Is Autonomy the strength or weakness of the Dental Profession?

For today’s blog I want to highlight three studies. The first is about motives to enter the Dental profession; the second about the reasons why Dentists leave the public sector; and the third about what practice setting creates the most job satisfaction for Dentists. All three have, basically, the same conclusion – autonomy!

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*source= http://www.mydentalhub.com/wordpress/wp-content/uploads/2014/11/Dr-Ted-Pinney-dental-specialty.jpg

College students who want autonomy choose Dentistry as a career – they want to make their own decisions. Public Health Dentists quit because of a lack of autonomy. The practice setting that is most satisfying to Dentists is the one that affords the most autonomy – Solo Practice. But consider this question – is autonomy in conflict with standardization?

In the United States, 58% of Dentists are in Solo private practice – an environment where the Dentist can enjoy autonomy in decision making. I can speak about my own small practice experiences – I worked in a 4 Dentist practice and taught at the University 1 afternoon per week before I decided to reverse that commitment in 2008. As a small private practice owner I did little to pursue best practices or evidence based dentistry – I was only interested in what works in my hands.

Monthly, I would read only the coverstory of the Journal of the American Dental Association and I received most of my continuing education from dental supply companies. If my co-workers saw one of my patients and disagreed with something I did – they would keep it to themselves because they would rather keep the peace than confront me. Additionally, I would afford them the same kindness. The result of this is that no one ever gave me feedback to improve.

It can be taken for granted, then, that one Dental Practice may have enormous variability in processes, materials and methods compared to another. Yet, we cannot argue that one is, necessarily, superior to the other because evidence about best practices is exceedingly limited in dental medicine. This is both the strength and risk of the Dental Profession – the variety means every patient can find a practice environment and provider operating style that suites them, however, standardization and true quality gains are near impossible.

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*Source= http://www.learningmarket.org/page.cfm/link=189

Thus, we confront a fundamental issue in our profession – that we value autonomy and seek uniqueness rather than valuing standardization and seeking best practices. This is a culture that may be in conflict with what is best for our patients. Our colleagues in Medicine have a very different perspective. Extensive research in Medicine demonstrates that standardization leads to reduced mortality, better quality and fewer complications. Moreover, checklists have never been broadly implemented in Dentistry even though we know checklists reduce medical error and improve outcomes. Dentistry needs a paradigm shift – rather than doing what works best in our hands we need a culture that pursues best practices and standards of care.

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Confessions of a Jerk Dentist…

My first job was as an Associate Dentist (one of only two)  in a small community hospital in Renmark, South Australia. If you follow the hyperlink and zoom out…you will see that we are one of the last hospitals before you head north into the Outback. We were an important resource for Aboriginal Australians and Mine Workers in the Outback.

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Source: http://www.carusosnaturalhealth.com.au/Article/341/discover-how-australian-aboriginals-used-the-healing-power-of-herbs

Within 6months my boss retired and I inherited the role of Dental Director……and I inherited a group of administrative staff and clinical assistants who were wonderful women born and raised in the area. In this region, Aboriginals had a reputation (among Non-Aboriginals) of drinking alcohol excessively, generally being good-for-nothing and failing to attend their medical appointments. None of my staff was Aboriginal.

When Aboriginal patients rang (recognized by their name) with oro-facial pain we would schedule them such that their appointment would be the last for the day (5.30pm). This was because, if the Aboriginal patient failed to attend (as we knew they would) we could go home early. This was a practice long established by my team and, rather than try to change it, I adopted it. Often, the postponement until the end of the day was unnecessary because we had openings (apart from 1 other dentist I had 7 Dental Therapists working for me too)…but those appointments were saved for other “more reliable” patients that may call later…but would be offered earlier emergency times because they were “more reliable” attenders.

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Source: http://www.awahs.com.au/what/programs/201012224494.asp

2016 is my 16th year practicing Dentistry and, on reflection, I recognize how awful and unprofessional my team and I were. I now acknowledge that severe cases may not have been able to wait until the end of the day and my Aboriginal patients may have found an alternative intervention.…hence, failing their appointment with us. Also, many traditional Aboriginals do not own a car and rely on public transport or ride-share arrangements. An end of the day appointment would be less convenient for such a set-up (for example, our grocery store and most other places of business would close at 6pm). Factors like this perpetuated our belief that “Aboriginals are poor attenders.”  This is discrimination by race and the intentional withholding of care based on race. It is deeply disheartening to reflect and realize how you may have contributed to someone’s poor health outcome by what seemed like a silly office tradition.

So what? My perspective is that it is critical that we, as healthcare providers, step back and consider how are we negatively impacting our patients’ health outcomes? Are we offering the best care to Medicaid patients or just offering a compromised alternative because we assume they won’t pay out-of-pocket. Do we assume a patient won’t improve their oral hygiene, and therefore, offer a complete denture rather than the opportunity to try and maintain their periodontally involved dentition? How aggressively do we work at getting a patient with hypertension to see their primary care physician? By the way, is compliance our problem or should we just drill fill and bill?

Some time ago we wrote a paper entitled “What is the Dental Profession’s Contribution to Worsening Access-to-Care Problems” and we received close to 50 heated emails from angry dentists. They felt we were undermining the reputation of our profession. Previous blogs have talked about how our Dental Profession has opposed Dental Therapists and how the solo-practice model may be in conflict with achieving improvements in quality. It’s time we worried less about how we are perceived by society, and worry more about delivering the highest quality care to them. The improved reputation will follow!