A New Century Wish List

It is customary at this time of year to extend the greeting, "Happy New Year!" On this occasion, however, it is appropriate to add an additional wish, "Happy New Century!" as it is unlikely that any of us currently active in (or retired from) the dental profession will have another opportunity in this lifetime to again experience that fresh beginning in time!

As we reminisced here a few months ago, the 20th century was a period of remarkable growth and achievement for the dental profession. But, what lies ahead for the profession in the 21st century? We don’t own the crystal ball that will provide satisfactory answers to that question. Certainly, there will advancements and changes, from both inside and outside the profession, that will either bring improvements or new problems to be addressed.  For now, we will consider a few current, observable trends that the profession would be well-advised to address and reverse if it is to remain a strong and respected institution, one that can continue to advocate and achieve the highest levels of oral health of the populace. This will be a short wish list that is not intended to be all-inclusive, and the thoughts will not be presented in any particular order of importance.

A first area of concern is similar to, but not precisely the same as, a problem we have seen in dentistry for some time. It is an ethical issue. In dentistry, it has been labeled fraudulent billing, or overbilling. But what really grabbed our attention recently was a news item reporting a survey conducted at Georgetown University Medical Center in which 58 percent of 169 internists in the survey considered it ethical to lie on an insurance claim for a patient who needed a heart bypass operation. Another 48 percent considered it ethical to lie to get intravenous pain medication for a dying cancer patient. In other words, many physicians believe that the only way they can be advocates for their patients in dealing with restrictive guidelines set by insurance companies or managed care organizations is to deceive those organizations. While in theory the physicians are supporting the intent of the Hippocratic Oath in their patient care advocacy role, it does raise a serious ethical question. Unfortunately, it is the wrong solution to underfunded benefit reimbursement mechanisms.

Fortunately, dentistry does not deal with the life-threatening or terminal conditions that were the basis of the survey, which might force this type of decision on dental practitioners. Nonetheless, we would hope that increased stringency in dental reimbursement contracts and the findings from these experiences in medicine will not encourage dental professionals to make such unwise choices. Fraudulent billing is clearly unethical. To lie, and to rationalize that it is done in the patient’s best interest, is a stretch that should not be permitted in the world of dentistry. Continuing efforts by individual practitioners and the profession to educate patients, coupled with continuing efforts for patient protection legislation, give us some hope that this danger can be avoided. The first wish then is that fraudulent billing practices of any form be reduced or eliminated (even though the latter is idealistic) from the dental landscape.

We are now seeing many new practitioners graduating with educational debt well in excess of $200,000. While many dentists have traditionally graduated with high debt or no assets, barely able to make ends meet during the start-up period after graduation, the debt loads in the current economy are unrealistic in view of the initial career opportunities available to graduates. It is impossible to pinpoint any one solution to this problem. Within a projected few years, a reduction in the dentist employment pool may assist new graduates in finding better-compensated opportunities than many can at the present. The most logical current solution is for more practitioners with stable practices to develop employment opportunities for younger dentists that will offer mentoring, an opportunity to contribute to an established practice, a better opportunity to earn an adequate income to pay down debt and meet living expenses, and the possibility of building assets toward purchase of their own practices. The best scenario, of course, is for a partnership or practice transition to result from such an employment relationship.

Very few of these kinds of opportunities presently await the new graduate in this state; or, if they do, they are extremely difficult to find. It may be easy for a new dentist to find a "job," but very few of these kinds of employment opportunities offer the desirable benefits previously described. Only the employment situation that permits the new dentist to grow will benefit the future vitality of the profession. The employer/employee relationship that benefits only the bottom line of the existing practice does little to contribute to the future vitality of the profession. The wish here is for the profession to make strides in creating better access to, and opportunity for, career development for new dentists.

As reported in the cover article in this issue, we have heard from a number of sources recently that many dental schools have been experiencing a shortage of qualified dentists to fill faculty positions in the dental schools. As compensation levels in education continue to lag well behind those in dental practice or in other fields of endeavor, this disparity will increase. Increased difficulty in maintaining the quality of educational programs, given a shortage of qualified faculty, will continue to face the profession. Achievement of the wish to attract adequate numbers of faculty does not have an easy solution. However, it is one in which the profession must take an ownership position if the profession is to remain strong.

Another area that must be watched very closely is the developing emphasis on cosmetic dentistry. If cultivated properly, it clearly can be a service that is deemed important to a segment of the population served by the profession. However, we have been seeing increasing public criticism about the efforts of some practitioners to "sell" cosmetic procedures to their patients. These efforts often shift the emphasis of the profession from a role of providing good oral health care, to one where the effort is seen by the public as generating revenue by changing smiles for "a price." We have seen reports alleging that many patients are offended by a critique of their smile when such an analysis is performed. The dentist is not always aware of the impact of negative patient feelings as offended patients may merely change dentists. The wish here is that practitioners will learn to avoid overzealous marketing of cosmetic procedures. Properly offered, cosmetic procedures can enhance rather than damage dentistry’s professional health provider image while avoiding the obvious ethical implications that have been raised.

At the 1999 CDA House of Delegates, considerable debate was waged over a problem that has been troubling organized dentistry for quite some time. What is an acceptable and supportable level of active membership dues that will enable the profession to carry out its necessary work and at the same time represent good value to the average member?

For many years, CDA members were fortunate that growing for-profit revenues were accounting for an increasing percentage of the operating budget. Even in those days, some members were questioning the value from the local tripartite dues package, and leadership in some areas of the state and the data from surveys and focus groups started to raise the question as to whether the total tripartite dues was an obstacle to encouraging newer dentists and nonmembers to join.

Since the contribution of for-profit revenues has peaked, the concern about the level of dues and its impact on membership recruitment and retention is an even more important issue. While leadership has become sensitive in recent years to sunsetting obsolete programs, the cost of new programs and maintenance of continuing programs must face that inevitable fact of life in recent years, an increase in the cost of operating a business. As small-business owners, dentists should be among the first to understand why it is difficult to maintain existing benefits or take on new obligations without an increase in operating revenue.

The CDA House, possibly operating out of sensitivity to what has been a declining market share of potential members, defeated some delegate efforts to add incremental cost of living increases to the CDA dues tab for 2000 and beyond. However, it is clear that the Board of Trustees, future Houses of Delegates, and the membership at large will need to prepare themselves for future increases that will enable the association to take on all of the important work that faces it. To do otherwise would be foolhardy, because without the necessary resources, the organization will be forced to tread water with the result that members will not see value in their membership, and the number will decline. Bear in mind that a strength in numbers is essential to having our voice on dental health issues heard and respected.

The wish here is that all members can become educated to the fact that leadership and staff are dedicated to carrying out the important mission to keep the profession vital and effective and, in the process, carry out our responsibility to serve the needs of the public. Member pledges of dues support and their participation in the education and recruitment of potential members is essential if the profession is to successfully navigate the many issues that it will face in the 21st century.