Debate on SDN about the fairness of standard of care to specialists.

by KEVIN KUO, DDS, MMSc | March 10, 2019

I recently came across a discussion on Student Doctor Network about the saying "standard of care for someone with extra years of training". The original post discussed how some general dentists can place implants at par or even better than specialists. The user on follow-up discussions argued that a periodontics graduate may not always be as clinically skilled as a general dentist in certain cases and should not be deemed more of an expert as compared to general dentists by default. 

The following was my contribution to the discussion:

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This topic is a complicated subject for sure! I want to start with some definitions using endodontics as an example:

• "Standard of Care: There is no medical definition for standard of care, although the term is firmly established in law. In tort law, the standard of care is defined as “the caution and prudence that a reasonable person under a duty of care, in similar circumstances, would exercise in providing care to a patient.” Peer review and the courts recognize only one standard of practice in endodontics — and that standard is determined by the endodontist." (AAE Colleagues of Excellence)

• "Standard of Practice: This is defined as the acceptable level of performance or an expectation for professional intervention, formulated by professional organizations based upon current scientific knowledge and clinical expertise. When improved technology offers clearly superior results, it no longer becomes an issue of doctor/patient choice, but, rather, a requirement to fulfill the standard of practice. The use of microscopy for apical surgery with ultrasonic tips for retrofilling exemplifies improved technology and the current standard of practice in endodontics. Likewise, apical retrograde restorations should be performed with biocompatible materials, such as mineral trioxide aggregate, not with amalgam." (AAE Colleagues of Excellence)

In general, the Standard of Care is more of a legal term. The court determines whether or not a treatment is considered to be malpractice. And often, time and geographical location can completely change the Standard of Care. The same malpractice suit can be treated differently in one place and time as opposed to another. In other words, when people state that treatment should comply with the Standard of Care as a specialist, they are speaking more in terms of Standard of Practice, which is more the topic of this thread. 

Now comes the question, should the Standard of Practice be set at the specialty level? And the answer, I would say is now simple: yes. Because there are specialty organizations in dentistry, they are the ones that set the Standard of Practice. So in a way, yes is the default answer. Standard of Practice is defined by the specialty organizations. 

The new question now is, "Is this fair to general dentists?". The irony is that in medicine the standard of practice was developed decades ago to help physicians prevent malpractice suits. But now, especially in dentistry, the standard of practice understandably is meant more to protect the specialties and now potentially increases liability for general dentists. Whether or not this is fair is more challenging to answer. Specialties will be quick to state that additional training in a specialty program affirms advanced diagnostic and clinical skills, by default. This makes sense when we look at the cohort of specialists and general dentists and not individual practitioners. One can safely assume that the specialists as a group are likely more able to perform a treatment, like implant placement or endodontics, better than the general dentists. 

This is understandably tough for individual general dentists that actually perform good specialty treatment in accordance with specialists. Like @Rainee stated, general dentists will be more at risk of malpractice suits given that specialists exist and specialist organizations set the Standard of Practice. It is more and more common that the Standard of Practice is now used to formulate the Standard of Care in court. 

Just a tough question. One can argue that higher Standards of Practice betters patient care, while others argue that its overcomplicating matters.

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Read the rest of the thread here on SDN.