Relating to colleagues

One aspect of a professional career that sometimes receives less attention than it deserves, is the relationship that develops between professional colleagues.

Most of the time, these relationships adhere to ethical principles, although occasionally there may also be legal considerations - e.g. honouring business contracts or when allegations of libel, slander or other (criminal) activities are made.

Claims of superiority

Nothing seems to arouse the emotions quicker than professional colleagues who claim or imply that they are superior in some way, either directly or indirectly (eg. by suggesting that others are of a lesser ability or stature in some respect). Many such dentists seem unaware of the irritation that is caused when they make such claims, and then they compound the professional resentment that is generated by inappropriate comments made directly to patients, or in the promotion of their practice. Such claims of superiority are unethical and best avoided.

Referrals

An obvious example of the interaction between two professional colleagues is that which exists when making or accepting referrals, seeking second opinions or liaising with other healthcare professionals such as a patient's medical practitioner. Such commitments should always be conducted in a professional manner, respecting the usual professional courtesies which one would expect between two healthcare professionals.

Any correspondence in the course of this relationship, should be written in the expectation that the contents could possibly be viewed by the patient, or by any professional colleague who is referred to in the text. With disappointing regularity, one encounters instances where inappropriate remarks of an extremely disparaging nature have been made without it having crossed the mind of the writer that the colleague referred to in this fashion, might subsequently come to see their words.

Understandably, the person referred to will regard such overt (and perhaps gratuitous) criticism as being unnecessary, unethical and perhaps even defamatory (but see below), whether or not there might be any justification for their criticisms.

The existence or status of specialists, and the conditions appertaining to any such registration, vary from one country to another. In some places, a clinician can only be registered in a single specialty, and may not carry out work in any other specialty. In others, the same dentist can be registered as a specialist in more than one field.

The normal professional courtesy which is adopted when a patient is referred to a second dentist, is for it to be made clear at the outset what the scope of the referral is, and whether or not it is anticipated that the patient will be referred back to the original dentist when the relevant episode of treatment has been completed. This will almost always happen when a referral is made to someone whose practice is restricted to a specified (perhaps specialist) field.

Problems can arise, however, when the second dentist accepts the patient for their future care, when the original dentist was expecting the patient to be referred back. There may be perfectly sound reasons why this might happen -- not least, the patient's stated wishes -- but it is still preferable that this process is transparent, and the patient's decision is communicated back to the original dentist rather than allowing him (or her) to discover indirectly that the patient will not be returning. This perception that the patient has been 'poached' or unfairly influenced to change dentist is widely considered to be unethical, and here again it is simply a matter of treating professional colleagues in a manner in which we would wish to be treated ourselves.

Commenting on others

Overt criticism of colleagues and of any treatment provided by them, expressed directly to a patient, has long been regarded as a practice to be deprecated. Not only does it reduce the confidence of patients in the profession as a whole, but it can also cause unnecessary irritation and heartache for the colleague who is the recipient of such criticism. In general, it is wiser to avoid getting drawn into criticism of another dentist, no matter how much a patient may pressurise you.

In such cases your initial stance could be that any concerns should be raised, in the first instance, with the previous dentist who is, after all, the person best placed to comment because only that dentist is in possession of all the facts. You can comment objectively on what you find today, but not on what might or might not have been the case at some previous moment in time when you were not present.

Many criticisms are doubtless made by clinicians who feel that they have a duty to offer their views on treatment provided elsewhere, whenever a patient seeks their professional opinion and advice. Such an opinion may be given with the best of intentions, but without knowing all the relevant facts (including what problems were faced by the previous practitioner at the time); such criticisms can only be regarded as uninformed and possibly even irresponsible. As a result they will usually be judgmental rather than objective and factual.

Despite this, a small minority of clinicians appear to see themselves as self-appointed arbiters of what does and does not constitute an acceptable standard of care. They are quick to criticise and they invariably recommend extensive 'remedial' dentistry -- often at considerable cost. These same people, however, seem unable to accept any criticism of their own work, or challenge of their opinions.

A familiar and not entirely unnatural reaction to criticism is a demand that the colleague who has made the criticism should be sued in defamation forthwith. Everyone, however, is entitled to their own honestly-held professional opinion, and the chances of a successful action are remote, unless it can be proved unequivocally that the criticism was motivated by malice -- a fact that is notoriously difficult to demonstrate.

Defamation

Defamation may be defined as the publication of a false statement which lowers the reputation of a person in the eyes of right-thinking members of society. For such a statement to be actionable as being defamatory, it usually has to meet certain legal requirements (which vary from one country to another).

By way of general illustration, however, the statement usually has to be:

• 'broadcast' (that is, brought to the attention of others)
• have no lawful justification, and
• be made with the object of discrediting the person concerned, or exposing him to hatred, contempt or ridicule.

From this definition it is clear to see that defamation sits squarely in the middle of a legal minefield, and despite the occasional well publicised legal case involving enormous awards of damages, the reality is that actions in defamation are rarely the option of choice. The person bringing the action -- especially in the case of a professional person -- almost always finds that their integrity is more damaged at the end of the process than when the original offending statement was made.

Qualified privilege

On grounds of public policy, the law in most countries offers protection on certain occasions to persons who inadvertently make unflattering statements about another in good faith, and without any improper motive. Such occasions attract what is sometimes termed 'qualified privilege', on the basis that the person who makes the statement has a legal, social or moral interest or duty to make it, and the person to whom it is made has a corresponding duty to receive it.

An obvious example of this is a character reference given about an employee to a prospective employer, or an independent report of some kind, or an expert opinion given in the context of a legal process or investigation.

Complaints by patients to an appropriate authority, or to the owner of a practice about the conduct of a dentist working at the practice, or to a regulatory body (Dental Council or Board) would also fall within the category of qualified privilege so that the complainant in each case would have a defence if sued for libel or slander by the dentist concerned.

Patients in these situations will often ask a second dentist to provide a report detailing their findings, which may involve commenting on work provided by a previous dentist. It would generally be considered unethical to refuse to provide such a report, not least because it is in the public interest that the profession should not be seen to close its ranks on patients who are dissatisfied with dental care provided for them. Dentists must therefore be prepared to provide information to patients (and to justify any statements that they make), and in doing so they would generally enjoy the same privilege as the patient who initiated the complaint.

It is important to note, however, that this privilege is qualified rather than absolute. This means that it extends only to what is relevant and pertinent to the discharge of the duty or the protection of the interest which creates the privilege.

Thus, if a letter of complaint or a report prepared by another practitioner went beyond the facts relating to the complaint, perhaps adding the gratuitous observation that the practitioner concerned had a bad reputation locally or was habitually intoxicated, the latter statements would not be protected by privilege. A genuinely-held professional opinion would be protected, however misguided or misinformed it might be.

Practitioners unfortunate enough to receive disparaging communications from patients, and/or adverse and critical reports from professional colleagues, need to appreciate the principle upon which privilege is based. Certainly, such practitioners should resist the temptation to write back in anger, dispensing a few ill-chosen words giving their views of the colleague in question. Similar control should also be exercised over any temptation to respond with a kneejerk reaction to 'hearsay' accounts of what a patient has allegedly been told by another dentist, doctor etc. In these cases it would be much more professional to suggest that the colleague in question should be asked to confirm his observations in the form of a written report which can be directly attributable to him or her. In most cases this rapidly precipitates clarity by demonstrating that what the colleague actually said was very different from what the patient first reported them to have said.

'Justification' is one of the available defences to allegations of defamation. If indeed there is some evidence that the standard of treatment provided is unacceptable, then it is very unlikely that a critical report stating this fact could properly be called defamatory.

It should not be assumed from any of the above, however, that a practitioner should ignore, or seek to justify or excuse, poor dentistry.

Patients are entitled to know about their dental and oral health, and practitioners have an ethical duty to inform them on an honest and factual basis. If this can be done without denigrating one's colleagues on the basis of hearsay, both patients and practitioners can benefit. Problems are more likely to arise when comments extend beyond objective clinical opinions and become critically judgmental of a professional colleague. When these comments are fuelled by a personal animosity between the two dentists, with the second dentist perhaps deliberately embellishing and exaggerating the situation, this raises ethical questions about the second dentist over and above any clinical issues surrounding the dentist whose work is under scrutiny.

It is important to bear in mind that things are not always as they appear (or as first related by our patients) and there are two sides to most (if not all) stories.

When reviewing the work of another practitioner, a prudent approach is to describe things in the same way that you would wish to be spoken of yourself, were the roles to be reversed. There is nothing new in dentistry -- as in life in general -- with regard to the perils of criticizing others.

Differences of opinion

In academic life, or in a scientific and clinical environment such as dentistry, professional colleagues will not always share the same views and opinions. It is important to maintain appropriate ethical standards in managing these differences; there are accepted professional channels for airing and discussing these opinions (eg. professional literature and meetings) and one should avoid bringing these debates to any forum where the reputation of the profession and individuals within it might be damaged or called into question.

One should always respect the views of others and their right to hold and express sincerely-held opinions; however you might personally disagree with them.

Whether or not there is any scientific evidence to support the person's view is another question entirely. Professions tend to be conservative by nature and there is a trend towards intolerance of 'alternative' or 'non-mainstream' views. An ethical and professional response is to seek to influence the views of colleagues through reasonable and mutually respectful debate, as opposed to any attempt to discredit or ridicule the colleague in question, perhaps in a misguided attempt to vindicate or gain support for one's own point of view.

Occasionally, these differences of opinion can get out of hand -- usually when the situation is compounded by a clash of personalities or a personal dislike between the parties involved. Some such situations have led, in the past, to unwholesome public slanging-matches and or equally distasteful complaints, often made anonymously to Dental Boards and Dental Councils.

Every effort should be made to manage any differences of professional opinion through appropriate channels and in an ethical and professional manner.

Occasionally, you may be in a position to observe or influence the progression of differences of this nature between other professional colleagues; here again, the timely intervention of a professional colleague to remind the parties of their ethical obligations, can go a long way towards maintaining the reputation of the profession and avoiding a lot of acrimony and pain for the individuals involved.

Conflicts

When relationships of any kind break down, the emotional fall-out and anger that results can be painful and sometimes destructive.

When the parties involved are professional colleagues, there is an additional complication that patients and members of staff can become drawn into the conflict. The trigger for such disputes is often;

• professional rivalry
• jealousy
• wounded pride
• a financial/business dispute

The anger experienced in such disputes, can sometimes result in inappropriate comments being made about a professional colleague. These remarks might be of a personal nature (for example, impugning the character or integrity of the other person), or of a professional nature (criticising clinical standards or perhaps academic/research standards).

These comments are often made to patients, to members of staff or to other professional colleagues.

Where such feelings of anger exist, they can cloud the objectivity and proportionality of any opinion expressed and in many cases the clear intention is to undermine or discredit the other person involved.

Because of this, the comments often go a lot further than the context would reasonably require.

Professional disputes can be acrimonious, and they demand a high level of ethical awareness and restraint, because even when the original 'offence' may have been committed by Dentist A, it reflects no credit or honour upon Dentist B when s/he allows emotions to compromise standards of professional and ethical behaviour that would have prevailed in normal circumstances. Unfortunately, one frequently finds that a display of unethical behaviour by one party can provoke a similarly unethical response from the other; each dragging the other down into less and less acceptable behaviour.

Competition

Professional life creates many instances where colleagues are competing for jobs, for representative appointments or positions of responsibility in dental associations, colleges and academies, Dental Boards and Councils, and so on.

Many of the processes leading to these appointments remain confidential within the profession rather than being in the public domain, but they still reflect upon the profession and the standards within it.

It is in the nature of these matters that past differences between professional colleagues can come to the surface, personality clashes can get in the way, and -- as in all human encounters -- ambition and competitiveness can verge upon ruthlessness and professional jealousies can have unfortunate consequences.

We will, from time to time, have strong views about certain professional colleagues with whom we come into contact. There are occasions when it would be appropriate to express such opinions openly or in the context of having been asked for one's views, and other occasions when it is wiser to keep these views to oneself. Particular care should be taken to;

• Separate facts from personal opinions
• Recognise situations where you might be biased, especially if you stand to gain personally from expressing a particular view
• Separate the views being expressed from any feelings you might have about the person who is expressing them
• Declare any conflicts, whether real or perceived
• Respect the right of others to hold views that are different from your own
• Try to keep any comments objective and proportional to the context in which your views are being sought
• Avoid gratuitous criticism -- that is, uninvited, unnecessary and excessive criticism, especially if it is malicious.

It is unworthy and unethical to deliberately disseminate adverse information about a professional colleague -- even if true -- if the purpose of doing so is vexatious (designed only to cause hurt or damage to the other person) or self-serving (designed to promote one's own interests).

Raising concerns

Elsewhere in this series (Ethics module 4), a professional duty of care is explained and the broader aspects of professional responsibility are discussed. Your first duty is to the patient and this extends beyond a particular patient under your immediate care, to patients and potential patients in the wider community.

If, in the course of your professional life, you see or hear something that leads you to believe that patients could be placed at risk or the quality of their care compromised by the actions or performance of a professional colleague, then you have an ethical duty to take reasonable and appropriate steps to:

• Raise your concerns with the colleague directly, if this is appropriate to the situation
• Deal with the problem yourself (if this is within your power)
• Take advice as to how best to manage the situation

Making others (particularly, those in authority) aware of your concerns, is sometimes referred to as 'whistle-blowing', and historically the tendency was to keep these concerns to oneself. Unfortunately, this approach can sometimes leave patients exposed to continuing risk and there is an increasing awareness that in order to discharge our ethical duty to protect the public, it will sometimes be necessary to bring your concerns to the attention of a body (such as a Dental Board or Council) that is in a position to investigate the situation more fully. This will rarely be the first step, however, and in the first instance it is usually more appropriate to discuss your concerns with other professional colleagues, with a practice owner or immediate manager (if relevant) or with higher authorities in a corporate institution or hospital setting. Dental associations, protection/indemnity organizations and other professional groups can all be useful sources of such advice.

It is also unwise to act upon 'hearsay' rumours about a professional colleague, or to jump to conclusions without trying to find out for yourself, both sides of the story. On the other hand, it would be imprudent to automatically dismiss such concerns without giving them some thought and consideration because there are many past examples of patients suffering serious consequences which could and should have been avoided, had the appropriate action been taken by other healthcare professionals who were wellplaced to appreciate an obvious risk which had the potential to impact upon patients.

It is also worth remembering that you may actually be helping a professional colleague to come to terms with, or to deal with, a problem that previously they might not even have acknowledged. Dealing with a problem at a lower level, however awkward at the time, can prevent it from escalating into a situation where the stakes (and the professional consequences) are higher.

The way in which such concerns are raised, certainly has an important ethical dimension and it is usually not too difficult to distinguish a genuine concern to protect patients while trying to support a professional colleague, from a vexatious attempt to cause problems for the colleague in question.

Summary

Many unwelcome situations are caused by a breakdown in the relationship between professional colleagues. Most of them can be avoided through scrupulous adherence to basic ethical principles.

Where such conflicts do arise, every effort should be made to contain them in a manner which;

• Avoids placing patients at risk
• Maintains the continuity of patient care and safeguards their rights and the quality of the dental care they receive
• Avoids bringing the profession into disrepute
• Maintains public confidence in the profession
• Treats professional colleagues as we would wish to be treated ourselves.