A patient’s autonomy to make decisions regarding their health is a bedrock axiom of medical ethics. A doctor may disagree with a patient’s course of action, but, it’s their life.
Of course, the doctor does not have to be a willing participant in that patient’s case if he disagrees with the patient’s choices. The classic example. Blood transfusions for Jehovah’s Witnesses. Adult patients strongly committed to that religion will generally avoid any transfusion even if it means they could hemorrhage to death on the operating room table. Many surgeons choose not to operate on such patients because it is hard to square their beliefs with those patients’. Still, there are centers that specialize in such treatment, where the doctor will accommodate the patient while conforming to medical ethical norms.
But an adult Jehovah’s Witness cannot impose their view on transfusions onto a minor child if the child requires a life-saving transfusion. Only when that child becomes an adult can he make that call for himself. A court will generally intervene to give the doctor legal cover to perform the transfusion on the child.
So, the state has a lot to say about the care a child receives.
Recently, a dental practice in Pennsylvania sent a letter to select families. I am not sure if it was sent to families whose children had missed appointments. I do not know if it was sent to families who had not made appointments for their children. I’ll be generous for the moment and assume it was a friendly reminder to bring their kids in to be seen. I often get reminder notices from my doctors. Perhaps it’s a been a while since my last colonoscopy or eye exam. I’m sure you receive such reminders too.
Here the gist of the dentist’s letter:
Our goal is to keep children as healthy as possible through education, regular dental checkups, and timely treatment as needed. In order for us to do that, you must bring your child to one of our [centers] for regular professional cleanings and treatment.
According to law, failure to bring your child for dental care is considered neglect. Pennsylvania Act 31 (Child Abuse Reporting and Recognition Requirements) states that health care providers must report your failure to bring your child to the dentist for evaluation and care. A copy of Act 31 is enclosed for your reference. [Our organization] has not reported your child’s outstanding dental treatment as of yet. Since this law is in effect, we hope this letter encourages you to schedule an appointment to follow through with needed dental treatment for your child…..To keep your child as healthy as possible and avoid a report to state authorities, please call [our organization] immediately to schedule a treatment appointment within the next 30 days.
The dental group did say that if the child sought treatment with another provider, they want the name of the new provider, and they would be happy to forward records.
Take a guess as to how this letter was received.
Yep.
By the way, one investigative report said that the dental group reported 17 cases of neglect last year alone.
While there may be many indicia of neglect identified in a patient who has been seen and evaluated, I cannot agree that missing dental appointments requires the same conclusion.
I eyeballed Act 31 and there is no text which concludes missing dental appointments is reportable to state authorities.
Still, I was able to locate a document categorized as Clinical Practice Guidelines (adopted in 1999, revised in 2005, and reaffirmed in 2010) for the American Academy of Pediatric Dentistry
The purpose of this report is to review the oral and dental aspects of physical and sexual abuse and dental neglect and the role of physicians and dentists in evaluating such conditions. This report addresses the evaluation of bite marks as well as perioral and intraoral injuries, infections, and diseases that may be suspicious for child abuse or neglect. Physicians receive minimal training in oral health and dental injury and disease and, thus, may not detect dental aspects of abuse or neglect as readily as they do child abuse and neglect involving other areas of the body. Therefore, physicians and dentists are encouraged to collaborate to increase the prevention, detection, and treatment of these conditions.
The universe of topics that were addressed include oral gonorrhea in prepubertal children; unexplained injury at the junction of the hard and soft palate; and evidence of bite marks. I’m sure there is universal agreement that such findings would be reportable to authorities.
The final category in the Guidelines focused on “dental neglect.”
Dental neglect, as defined by the American Academy of Pediatric Dentistry, is the “willful failure of parent or guardian to seek and follow through with treatment necessary to ensure a level of oral health essential for adequate function and freedom from pain and infection.” Dental caries, periodontal diseases, and other oral conditions, if left untreated, can lead to pain, infection, and loss of function. These undesirable outcomes can adversely affect learning, communication, nutrition, and other activities necessary for normal growth and development. Some children who first present for dental care have severe early childhood caries (formerly termed baby bottle or nursing caries); caregivers with adequate knowledge and willful failure to seek care must be differentiated from caregivers without knowledge or awareness of their child’s need for dental care in determining the need to report such cases to child protective services
Failure to seek or obtain proper dental care may result from factors such as family isolation, lack of finances, parental ignorance, or lack of perceived value of oral health. The point at which to consider a parent negligent and to begin intervention occurs after the parent has been properly alerted by a health care professional about the nature and extent of the child’s condition, the specific treatment needed, and the mechanism of accessing that treatment. Because many families face challenges in their attempts to access dental care or insurance for their children, the clinician should determine whether dental services are readily available and accessible to the child when considering whether negligence has occurred.
The physician or dentist should be certain that the caregivers understand the explanation of the disease and its implications and, when barriers to the needed care exist, attempt to assist the families in finding financial aid, transportation, or public facilities for needed services. Parents should be reassured that appropriate analgesic and anesthetic procedures will be used to ensure the child’s comfort during dental procedures. If, despite these efforts, the parents fail to obtain therapy, the case should be reported to the appropriate child protective services agency (emphasis added).
I understand why the state would intervene to mandate a minor receive life-saving transfusion against a parent’s wishes. I also would understand why the state might intervene to address a pediatric dental abscess the family might be ignoring.
I am skeptical that missing dental checkups is equivalent.
That said, administering care to minors becomes a quagmire when the standard of care doesn’t jive with the wishes of the child’s legal guardians. The law is clear – but managing the emotions of the parents can be tricky. You don’t want a dispute with the family becoming a liability for your young patient or a distraction for your practice.
Medical Justice is well acquainted with the laws and regulations governing these encounters. In the event you are propelled into this situation – or any prickly medico-legal obstacle – contact us. We’ll guide your through the storm.
Use the resources shared below to further develop your understanding of the medico-legal space. And share your thoughts regarding this week’s publication in the comments.
Perfect Patient Dismissal & Termination Letters
Respond Masterfully to Negative Patient Reviews
Discover the Regulatory Landmines Most Doctors Miss
Jeffrey Segal, MD, JD, FACS
Chief Executive Officer and Founder
Dr. Jeffrey Segal, Chief Executive Officer and Founder of Medical Justice, is a board-certified neurosurgeon. Dr. Segal is a Fellow of the American College of Surgeons; the American College of Legal Medicine; and the American Association of Neurological Surgeons. He is also a member of the North American Spine Society. In the process of conceiving, funding, developing, and growing Medical Justice, Dr. Segal has established himself as one of the country’s leading authorities on medical malpractice issues, counterclaims, and internet-based assaults on reputation.
Dr. Segal was a practicing neurosurgeon for approximately ten years, during which time he also played an active role as a participant on various state-sanctioned medical review panels designed to decrease the incidence of meritless medical malpractice cases.
Dr. Segal holds a M.D. from Baylor College of Medicine, where he also completed a neurosurgical residency. Dr. Segal served as a Spinal Surgery Fellow at The University of South Florida Medical School. He is a member of Phi Beta Kappa as well as the AOA Medical Honor Society. Dr. Segal received his B.A. from the University of Texas and graduated with a J.D. from Concord Law School with highest honors.
In 2000, he co-founded and served as CEO of DarPharma, Inc, a biotechnology company in Chapel Hill, NC, focused on the discovery and development of first-of-class pharmaceuticals for neuropsychiatric disorders.
Dr. Segal is also a partner at Byrd Adatto, a national business and health care law firm. With over 50 combined years of experience in serving doctors, dentists, and other providers, Byrd Adatto has a national pedigree to address most legal issues that arise in the business and practice of medicine.
Drop the shoe!! What happened, Jeff? Did the dentist get whacked?
As best I can tell, the uproar was in the court of public opinion. Followup on the story: “There were allegedly 17 cases where parents were reported to Child Protective Services” by the practice.
https://healthimpactnews.com/2018/did-pennsylvania-mom-who-stood-up-to-dental-bullying-uncover-massive-pediatric-dental-fraud-nationwide/
I agree that at first glance that missing a child’s hygiene appointment may appear a minor event and not rise to the level of child abuse, however, cavities, undetected and untreated in the primary dentition can become a life altering disease. The possibility of pain, infection, loss of teeth and the possibility of developing a dental phobia as a result of treatment, can psychologically harm a child for life. Children require daily, weekly, monthly and yearly routines for proper growth and development, not providing regular dental care is missing one of the most important opportunities for the prevention of disease and the interception of growth issues. Furthermore, the opportunity to detect growth and development and to intervene when breathing problems develop has a unique window of opportunity while children are young. Missing that window the individual may have breathing problems, sinus infections and poor occlusion. I would encourage any provider to learn more about the significance of pediatric dentistry and the welfare of the individual. While I can not condone reporting a parent who misses an appointment, I think a parent who doesn’t take a child for dental care over a one or two year period needs to be woken to the issues at stake.
I agree with Dr. DiDonato., although I don’t think he goes quite far enough. Several years ago a child died due to an untreated dental abscess. A parent may not bring a child anywhere for dental treatment due to their own fears of the dentist. However, they generally bring their children to the physician for checkups, vaccines (hopefully), etc. It would behoove all physicians, pediatric and otherwise, to become familiar with what a “normal” mouth looks like and actually check their patients’ mouths at each visit to check for out-right abnormalities. Is there a large lump or bump that’s out of place? Is it painful? Are the gums puffy and really red? Are there any holes in the teeth, or large black areas? These could all indicate infections of varying degrees that would also influence your patients’ general health. Please refer them to a dentist, whether in a private office, a clinic, hospital setting, health department, or dental school.
This really strikes home with what I encountered when I was early in my practice. These types of guidelines lead to radical enforcement by people who think they are “saving children”. We had an ER nurse who was taking the lead for the facility on “child abuse”. She saw child abuse in every possible instance possible. So, if a child had bilateral bruises on their extremities, that was considered a sign of child abuse. Never mind that a kid who fell down on both knees at the same time could have had bilateral bruises. The parents were reported first because bilateral injuries “HAD TO BE” a sign of abuse.
This radical paternalism has cause untold injuries and harm to parent child relationships introducing court proceedings (which is where all of these cases wind up) for good parents who happened to stumble across one of these radical child abuse practitioner enforcers.
Scenario: A two year old girl was in a department store with her mother. She was having a tantrum and was hiding out under a clothing rack filled with clothes. She would not come out. Her mother on hands and knees finally got hold of her hand and pulled her out from under the rack and proceeded home. The mother noticed that the daughter had the arm dangling at the elbow. The father was a physician at a facility with a radical child abuse advocate. The daughter was adopted.
Would the physician father take the child to his own facility with the radical child abuse advocate who would think that pulling the child out from under the clothing rack at the department store was child abuse? Would he risk having the adoption nullified in those circumstances? Knowing that the child abuse advocate would call this isolated incident child abuse and would report it to the authorities as such, would the physician father dare to take the child there for examination?
Or would the father call an orthopedic colleague at a neighboring hospital, without a radical child abuse advocate, and explain the circumstances, and ask to be seen at the neighboring hospital?
What would one think if the orthopedic surgeon in such a scenario, saw the child in the lobby of the hospital to avoid creating a medical record, and popped the dislocated elbow back into place?
What would one think if the child in such a scenario, went on to grow up with loving parents and went on to become a professional?
These types of radically applied child abuse guidelines sound wonderful on paper. The potential to harm and the actual harm that has come by the misapplication of these guidelines is vast. The fact that this practice actually reported parents to authorities is a grand over reach of professional authority. The dentist has no idea of family circumstances or patient circumstances outside of the office, whether it be financial woes, divorced parents, move of the family away to another town or state (common in our mobile society), or any one of 100 other variables outside of the office. I fully support appropriate dental care for children. I am well aware of what the neglect and poor dental care of kids can result in, since I provided anesthetic care for hundreds of children that needed full mouth extractions in our OR. However, in the vast majority of those cases it was simply a matter of poor education on the part of the parents that led to such care.
Letters provided by the dental practice in question here are using scare tactics with their letters.
Getting someone to buy a product or service with scare tactics is terrible.
It is paternalistic in one sense to tell someone what they have to do.
Many people will rebel from taking their kids back to such providers.
I saw many adults in practice that had horrible teeth as a result of non fluoridated water, poverty, lack of education, poor diet, and genetic background that predisposed them to poor dental health. I saw many teeth hanging by a dead root and when simply touched came out. Having lived and practiced in one of the poorest areas of the country for decades, we saw all of that and more.
But our job was to educate and elevate patients. It was not to report them to the authorities. Where did this socialist bent in our society come from?
We should be professionals and not crusaders.
I had crusading physicians on our medical staff that carried on mightily about the harms of smoking and railed at patients. THEY GOT NOWHERE.
I had gentle conversations with patients over time and helped them with techniques to cut down on their smoking, and chewing tobacco (which also started at a young age), over time.
Gentle education, and steady persuasion, tying it back to their current state of health won out over time.
Radical reeducation which is what the dental practice noted in this article wants to achieve, is more suitable for the gulag than a dental practice. Guidelines that become the law in the minds of some, have the potential to cause great harm. In some cases (not the ones described here) they have lead to either under treatment or over treatment. We should individualize care and adapt it to each patient with kindness and thought and appreciation for each families circumstances.