (APEC) that details values and ethical principles for the healthcare sector, including a commitment to managing conflicts of interest and bias. Plus, he says specific ADA policies govern behaviour in potentially tricky areas such as sponsorship of CPD activities and interaction with dental equipment and material suppliers.
“When it comes to, for example, dentists paying other dentists for incentives for referrals and things like that, I haven’t heard of it, and I’ve been a practitioner for coming up to 39 years.”—Dr Hugo Sachs, president, ADA
Beyond these policies, however, practitioners are expected to be guided by individual ethics and transparency. “When it comes to, for example, dentists paying other dentists for incentives for referrals and things like that, I haven’t heard of it, and I’ve been a practitioner for coming up to 39 years,” says Dr Sachs. “And [when it comes to pharmaceutical companies] you occasionally get free samples but from my viewpoint there’s never been any pressure.”
In contrast, the Australian Dental Industry Association (ADIA) has banned gifts provided by suppliers to dental professionals purchasing therapeutic products. Chief executive officer Troy Williams says the change recognises that the ethical promotion of dental products is central to the trust-based framework within which healthcare professionals advise and treat patients.
“The industry prohibition on the offering of gifts such as consumer electronics in connection with supplying a therapeutic good is abundantly clear,” he says. “It’s black and white. There’s no room for misinterpretation—gifts of that nature can’t be offered.
“There is no corresponding prohibition on asking for gifts or receiving them in the professional codes. The simple fact is that the industry’s expectations of its members are clearer and more stringent than those of dentists and allied oral healthcare professionals as set by the Dental Board of Australia and the relevant professional bodies.”
Calling for change
Williams says codes of conduct for dental professionals should be updated to reflect the changes in the dental industry. “It’s the ADIA’s view that the obligations of the dental industry and dental profession should be mutually supportive,” he says. “In the same way that manufacturers and suppliers are unable to offer gifts with the supply of therapeutic products, dental and oral healthcare professionals should be unable to seek or accept them.”
Likewise, Dr Holden says current guidelines don’t exist beyond the bare minimum, and he believes introducing new codes of conduct to govern gifts and incentives will help to ensure the profession retains integrity.
“The Dental Board of Australia hints at some things being problematic but doesn’t necessarily come out with black and white guidance, so there is still a lot left to the judgement of individual practitioners,” he says.
“There’s an opportunity for professional organisations such as the ADA to really take the lead. Currently there is very little within their guidelines that would support a dentist, for example, making decisions about whether or not a gift at Christmas time from a referral practice is acceptable.”
But, thankfully, that’s not to say the profession needs to employ a nanny-state approach. “We recognise that dentists work very hard and sometimes it’s nice to have an extra thank you from patients other than what they’re obliged to pay for services,” says Dr Holden. “We don’t think taking a blanket approach to anything is helpful but an approach that’s based on thoughtful practice is definitely needed.”