Delegation, Outcome Guarantees, and a Referral Fee at a Mall Clinic
Dr. R is two years into practice at Klinik Gigi Bersama, a mall clinic owned by PT Mitra Sehat, whose director is a businessman and not a dentist. Her contract sets a target of 60 patients a month, pays her 30% of production, and adds a separate clause paying her Rp 250,000 for every patient she sends to the implant suite on the floor above, which the same director owns. One Saturday the schedule holds 22 patients in nine hours. The director instructs Yuyun, a dental assistant with a one-year diploma and no registration, to give inferior alveolar nerve blocks and to run 35% hydrogen peroxide in-office bleaching on four package patients while Dr. R works in the other rooms, saying "she has been trained, and you signed the consent." That evening the clinic's Instagram posts a before-and-after photograph of a patient's smile with the caption "white in one visit, guaranteed, or your money back." The patient pictured signed only the general treatment consent form.
1. How should Dr. R respond to the instruction to have Yuyun give nerve blocks and perform the bleaching? Which tasks may an unregistered assistant perform, and what is Dr. R's exposure if she agrees?
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Divide the requested tasks into three buckets and answer from the buckets, not from the training.
Non-delegable. Inferior alveolar nerve blocks and in-office bleaching with 35% hydrogen peroxide are invasive, diagnosis-dependent procedures that sit inside the dentist's own kewenangan. They require an operator who can take a history, screen for contraindications, manage a syncopal or allergic reaction, and carry legal responsibility. A one-year diploma and informal training do not create authority. If Yuyun performs them, she is practising dentistry without registration, and Dr. R is the licensed professional who enabled it.
Delegable under supervision. Suction, retraction, instrument transfer, mixing, cleaning and disinfection, radiographic processing, oral-health instruction. Delegation here is bounded by the assistant's registered competency, not by convenience.
Structural problem. 22 patients in nine hours is roughly one every 24 minutes. That schedule, not Yuyun's training, is the root cause. Dr. R cannot obtain meaningful consent or supervise delegated work at that pace, and "you signed the consent" is exactly backwards: consent she had no time to explain is the weakest kind.
The practical move: refuse in writing, state which tasks are non-delegable and why, propose rebooking or a second dentist, and document the refusal. Agreeing exposes her to disciplinary action, a negligence claim she cannot defend, and possible criminal liability for aiding unregistered practice.
2. Assess the Instagram post. What is wrong with the claim and the photograph, and what would have to change for the clinic to post it lawfully and ethically?
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Two separate defects, and they fail for different reasons.
The claim. "Guaranteed, or your money back" converts a clinical intervention into a promised outcome the dentist cannot deliver. Shade relapse, sensitivity, existing restorations and the patient's diet all affect result. Advertising must be truthful, not misleading and not exaggerating; an outcome guarantee plus a refund is a commercial inducement attached to a health service, and it pressures patients toward a procedure that may not be indicated.
The photograph. A general treatment consent authorises treatment. It does not authorise marketing. Publication needs a separate, specific, written authorisation that states where the image will appear, for how long, and that the patient may withdraw it. Even then, the image should be non-identifiable, since a smile close-up together with a clinic location can identify a person. Before-and-after images also imply typical results, which is a representation in itself.
What a compliant version looks like. Describe the procedure factually, state that suitability is determined after examination, state the price or the basis for it accurately, drop the guarantee and the refund promise, and use either no patient images or specifically authorised, non-identifiable ones. Dr. R should ask for the post to be taken down the same day and record the request; the account is the clinic's, but the professional accountability for a clinical claim made about her work is hers.
3. The Rp 250,000 per referral clause: analyse it against professional ethics and the practice framework, and say what Dr. R should do about the clause.
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Referral is a clinical act. The only defensible reason to send a patient upstairs is that the implantologist's competence, equipment or availability serves that patient's need better than what Dr. R can offer. A payment tied to the referral changes the question being asked from "what does this patient need" to "what is this patient worth to me", and that is the core objection, independent of whether the implantologist is competent.
Fee-splitting and inducement payments for patient referrals are inconsistent with the professional code of conduct and with the fiduciary character of the relationship. The clause is also a conflict of interest the patient is entitled to know about; if Dr. R keeps the clause and refers, she must disclose the arrangement, and a disclosed kickback is still a kickback.
What to do. Ask for the clause to be deleted in writing, and decline the payments already offered. Where a referral is clinically indicated, refer and record the reason in the note; if the patient asks why, answer honestly. If the director refuses to remove the clause, that refusal belongs in any later disciplinary or employment file, because she will be the one named if a patient complains. Separately, check the ownership structure: a non-dentist investor may own the premises and the company, but the dental service must be led and delivered by licensed professionals, and a director who dictates clinical staffing is drifting across that line.