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.



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.



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!

Dentists fear Disruptive Innovation!

The US Healthcare system is the most expensive healthcare system on earth…..yet our outcomes are not much better than anyone else. We have to find innovative ways to reduce cost without cutting quality or our healthcare system, and our country, face failure. The scope of practice of “Mid-level” providers in Medicine is broad –Physicians’ Assistants (PA) and Nurse Practitioners (NP) are the lifeblood of efficient Hospitals and Medical Offices. The Medical Doctor (MD) effectively offloads tasks according to the scope of practice of their PA’s and NP’s. This allows the MD to “practice at the top of their license” and optimize the utilization of their skills, while maximizing the effectiveness of their support staff.

Dental Hygienists are our partners. Understanding their scope of practice and learning how to work most effectively with them will maximize your efficiency, profits and improve the access to care your Office provides. We don’t have a Dentist shortage in America – we have a Dental utilization shortage!

Research demonstrates that “dental hygienists are a good investment” – higher production and higher net incomes are associated with Dental Offices that have Dental Hygienists as partners. Research also exists that supports the successful integration of Dental Hygienists into Medical Practices. However, to date, the American Dental Association (ADA) has not actively endorsed such revolution on a national level and expanded function Dental Assistants, expanded duties Dental Hygienists and Dental Therapists remain limited to a very few states. In fact, ADA has actively discouraged some of these innovations. The ADA must re-think it’s cautious approach and embrace revolution. Therapists and Expanded Function Dental Hygienists are a disruptive innovation and must be encouraged and supported, not feared!



Dental Practice models need to change to improve Quality and reduce Cost

About 32% of Physician Offices are solo practice or two doctor practices. However, Physicians often belong to large Physician groups and Hospital networks. Within these larger organizations there exist more structured endeavors to measure and improve quality including the hiring of Chief Quality officers and the like. Additionally, research has demonstrated that higher volume hospitals have better outcomes. Recruitment into solo medical practice is falling as the larger hospitals thrive, however, the Dental profession is lagging behind this reform and failing to acquire the benefits of large group practices. Apart from the obvious benefits of economies of scale and greater leverage when negotiating with third party payers, there may be an unrecognized benefit – improved quality.

Even though evidence is mounting of growth in large group Dental practices and a subsequent decline in solo practice, an astonishing 58.0% of Dentists continue to work in a solo practice today. The problem with this is solo practicing dentists are not subject to quality improvement measures and have little cushioning against the threat of litigation. It has been known for decades that Dentists value autonomy and 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. This is both the strength and risk of the Dental Profession – the variety means every individual can find a practice environment and provider operating style that suites them, however, standardization and true quality gains remain elusive. Although provider consolidation is becoming more evident in Dentistry, the profession is significantly lagging in leveraging size of practice to reap a variety of other benefits including optimizing quality.



In terms of consolidation, a field that is ahead of Dentistry and Medicine is Law – the law courts are now considering other business models as liable for corporate negligence through vicarious liability. For example, Dental Service Organizations (DSO) have already been targeted for a lawsuit with the plaintiff alleging that the DSO is not only “managing” the practice but effectively “owning” the practice too. However, anecdotally, the Dental Profession considers DSO’s to be a non-clinical manager of your practice which is in conflict the above mentioned lawsuit.

To standardize, improve quality, improve efficiency and reduce cost the Dental Profession needs to embrace and move toward larger group practice models.


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