This event jointly
sponsored by the
The summit was a primarily interactive affair with participants breaking out into groups a number of times during the event and reporting back to the plenary session their findings and recommendations in response to specific tasks. On the first afternoon, Dr. Gordon Christensen gave a keynote address outlining evidence that he sees for a mounting influence of commercialism in the dental sector. As the scene was set for the summit, Dr. David Chambers who was moderator for the duration of the summit indicated that he assumed that commercialism is on the rise and also that this trend is detrimental to the well-being of the dental profession.
Participants were given a number of tasks during the summit, which are outlined below:
Task 1 – Define commercialism as it applies to the summit
Task 2 – Assess the current status of commercialism in dentistry, which also encompasses assessing the factors that are leading to the rise in commercialism and which of these factors the profession can hope to influence
Task 3 – Explore the consequences of various commercial activities for the long-term integrity of the profession.
Task 4 – Determine which features of commercialism, if any, are acceptable and which are not. This encompasses exploring the reasons and the ethical principles that make some practices distasteful or damaging.
Task 5 – Make recommendations.
Introductory
remarks
Stephen Ralls
Dentistry is trending towards a commercial model of professionalism. Business forces are duelling with commercial forces and the profession is sending out mixed signals to the outside world. We can assume that there is rise in the prevalence of commercialism and that attitudes to this vary by age and generation.
The three expected outcomes of the summit are:
1) Advance the discussion on commercialism in the profession
2) Create discussion on the topic in dentistry print media
3) Create recommendations for professional organizations
David Chambers
David proposed in opening that the three big issues facing the profession over the next 25 years are:
1) Its relationship with the public
2) Its relationship with the biomedical sciences
3) Commercialism
He advanced the following definition of commercialism as a starting point for discussion:
“Attitudes or methods that excessively emphasize profit or business success in dentistry.”
The debate that ensued did nothing to move us away from this definition which was taken as standing for the sake of the rest of the summit. Capitalism or making a profit in itself wasn’t viewed as being bad. It was simply that this focus on profit could be carried to a harmful degree. David placed much emphasis on the fact that the success of the profession is built on trust and anything that could erode this trust is harmful. Task 1 was thus completed.
To complete Task 2, David had us complete a survey in which we were asked to rate the importance (scale 1 – 10) of 24 statements about factors contributing to the current status of commercialism in dentistry. The five factors that ranked highest (in truth, there was not a very large spread between all 24 results) were:
1) Society stresses financial success and a me-first attitude
2) Tradition professional ideals are insufficiently emphasized
3) Debts from dental school adversely affect the professional behaviour of young dentists and promote commercialism
4) Continuing education courses depict and promote dentistry as a commercial endeavour
5) Practice management course overly emphasize profit and business success.
Gordon Christensen then gave his keynote address entitled: Dental Commercialism 2006.
The objectives of his talk were to:
1) Describe the current state of commercialism in dentistry
2) Generate some discussion about the related issues
He was careful to emphasize repeatedly that he was not passing judgement, but simply ringing issues to our attention. A selection of the points he raised include:
The profession is unhappy with the state of commercialism that is on the rise.
There is increased advertising to the public by dentists and even dental labs – he mentioned many times about ads in hotel magazines.
Fifty per cent of the
gross revenues in
Many of the dentists that are sued get into trouble because they do not get proper informed consent from patients before carrying out procedures.
The Federal Trade Commission ruling in 1976 that allowed professionals to advertise ushered in the era of commercialism.
The biggest advertisers are usually the “borderline” practitioners. He said that patients came to him after they got to know him through his civic involvements.
Today everybody is a “cosmetic dentist”.
One third of the revenues for dental labs in 2005 was for veneers.
The so-called “Institutes” are promoting massive over-treatment. Young grads attend courses there because they get so little experience in so many procedures in dental school. Some of these institutes are “good” and others are “bad”. There is no regulation of these institutes.
He is an admirer of
the
Specialists are providing all sorts of “goodies” for general dentists who refer patients to them including: continuing education courses, gifts, trips and kickbacks.
Many manufacturers are providing services to the profession and individuals that range from the “great” to the highly questionable.
Providers are advertising very heavily through all sorts of media. As an experienced CE provider he knows that if he doesn’t advertise he is out of business.
Some of the sharp practices in the dental literature include: Ghost writers, payments to authors, infomercial articles, ads placed alongside articles and articles commissioned and paid for by industry.
It is hard to know today where to seek the truth in the literature.
End
of Day 1
The group discussed the results of the survey taken the day before. There was agreement that commercialism exists in dentistry, it is bad and it is harmful because it is eroding the public trust in the profession.
There was agreement to keep the definition proposed the evening before – with an “excessive” emphasis on profit. One person asked if there was concrete evidence that bad business practices were on the rise.
In the discussion, the factors that were emphasized as leading to a rise in commercialism were:
1) Practice management courses
2) Regulations not being adhered to
3) Industry pushing products
4) Societal pressures for aesthetic procedures
5) Societal stresses on dentists to succeed financially.
The leadership of the profession is not seen as responsible (by acts of omission or commission) for the developing state of affairs. There is also a difference between the generations about the effectiveness of the dental profession’s leadership.
Attendees bemoaned the fact that society doesn’t seem to place the same value on expertise that the profession places on it. As we move away from being a health care profession to providers of aesthetic services we will operate more on the terms of our customers than on out own terms. With this trend will come a lowering of the value placed on being a “profession”.
Some other observations made in this discussion period included:
Should we be assuming that the young members of the profession are the problem?
There is a general discomfort with the changing environment in which the profession is operating.
Michael Glick spoke of the profession now tending to “create need” as opposed to providing medically necessary care.
Dental schools are opening aesthetic dentistry program and are turning away patients who cannot pay for care. This is providing a very poor example to students.
With the rise of consumerism we are moving away from doctor defined need to an era of co-diagnosis. There was discomfort expressed about this trend because as one attendee said “ our professional responsibility is to guide patients”.
So what does all this mean? & What are we going to do about it?
These questions provided the cue for breaking into groups (on repeated occasions interspersed by reporting back into plenary sessions) with the goals of examining the consequences of these trends, identifying what factors could be influenced and finally to create recommendations for action.
Four breakout groups to deal with factors under the following headings
Society
Profession
Regulation
Education & generation
We were asked what are the three “biggest bullets to dodge” under these headings.
Change in public perception of the profession
Increasing consumerism is driving aesthetic dentistry. Less dentists are providing medical care, therefore there is a subsequent drop in access to care for the population.
Loss of legitimacy of the profession tied to the erosion of adhesion to the code of ethics.
Door must be open to alternate care models.
Decrease in status of dentistry as a profession accompanied by a drop in levels of collegiality, associated with increasing segmentation in the profession leading to a diminution in the amount of health care provided.
Decreased autonomy linked to external control
Decreased public and government support for dental research and education
Organized dentistry must be at the table to help mould the future of self-regulation.
Dentists must be re-educated about their responsibility to adhere to the code of ethics.
External organizations must be educated about what dentistry is doing to ensure responsible self-regulation
Dentistry must be willing to self-regulate with force – despite the “legal chilling” caused by fear that accused dentists will sue regulatory boards for loss of livelihood (human rights). Dental boards may be tied up with more “important” issues than commercialism such as impaired practitioners and those committing sexual abuse misdemeanors.
We must get young dentists participating in organized dentistry
We must address the “quick fix” mentality that the public is increasingly displaying – in terms of easing the pressures of consumerism on young practitioners.
We must re-educate young practitioners about the value of professionalism and the privilege of monopoly licensure that we enjoy.
Decrease student debt
We must create a feeling among dental students that they are being educated to be “men and women of science”.
We must work to diminish the impact of the unethical CE institutes.
Teachers in our dental schools must take their role model responsibility very seriously.
The plenary group prioritized all these issues and the three that were seen as most important were:
1) Increase in consumerism driving cosmetics leading to a decrease in available health care leading to alternate models of care
2) Segmentation leading to a diminution of health care availability leading to an increase in external regulation and a decrease in external support.
3) Unethical CE providers
David Chambers then spoke for a while about how different generations differ in their value systems and interest.
We then edited the “bullets to dodge” and worked to identify those on which we have the potential to have an impact.
“Fixability”
in terms of a scale from 1 (least fixable) to 5 (most fixable)
Change in public perception of the profession 3.4
Increasing consumerism 2.7
Erosion of code of ethics 3.8
Loss of profession’s credibility as source of health care and of information 4.2
Segmentation …. 2.7
Loss of participation in organized dentistry and loss of single voice 3.8
Not valuing profession, loss of monopoly 3.1
Student debt creating undesirable pressures 2.7
Maintain science foundation 3.7
Unethical CE, decrease science-based care 3.7
Schools not providing good role modeling 3.6
All of these were boiled down to the following 5 priority areas which could be influenced and for which we needed to create recommendations
Public
perception of the profession
Recommendations:
Create
realistic expectations for patients -- informed consent, comprehensive,
continual care, etc
Reinforce
message that oral health is part of overall health
Create
media for patients
Commercial
impact on patterns of delivery
Recommendations:
The profession must take the lead in addressing the
access issue
A
significant campaign should be mounted to promote comprehensive oral health
Public relations activities should continue to draw
attention to dentistry's positive role
Codes
& Regulations
Recommendations:
Create a Patient Bill of Rights and Responsibilities
Mentorship and early involvement of young professionals
Engage component societies in education and enforcement
Segmentation
Recommendations:
Increase
incentives for practice in underserved communities
Create a Patient Bill of Rights and Responsibilities
Increase reimbursement levels for underserved
populations
Develop guidelines for non-specialty practice areas
Increase dental office productivity
Bring young practitioners into professional relations
early
Sound science-based information.
Educate
the public about what comprehensive oral health care means
Develop
standards for commercialism, e.g., disclosure, and publicize them
Increase expectations that dentistry is based scientifically grounded claims