You’ve almost lost count of all those educational loans you have accumulated since your college days. All well worth it, you concede, since you’ve finally accomplished your ultimate goal to become an orthodontist. You have recently combed the area to identify a practice opportunity close to your fiancé who is enrolled at a local law school. Your lifelong dream has been to acquire your own office and treat your patients in a low-volume setting similar to the style in which your own orthodontic care was delivered. But the perfect storm of a sluggish economy, delayed retirement of local orthodontists, and decreased patient flow has made such opportunities unavailable. So you decide to accept a position in a high-volume, multi-provider setting that employs 2 other orthodontists and an array of general dentists and specialists.

In this particular facility, the emphasis is on production. Billboard advertisements, fee incentives for patients, and fancy promotions including various gifts are publicized to lure patients to the facility. You’ve been educated to deliver the same level of personalized, quality care that changed your own smile, but this organization’s business philosophy is all about numbers. The daily patient volume is so high that you can’t possibly remember your patients’ names, much less their treatment plans. To fulfill your contractual responsibilities, you must see a prescribed number of patients and complete their treatment within a rigidly specified time span. The ground rules are immutable regardless of your sincere desire to prioritize quality over the numbers of patients you see each day.

Orthodontics, among other specialties, is a personalized business entity that has traditionally been quality driven. The balance between “business entity” and professionalism is a delicate one that requires enduring scrutiny—and protection.

Professionalism can be eroded when emphasis on salesmanship eclipses that of quality. This can be a veiled issue in orthodontics. Consumers of a luxury car or a fine pair of shoes can discern the reliability or comfort of these products. In contrast, our patients cannot judge the quality of our product any more than we can appreciate the difference between good and bad vascular surgeons, or the cleanliness of the kitchen in an elite restaurant. If aligning the “social 6” using an inappropriately applied, slickly marketed appliance just to start the patient leads to a dehiscence, the teeth may appear aligned, but the health and stability of the dentition are compromised. Did salesmanship trump product quality?

The technology icon Steve Jobs acknowledged the importance of product quality over salesmanship. He warned that when the emphasis on salesmanship supersedes that of product quality, businesses often fail. “The company does a great job, innovates and becomes a monopoly or close to it in some field, and then the quality of the product becomes less important,” Jobs said. “The company starts to value the great salesmen, because they’re the ones who can move the needles on revenues.” This shift in emphasis induces “the fall of the company because in the end, what consumers want is great products.” Jobs’ management strategy, therefore, placed ultimate emphasis on building great products rather than on salesmanship. Glitzy promotions and deceptive promises might work well elsewhere, but these don’t trump quality in orthodontics.

Multiple ethical concerns arise if salesmanship becomes the dominant emphasis in orthodontic care. If the principle of beneficence is to be served, a “do-good” philosophy must include providing the highest level of care possible. Anything less without allowing the patient to make an informed choice of a compromised option requires the patient’s autonomous decision. Nonmaleficence requires that the orthodontist has sufficient clinical competence to place the teeth in a position that would not jeopardize their prognosis. And unless a patient receives what he was promised, trust (fidelity) has been violated.

There is no substitute for quality. Not flashy salesmanship, flamboyant public relations campaigns, or slick deals on fees. The predominant emphasis for the professional is on quality: the basis of our patients’ trust in us.

In our arena, quality rules.