A friend in need

MY medical colleagues often express amazement that dentists routinely treat their family and friends. This is primarily because the GMC takes a very restrictive view of this practice, advising registrants to avoid “providing medical care to anyone with whom you have a close personal relationship”.

Obviously, this rule is not invoked in emergencies and I suspect that in other circumstances, such as where a doctor works in a remote setting, common sense is allowed to prevail. However, there’s plenty of anecdotal evidence that doctors take the GMC guidance very seriously and will generally arrange for relatives to be seen by another practitioner.

Other than to provide stringent guidance in relation to drug prescribing, the GDC has not imposed such restrictions. This is perhaps unsurprising since the practice of dentistry does not involve intimate examinations or life and death decisions. However, advice sought from MDDUS does indicate that a less formal dentist-patient relationship does present its own hazards.

Just a friendly handshake

Firstly, there is the issue of consent. Ordinarily, before treatment can commence patients will be advised of factors such as the risks, benefits and alternatives. However, familiarity with a patient can make adherence to standard procedure seem unnecessary and even a little awkward..

One particularly tricky aspect of consenting close acquaintances is the issue of money, with dentists often feeling obligated to discount fees or “just charge the lab bill” as a gesture of goodwill. While this act of generosity is usually appreciated it often remains undocumented, an aberration which can unfortunately lead to problems. To paraphrase Mario Puzo, “friendship and money are like oil and water” – it’s not unknown for even the most generous price reduction to be subsequently challenged or even misrepresented as a tacit admission of substandard treatment. If there is no record of what was agreed and on what basis, the practitioner is left in a vulnerable position.

Clinical considerations

Over-eagerness to help our friends may not only result in poor consenting, but may also skew our clinical judgement. It is quite understandable that, when treating those close to us, we may adopt practices that would not be routinely countenanced. A restorative plan, which would normally be regarded as over-ambitious, might just be attempted. A posterior resin might be claimed as NHS amalgam (in Scotland) to improve aesthetics and reduce the patient charges.

Usually, treatment will proceed as planned and any such aberrations will have no relevance. Even when problems do arise, good friends or immediate family members will generally accept the outcome and be appreciative of our efforts.

However, it’s not hard to imagine circumstances where, for example, a more distant or estranged relative takes a less indulgent view. Equally, former auxiliary staff who may have left the practice in less than amicable circumstances may feel disposed to second-guess any treatment offered to them gratis, particularly if it was of the exotic variety. These patients, who may have been quite happy to benefit from your kindness when all was going well, can prove to be especially ungrateful if the finished treatment does not meet expectations. If the investigation of a subsequent complaint reveals inadequate consenting or questionable treatment planning, the fact that these faults were a product of kindness will get little sympathy.

By the book

Possibly the best means of pre-empting such problems and avoiding causing offence is to apply the correct rules uniformly. Written treatment plans and cost estimates are expressly required in most cases for both NHS and private patients. If the practice policy is to provide everyone (except, perhaps, your mother) with this document prior to treatment of any complexity then no-one, not even your best mate, should feel affronted. Equally, no-one can subsequently attempt to take advantage of your good nature by “misremembering” the agreed charges.

Regardless of an appointment’s informality, records must include all of the usual observations, such as examination results and details of the treatment provided. Where there are any doubts, don’t feel abashed about requiring a signature on the consenting document. After all, this is the standard practice policy. Finally, don’t be tempted to consent your friend or discuss treatment in the course of exchanging personal e-mails. The GDC have taken the view that all clinical information must be included in the patient records.

A convenient prescription

If the provision of dentistry to family and friends is fraught with its own unique pitfalls, then the decision as to whether you should also write them a prescription is a real high-wire act. It is in relation to this particular facet of dentistry that the GDC has published Guidance on Prescribing Medicines which offers the following explicit guidance:

"If you prescribe medicines for someone with whom you have a close personal relationship you may not be able to remain objective and you could overlook serious problems, encourage addiction, or interfere with treatment provided by other healthcare professionals. Other than in emergencies, you should not prescribe medicines for anyone with whom you have a close personal relationship."

Any departure from this guidance (most probably where prescription medicine forms an integral part of a planned course of treatment) should be completely logical, safe and well-documented.

Quite understandably, the GDC have created an exception to allow for prescribing in dental emergencies. What, however, if the condition was serious, but of non-dental origin? Normally, the dentist’s involvement would be limited to recommending urgent consultation with a doctor or a trip to A&E. However, when the patient in question is a relative, there may be a temptation to intervene personally. Obviously, it would be impossible to prescribe for most medical conditions using an NHS script. However, there is no restriction on the choice of drugs that can be prescribed by a dentist on a private basis. Beware – even if the condition is common and its treatments and their hazards are scrupulously researched, this is not carte-blanche to prescribe at will.

The GDC’s new Standards and Scope of Practice require that registrants only carry out treatments for which they are “appropriately trained… and indemnified”.

In support of this position, the GDC cite the example of a dentist who prescribed one week’s supply of diabetic medication for his mother who lived abroad and whose supply was running short. The Investigating Committee noted with sympathy the surrounding circumstances but still issued the dentist with a warning.

Bearing this example in mind, one must fear for the poor dentist who succumbs to pressure from a life-long golf partner and gives a penicillin script for a “sore throat”. While such an action might seem inconsequential, it would in all likelihood, breach the requirement that registrants should prescribe for identified dental needs and that registrants should prescribe within their competence. It also contravenes the restriction on prescription to close friends outside emergency situations. A full house if ever there was one!

There may be an assumption that such minor transgressions would only come to light in the event of some catastrophic complication. Admittedly, such an outcome is pretty unlikely. However, it only takes an unfortunate drug interaction or a report from a professional colleague to spark off many months of regret and worry.

So, reflect very carefully before departing from your normal prescribing, treatment planning or claiming practices. Dentists who stretch the rules for friends will usually do so out of compassion and not for personal gain. However, previous instances have shown that, where these actions conflict with GDC standards, NHS regulations or accepted clinical practice, such mitigating arguments are of limited value.

Doug Hamilton is a dental adviser at MDDUS

From Summons Winter 2014 pp18-19

Summons Winter 2014
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