2

CASE: GRIND IT OUT!

Jack Williamson, a fourth-year dental student, has just returned from a visit and interview at the main office of a prospective employer, Dr. Edward Prentice. Dr. Prentice runs three dental offices and plans to open a fourth in the summer. He has been interviewing senior students from dental schools in the state to help staff his new office.

Like many dental students today, Jack Williamson will graduate with very large debts. There is little chance a bank will loan him the money to start up his own practice, as his father was able to do. Jack’s ailing father, unfortunately, had to sell his practice early, when Jack was in high school, and Jack’s wife’s job and the couple’s desire to remain near his aging parents make a move away from the city unacceptable at present. So Jack is looking for a job in the area. As soon as Jack walks into the students’ common room, everyone knows he had been out on an interview. “Nice suit, Jack! Are you trying to upgrade the clinic? Too much boring white?” says Len Billings, another fourth-year student. “How did it go?”

“A little weird,” Jack answers. “Do you know where I was? Prentice’s Smile Centers.”

“I’ve seen the ads. ‘Quick appointments when you need care; short waits when you get there.’ What’s it like?”

“Very cushy. The new place is going to look like the Taj Mahal. All the newest technology, too. That part was pretty interesting.”

“What’s the other part?” asks Becky Lissen, another classmate.

“The part about taking care of patients,” says Jack. “I spent about an hour and a half at the Oakville Boulevard place—that was Prentice’s second office. It’s where he has his private executive office. The number of patients there was huge, and more were waiting for treatment. It looked like ‘grind it out’ was the motto.”

“What do you mean?” asks Sandra Teng, another fourth-year student.

“I saw six dentists—three guys and three women, much like us, probably just out of school—working as fast as they could. They had the latest technology and lots of assistants, but all were set for speed and volume. They might as well have had ‘grind it out’ tattooed on their foreheads.”

“Is Prentice pushing them that hard?” asks Len. “Anyway, what did you expect? If they didn’t want to start their own practices, or couldn’t afford to do it, then they probably had to take what they could get—just like some of us will have to. But you can handle that, Jack. Any of us in our group could. We all know how to work hard, and we’re pretty fast, too. I mean, unless Prentice is some sort of jerk. So what’s the problem?”

“He wasn’t a jerk, Len, and hard work doesn’t bother me either. I’ve worked for plenty of bosses who pushed me hard on the job, not to mention the kind of pressure on all of us here in this place. No, it’s the quotas that got me, Len. They have target numbers, a certain amount of billable work per patient, per hour, per day, and so on, and they’re judged by it. Prentice is very clear about that. It’s simply what’s expected. Once, while Prentice was on the phone, I saw one of the guys who was between patients. I went into his operatory and asked if there is a big push to get patients in and out or to pressure them into buying lots of care. He looked to see who could hear him first, then he leaned into my ear and said, ‘Grind it out or get your butt out of here. That’s the story.’

“I said that Prentice didn’t seem like a bad guy, and he said, ‘Oh, he’s not nasty about it. In fact he’s a very friendly sort of guy, but that doesn’t change the expectations. He doesn’t have to be nasty—he’s in charge. He hires and he fires. If someone doesn’t perform, they get the boot—and it doesn’t take long for Prentice to figure it out. His data and contracts are iron tight.’”

“Do they do unnecessary care?” asks Becky. “Are the dentists there supposed to trick patients into thinking they need something they don’t? Are they doing treatments without getting patients’ consent? How do they handle all that?”

“I asked Prentice something about that after he got off the phone. I said I noticed the impressive volume of treatment and wondered how patients reacted to that or if it made for a lot of stress for his dentists.”

“What did he say?”

“He said something about clear expectations making for good employee relationships. And if I came to work for him and wanted to know where I stood, I could easily figure it out myself by just comparing my work to the target numbers. He said that would make things very clear between us—as it does for all the people who work with him. As far as the patients, he said of course they had to give consent before they were treated. That’s the law, and he certainly doesn’t want his employees breaking any laws. He was very clear about that and added that he has a team of lawyers that keep up with all the legal changes and come in periodically to keep everyone up to date. He said a lot of practitioners don’t bother to pay for that advice and put themselves at risk. He was really proud that he was protecting his employees that way.”

“Maybe so, but what about pressuring patients?” asks Becky. “It doesn’t seem like they’re talking with people the way I’d want to talk with them, or even how I’d want any doctor to talk to me.”

“He said patients know very little about dentistry. Some of them think they do from what they read online, but in the end they all depend on dentists to tell them what they need, and that’s how his dentists create a high volume of work. He said he didn’t want his dentists telling patients they needed things that would harm healthy teeth. That wouldn’t be good dentistry, and the third-party payers he contracted with wouldn’t pay for it anyway. But that still leaves a lot of leeway. So I asked him, ‘Like what?’ He gave the example of an amalgam showing signs of wear. They always recommend replacing it if it’s within the patient’s insurance contract limits. They don’t recommend patching or repairing any tooth with a second or third amalgam, or even a large first amalgam, if a crown can be placed, and so on. He said some insurers don’t always agree, but the goal in his offices is to offer patients the best that dental technology and expertise can provide—and that way we all go away happy. He also mentioned discolorations and other aesthetic things. He said lots of things can be proposed as needing work without lying to patients, and patients always have the right to accept or reject the recommendations.

“He has regular mandatory meetings with his dentists about how to become better salespeople. He said dental schools don’t know how to teach good business. They try, but the market and technology keeps moving and they can’t keep up with all of it. For one thing, it’s expensive, and all dental schools have limited budgets. Lots of times they think they’re getting a deal with a company who gives them something free, but then they get stuck with old equipment or something from a failing business trying to dump some old product or a long service agreement on them just so students might buy it when they graduate. He said if I came to work for him, I would really have a chance to work with the best and the newest equipment.”

“I’m still struggling with how they do patient education,” says Sandra. “If they were really educating patients, patients would be told that some of these things are not serious reasons for treatment, at least for most people. Some people can’t afford a crown on their budgets. My brother needs one and can’t even pay for the one I want to do on him to finish my competency requirement here at school. Anyway, there are often less expensive options than a crown, too.”

“I asked about that,” says Jack. “Prentice said patient education was important. Doing it was good dentistry, but doing it right takes time. But most patients won’t sit still for it once they know the meter is running. Most just come in to get their teeth fixed, and his dentists fix them. That’s what customers are interested in, he said, and that’s what he’s interested in. ‘One of the reasons patients like it,’ he said, ‘is that they can come in, get the work done, and get out—just like our ad says: Quick appointments when you need care. Short waits when you get there.’”

“Then those patients don’t really know what they’re consenting to,” says Becky.

“Maybe,” says Jack, “Prentice said if a patient started asking for information that was going to take more than a minute or so to answer, then their practice was to politely tell those patients that they have to wait till another time or make other arrangements with one of their hygienists or patient managers, who are trained to do that kind of education. He said his dentists should, of course, gladly offer to answer their questions and, if a patient is interested, they offer the patient a separate contract for educational services that would start the meter running. If people aren’t interested, then they’re advised to go down the street. It’s just the same as what they do with people who aren’t captured in Prentice’s third-party contracts but aren’t willing or able to pay up front for exams and emergencies. They tell them to find a different dentist.”

Imitating Prentice’s confident and self-assured manner, Jack quotes him: “We have to be realistic here, Jack. The rule of the marketplace is caveat emptor: Let the buyer beware. We never lie to patients. We only plant seeds and make recommendations. So if the recommendations are well made, carefully made, they can work very effectively and help sell treatments that will keep our numbers high. That’s what we expect of everyone in my offices, myself included. If we all follow through on that, we all make a good living out of it. Anyone who isn’t interested should work someplace else. If you want to be idealistic, you can always participate in our yearly one-day free clinic. I can’t tell you how good it makes me feel when I see those people really appreciating what we do for them that day. It’s a voluntary day and we encourage all our dentists to do it. It’s a win-win—one of our best community marketing events.”

“I couldn’t work in a place like that,” says Becky, “even if they do seem to care about people and community needs.”

“It bothers me, too,” says Jack. “But a dentist has to make a living like anybody else, and my debt numbers are really starting to scare me—especially when the practicing dentists who come to teach in our clinic talk about what it’s really like out there.”

“Lots of dentists make a good living without doing it that way,” says Sandra. “Did anyone there even mention doing what is best for the patient? That’s what we’ve been taught, that the patient comes first. It doesn’t sound like patients come first there—it’s their wallets or their insurers’ wallets that come first. It seems like those with no wallets are just left hung out to dry—except for the yearly free clinic thing.”

“Did you ask Prentice about that?” asks Becky. “I mean, that it seems unethical to practice that way?”

“Not exactly, but he could tell I was having a problem. As I was getting ready to leave he looked at me and said he once had that student idealism about dentistry when he graduated but that it soon went away when he had to practice in the real world.” Jack starts to imitate Prentice again: “Remember, if your patients in the school’s clinic don’t pay, it doesn’t come out of your pocket. When it comes from your pocket, things won’t look the way they did in school. No one is out there saying, ‘Dentists are good people and do a lot of good, so let’s make sure they can pay their debts, get their fair share, and earn a good living.’ You’ll learn very quickly that you have to make your own way. We all do. I’ve found a way to do that and to practice technically good dentistry at the same time. I don’t hire bad dentists. I don’t even interview bad dentists, Jack, only dentists in the top half of their class. That’s because bad dentistry is bad business. But if you don’t see that dentistry is first off a business, if you keep that idealism, Jack, then you’re going to be living in La-La Land. You’re welcome to try it if you want, but I think you’ll find out very quickly that it won’t hold up. You’re free to look elsewhere, of course. There are plenty of corporate arrangements like mine, and we’re all trying to tie into the whole health care picture, but mine’s the best.”

“That’s sure a long way from what I’ve been taught,” says Becky. “And he doesn’t seem to be like any of the dentists I’ve really admired. I think it’s unethical to practice like that.”

“Maybe it isn’t your ideal,” says Len, “but maybe it’s realistic. It’s a different world out there from what it was thirty years ago, when the dentists we admired as kids were starting up. Most could graduate without huge debts, get a loan from a bank, and set up a lucrative practice. My uncle and maybe lots of others like him did that back then, and even if their borrowing, considering inflation, was close to ours now, they still did fine. But it’s not that way anymore. I mean, not in today’s climate. Insurance contracts and government policies are going to keep changing—and not in ways to help people like us. My debts are as big as Jack’s, and the rest of you are probably in the same boat. Those guys back then could still be idealistic and still make a good living because they didn’t have all these outside forces pushing on them. Maybe some of us will be lucky enough to end up in private practices that are still like the good old days. But you sure can’t count on it.”

“I’m not competing with Jack for a job,” Len continues. “I’m going back to Minnesota. So I can hope Jack gets lots of offers so he can stay here in town. But suppose that Prentice likes Jack and makes him an offer, and suppose Jack doesn’t get any other offers to choose from. Jack’s dentistry is excellent, and he’s a good guy and all that, but are you saying, Becky, that Jack shouldn’t take Prentice’s job? Maybe Prentice is a little extreme with the ads and the marketing and everything. But he doesn’t practice bad dentistry. He doesn’t harm people, and patients still have to consent to every treatment his dentists do for them. And he has some concern about the community, those in need, and the bigger health picture. Are you saying that it would be unethical for Jack, or any of us, to work for a guy like Prentice if the alternative is worse, like maybe not practicing dentistry at all?”

“It may mean some hard choices,” says Sandra, “but if you stand for something, then you have to draw the line somewhere.”

“Yes,” says Jack, “the line has to be drawn. But where?”

TWO VIEWS OF DENTISTRY

Dentistry has long prided itself on being a profession, and dentists routinely describe themselves as professionals. Dentists, in fact, can clearly claim several of the most common characteristics of professions and professionals for themselves: (1) Dentists possess a distinctive expertise that consists of both theoretical knowledge and skills for applying it in practice. (2) Dentists’ expertise is a source of important benefits for those who seek their assistance. (3) Because of their expertise, the larger society accords dentists, both individually and collectively, extensive decision-making authority in matters pertaining to it.

But there is a fourth widely accepted characteristic of a profession that requires careful examination here. There are two sides to this characteristic. One of these is professional ethics. Most people, both inside and outside of professions, hold that professional ethics is a central characteristic of a profession. Professions and professionals, therefore, have special obligations that other members of a society don’t necessarily have. When a group becomes a profession, this view holds, it is precisely in doing so that it undertakes certain obligations to the rest of society. Similarly, when an individual becomes a professional—becomes a member of a profession—it is precisely in doing this that he or she undertakes the obligations that we summarize in the phrase “professional ethics.” The other side of this fourth characteristic is trust—trust on the part of the people who are receiving professional services and trust by the society at large that the needs and well-being of the persons being served by the profession will be the primary goal of the profession as a whole and of each of its members. This commitment to give priority to the well-being of the persons the profession serves is often stated in the dental literature as “the patient always comes first.” This way of stating this commitment does not serve any profession well, because the “always” asks more than any human can reasonably commit to. Thus, as chapter 6 will explain, it is sometimes a complicated matter to determine what this priority of the person or group receiving professional services requires. But such qualifications aside, most people—both inside and outside of our society’s professions—hold that such trust is a central characteristic of society’s relationship to each of its professions and that the basis of this trust is the profession’s and its members’ adherence to the profession’s ethical standards.

Is dentistry a profession, then? Are these things true of dentistry and of dentists? Clearly dentistry has a distinctive expertise that enables it to respond dependably to people’s oral health needs, and our society has been granting dentistry professional authority in matters of oral health for more than a century. But is this true about professional ethics and trust?

Many people would say, “Of course dentistry is a profession. Of course dentistry and its members are committed to and actually adhere, with only occasional exceptions, to an appropriate set of ethical standards. They are professionals who have earned the trust of those to whom they provide professional services.” But others have challenged this view, claiming that it is an incorrect description of dentists and dentistry. Therefore, it is important to ask, before going any further, whether it is true that dentistry as a whole, as well as each individual dentist, has specifically professional obligations. If not, then a study of professional ethics at chairside can be very brief; for it need only be long enough to demonstrate that there is no such thing. If the dental community and individual dentists, however, do have specifically professional obligations—if Jack, Becky, Len, and Sandra in the case that began this chapter are right in thinking that they will have special obligations because they are dentists—then it is important to understand why this is so, even before asking more specifically what these obligations are.

To this end, it will be useful to contrast two fundamentally different pictures of dentistry. The Normative Picture holds that there are special norms that apply to dentistry in our society and that dentists therefore do have special obligations precisely because they are professionals. The other picture can be called the Commercial Picture. It claims that dentistry is no different in principle from any other activity in the commercial marketplace, with some people or organizations offering a product for sale in the marketplace and other people or organizations purchasing it from them. The following two sections will contrast these two ways of looking at dentistry in detail.

Dentistry: The Commercial Picture

The Commercial Picture, as indicated, takes dental practice to be no different in principle from the activity of anyone who produces and sells his or her wares or services in the commercial marketplace. The dentist has a product to sell and makes such arrangements with interested purchasers as the two parties are willing to make. Depending on one’s view of the marketplace and society’s control of the marketplace, there may be some fundamental obligations that all participants in the marketplace have toward all other participants. The usual list of these would include obligations not to coerce, cheat, or defraud other marketplace participants. Note that these are all obligations to refrain from acting in these various ways, in contrast with obligations to act positively in some way regarding others. In fact, obligations to refrain—for example, to refrain from coercing, cheating, or defrauding others—are the only kind of obligations that are ordinarily thought to be relevant in marketplace participants’ dealings with one another. According to the Commercial Picture of dentistry, then, dentists do not have any obligations to act positively toward anyone else, including their patients, except insofar as a dentist voluntarily makes specific commitments to act in certain ways toward those individuals or groups. From this it follows that, according to the Commercial Picture of dentistry, the fact that a person is a dentist and a member of the dental profession has no moral/ethical import of its own. Dentists are like all capable humans in that they have an obligation to refrain from violating others’ liberty by not coercing, cheating, or defrauding them. After that, any other obligations that a dentist might have will be the result of specific, voluntary arrangements between dentists and other participants in the marketplace, especially the dentists’ patients.

According to the Commercial Picture, then, dentists have no special obligations to their patients and therefore no obligation to give priority to their patients’ needs and well-being. From this it follows that the principal reason for patients to trust their dentists to ordinarily place the patient’s needs and well-being ahead of the dentist’s other interests is also missing from the Commercial Picture of dentistry.

According to the Commercial Picture, then, dentists’ expertise and the application of it to the lives of patients is a commodity that dentists sell and patients buy, analogous to any other commodity bought and sold in the marketplace. The dentist is a producer; the patient is a consumer. Their entire relationship consists of communications about the commodity and its price, some agreement regarding an exchange (if an agreement is achieved), and then the actual exchange of the agreed-on commodity for the agreed-on price.

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