Parallax View is an editorial series presented for educational and discussion purposes only.

The opinions expressed are those of the authors only, and by no means is any anti-trust action implied or to be inferred.

 

Dear Reader’s Digest,

January 20, 1997

 

I read your feature, How Honest Are Dentists?, with great interest. William Ecenbarger brought up some serious issues confronting dentistry today, including some issues that the profession of dentistry shows little organizational awareness of. As public opinion is the major factor that creates the true essence of dentistry in our time, articles such as this bring the flaws of our organizational paradigm into jarring light.

Being able to step out of our white coats and see our practices and our profession through our patients’ eyes is a most difficult thing, and I applaud Reader’s Digest for addressing a difficult issue. While I think that the article is correct in many aspects, I also think that Mr. Ecenbarger’s conclusions in some cases were lacking in big-picture vision. In this short thesis, I will attempt to, without ego or professional-defensiveness, address as many of the points as possible.

ONE) The character of a profession is never an all or none phenomenon, otherwise we would have done away with the attorneys, the press, and the clergy long ago! Disagreement between analyses of similar data is common in every walk of life; to assume that the health care profession must deal in absolutes and thus have every practitioner come up with the same treatment plan is to set one’s self up for a lifetime of disappointment. However, recent history has shown an increasingly litigious society, in which culpability for a bad outcome must be assigned and redressed. Unlike many countries, we have grown accustomed to the perception that cutting edge health care is our due. Hence, there are more MRI machines in Dade and Broward Counties in Florida than in the entire country of Canada! We are expected to be not only absolute, but omnipotent. In these days of consumer awareness, trust is earned and re-earned with each interpersonal contact. The article spotlights today’s health consumer paradigm. Those of us who have practices that are able to develop "patients for life" are always aware of this fact and understand that honesty is the only policy. Mr. Ecenbarger obviously has that kind of relationship with his personal dentist, and uses that dentist’s opinions as an absolute for this article. Please note that his panel of "financially disinterested dentists" stated that his necessary treatment could cost as much as three times the amount quoted by his personal dentist, already a variation of 300% in the "control group"! The expectation of absolutism in diagnosis and treatment planning is society’s problem, not dentistry’s. The obvious answer is to demand freedom of choice for patients to choose the dentist they trust and want to build a relationship with, with free market forces applying.

TWO) Many dentists mistakenly co-mingle cosmetic plans with those that are health necessities. As there are numerous possible qualifications for the word need, I don’t think that law or organizational policy can regulate this issue. I do think that it would behoove our profession to present treatment plans to our patients in four parts: diagnostic findings, treatment plan to establish long term health, options within that plan, and cosmetic options on request. I agree that some dentists can come off sounding like snake-oil salesmen when they talk about tweaking insurance benefits to allow for unrequested cosmetic treatment. Consumers should be well informed and make sure that they are the ones who have made the decision.

THREE) There is no question that every new patient examination and continuing-care examination should include an oral cancer screening, a periodontal evaluation, an occlusal (bite)examination with muscle palpation, and then the tooth examination. Consultations are generally problem-focused and as such the provider is not responsible for a comprehensive exam (you wouldn’t expect a rectal exam at an allergy consultation, but would expect the allergist to have complete knowledge of your health and history if you did accept treatment and become a patient of that doctor), although many of us do feel so obligated and do provide complete examinations for all patients, whether they are consultees or patients of record. If Mr. Ecenbarger was charged for an Initial Examination, then he should have received a complete examination. Any dentist not providing this level of examination is wrong. Period.

FOUR) Some fee differences are to be expected regionally, as lease/real estate costs vary greatly as well as acceptable staff salary ranges. Price also varies with the level of "patient experience" provided. It does cost more to provide a Park Avenue dental experience than it does to provide a Newark dental experience. Again, if patients have the freedom of choice to decide where and how they prefer to be treated, then this difference provides no problem; it is a strength of our country! Some people like Mc Donald’s, some people like prime rib, but no one goes to Mc Donald’s expecting prime rib.

FIVE) To denigrate the intraoral camera as a mere selling device is like welcoming blindness. This devise offers caring dentists the opportunity to educate their patients in ways heretofore impossible, because it’s hard to see inside your own mouth. We finally have the opportunity to allow patients to co-diagnose and co-verify recommended treatment. Mr. Ecenbarger should applaud this device as a giant leap in consumer education. Without it, patients must blindly trust the word of their dentist, and remain unknowledgeable as to their own condition. Of course it can be abused, but only by outright lying on the part of the dentist. Don’t misinterpret this wonderful tool.

SIX) Publications and seminars along the line of The Profitable Dentist are a symptom of two things lacking in dental education: business skills and human behavior skills. The fact is that the knowledge base for a satisfactory dental education can barely be taught in a four year program. Mr. Ecenbarger’s statement that these modalities of dental education serve to "persuade patients to accept expensive restoration work instead of fillings" is without foundation, is conjectural, and is inflammatory on his part. Yes, Mr. Ecenbarger, dentistry is competitive, but not necessarily in the way you characterize in your article. You see, dentistry competes on the basic financial level with disposable income. Which would you rather have, in your heart of hearts, that crown on number 30, or that new Pentium 5000 computer. Or that new suit. Or that trip to the Writer’s Convention. Come on, which do you want most? You probably would feel differently about a proposed bypass operation after being diagnosed with coronary occlusion; you would want that more than recreational or consumer goods, because you understand and have accepted its value. Dentists enter our field ill equipped to be in business and communicate well with the myriad of personality types our patients present to us. Those of us sentient enough to "know what we don’t know" embark on a knowledge quest as to how to better educate our patients as to their dental health needs so that they do value that crown on number 30 more than the Gucci purse. And learning how to use modern business practices allows us to provide optimal dental services as effectively as possible at a reasonable fee. And, if dentistry is allowed to function in a free market, then patients, not dentists, will provide the definition of a reasonable fee. Most of us want to be directly responsible to our patients, and not the third party payers, as is so often the case today.

SEVEN) Mr. Ecenbarger reports nothing about the postgraduate education available in dental excellence, such as the Pankey Institute, Peter Dawson’s Seminars, Terry Tenaka’s Seminars, etc. Not all dentists take advantage of these opportunities, but the fact that dentists work from knowledge and experience bases that are drastically different may explain some of the differences in his treatment plans. We literally all do not see through the same eyes. This is why some of us may see a reconstruction where others see only one tooth with a hole. And only the future of each individual patient can bear out which is correct. Disagreement does not imply dishonesty. Again, beware of thinking in absolutes. Just because nine out of ten dentists agree doesn’t mean that the one is wrong- he or she may have the better vision of long term health.

EIGHT) Guidelines and regulations are not the answer, unless you see the Postal Service as a role model. Health care is not cookie-cutter in its delivery, just as it is not absolute in its diagnosis and treatment planning. Our government cannot even agree on standards, as evidenced by the fact that most states or regions have separate and non-reciprocal board examinations, all extolled to protect the citizens of that particular state. This implies that the standards of one state are significantly different from those of another to the extent that the welfare of patients may be in jeopardy should a dentist cross state lines. Neither organized dentistry nor government has addressed this assumption to any significant degree for several generations. Further, the legal profession has repeatedly ruled that the concept of "standard of care" is defined locally, not nationally. The definition of standard of care is diagnosis and treatment provided with expertise and judgement congruent with that of the predominance of providers in that community; if the treatment involves a specialty area, then the provider is held to the standards of the predominance of specialists in that community. There is no national standard of care. If our civic, legal, and professional leaders cannot agree on a national standard for basic skill levels for dentists, then from where should we derive our guidelines? Again, consumer education and a free market give the best alternatives, and should be welcomed by the profession and patients alike. Well educated citizens can define and enforce the standard of care much better than any regulatory body. The dental profession continues to be remiss in not satisfactorily educating our citizens.

FINALLY) Mr. Ecenbarger does a great service to the profession of dentistry by highlighting the issue of trust. It is much easier to trust a dentist that you researched and chose for yourself than it is to trust one from the insurance company’s "exclusive" list. Don’t get me wrong, almost every type of dental insurance has some validity for certain patients, but I feel strongly that any plan that does not allow a patient to see any dentist he or she chooses (and receive reimbursement) is flawed. Insurance companies work in a bottom-line paradigm; that is, profit for their shareholders. Insurance companies are therefore primarily responsible for the financial benefit of their investors. This is a basic truth. Dentists, on the other hand, are directly responsible to their patients, who have given of their trust and deserve to be treated by doctors worthy of trust. This is a fundamental relationship, that if disrespected, will lead to the demise of quality dentistry as we know it. We don’t want that to happen, for your sakes. Honestly.

 

K. Randall Groh, DDS

Coral Gables, FL

 

K. Randall Groh, DDS
Acting Chair
The American Independent Dentist’s Association
336 Alhambra Circle
Coral Gables, FL 33134
E-Mail feeforserv@aol.com
January 20, 1997

© K. Randall Groh, 1997

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