Losing Control -- The Deprofressionalization of Dentistry

Copyright 1998 Journal of the California Dental Association.

We should be concerned. Jack Conley expressed his dismay over the closing of Northwestern University's dental school in the March 1998 CDA Journal. Dr. Conley focused on the failure of the profession to educate university administrators and boards about the importance of dentistry to the American population, and suggests that we be more positive and "aggressive" in ensuring that dentistry continues to receive support as a university educational discipline, and "is worthy of its status as a profession." We need to take these words to heart.

Northwestern based its decision on several factors, but the most chilling from the dental profession's viewpoint is the Northwestern administration's perception that dentistry does not fit into the mission of their medicine and life sciences programs. Dentistry is no longer considered a brainpower pursuit, worthy of elite graduate studies. In the eyes of at least seven university administrations, dentistry is a technical field, not a scholarly pursuit central to the mission of university graduate studies. To them, a DDS is something less worthy than an MD, a PhD, a JD, or even an MBA degree!

On the cover of U.S. News & World Report that same month, America's Best Graduate Schools" was the feature title for the cover story. The subtitle was ABusiness, Law, Medicine, Health, Education, Engineering, Public Affairs -- 1998 Annual Guide ... Exclusive Rankings." It's their best-selling issue, widely read by parents, teachers, and counselors.Dentistry was not even mentioned in the article.(128:1494-7, 1997) It really should not come as a surprise to us that dentistry has slipped from the rankings of professional prestige and public respect as well. Our status as a profession is compromised each time a dentist places an ad in the yellow pages that panders to patient fears, sells trivial services, or makes inflated claims about how warm and wonderful the dentist is. We are compromised as a profession when a dentist sends a cheap advertising mailer or tabloid with his or her photo along with a coupon for free services or a discount, or rents a billboard for a few months. Worse yet is the indignity of opening the phone book and finding a ADental Referral Service" that claims to provide Aprescreened" doctors, implying that the rest of us are unworthy in some critical way. Or the referral service is a bogus front for one of our colleague's private practices or clinics, and the state Board of Dental Examiners hasn't the time to investigate the allegations.

We suffer a loss of professionalism when our colleagues run their businesses so poorly that they cannot afford to provide a quality service and so take shortcuts with time, procedures, and supplies.

When a colleague fails to make a careful diagnosis and treatment plan, jumps into treatment without a clear financial arrangement with the patient, and then sends the patient's account to a collection agency, we all suffer a loss of credibility. The colleague who makes overt claims of personal superiority to his or her patients or makes derogatory comments about another dentist, about the patient's existing dental work, or about dentists in general, causes all of us to lose the confidence of that patient. When a large clinic exploits new graduates and produces factory dentistry in an assembly-line process with captive patients who feel forced to go there by the circumstances of their employer's decisions, we are demeaned as a profession. The patients know that the dentist in that clinic has the same license as every other dentist and expect their skills and treatment will be the same. The dentists who work there are not villains. They are often the same kids who just seven or eight years prior were star athletes and scholars at their local high schools. They now have a financial burden that those of us in the profession for more than a decade or so cannot even begin to comprehend.

When, although in the enlightened spirit of encouraging and embracing professional diversity, we sit back and allow the state Board of Dental Examiners, the largest dental licensing agency in the nation, to confer the title ADDS" to licensees who never earned the degree, we lower our professional standards. When the board makes it too easy to obtain a dental license and floods the professional market with practitioners of limited skills and experience, it sends ambiguous messages to the public. The DDS degree has been declared irrelevant by the State of California (AB 1116 passed with the support of the CDA). It is a wonder any university wants to continue granting the degree. There are now, or soon will be, many practitioners using a DDS after their names, who completed what to our sensibilities is nothing more than a technician course in a foreign country. Certainly they weren't ADA-accredited programs. Maybe all those who actually earned their DDS should be able to convert it to a DDS AE (Actually Earned), or a DMD. (What would happen if we all tried to convert our degrees to an MD?) This action by the Assembly is another nail in the coffin of deprofessionalizing the practice of dentistry. Soon, the right to practice dentistry could be entirely an administrative action by the state board, with no reference to training standards developed by the profession itself. The ADA accreditation program would have no teeth. The DDS degree, at least in California as of January 1998, is no longer an honest reference to an earned degree conferred by a faculty of an institute of higher education after diligent effort and scholarly pursuit. It is really a ARDS" -- Registered Dental Surgeon. Is the next perilous step to allow hygienists to challenge the state board exam without a dental school degree?

With this the state of affairs in California as of last fall, why would any dean or provost want to continue with a dental program? Perhaps Northwestern University believes the programs will move entirely into the state university systems, and eventually to the community colleges. Conversely, why haven't the deans of the California dental schools put forward a legal challenge to AB 1116? Don't they care that their degree has lost its meaning to the public? Obviously CDA won't take up that torch, since it supported AB1116 in the name of Adiversity."

When we fail to demand and support fundamental research, yet accept and utilize untested products from manufacturers on our patients, we are not behaving as professionals. When our diagnosis is based upon a cursory examination with weak fact-finding and weaker documentation, and our treatment planning is not evidence-based therapy, our patients are not served in a scholarly, professional, or ethical manner. When the products or therapies fail, and the doctor blames the patient instead of managing the case, replacing the restoration, or substituting a more predictable therapy, we all lose credibility. We cannot really answer even the most basic questions about the longevity of our various types of restorative materials with evidence-based conclusions.

When Northwestern looked at the recent contributions from its own dental research, it apparently came up with nothing that demonstrated support of Aexcellence" in its basic health sciences mission.

ADA has provided for its membership a preliminary promotion and survey of the proposed public awareness campaign. The House of Delegates to the ADA will vote on this in October. It is a form of institutional advertising designed to elevate the image of the profession by public awareness marketing techniques. It is important to take a hard look at it and express your opinion to your delegates. Is it the solution to a deteriorating public image? Probably not, because it has no discernible focus. It may help, and at very little cost per member on an annual basis. But it has no identified target audience, and it does not address the problem. Our problem is not a failure to market the profession. We have a problem of what defines the profession.

Is public awareness advertising enough? I doubt it. Much more needs to be done. In the video that promotes the campaign, there is a dentist who says that we can do nothing about our image problem as individuals and must band together and tell our message in the media. But we must also Awalk the walk" if we are going to Atalk the talk." If each individual dentist does not take a hard look at his or her personal professional behaviors, and measure his or her own professionalism against a respected mentor or role model, then the campaign is wasted money. If we continue to tolerate the transgressions against professionalism that have become uncomfortably common of late, our campaign could even become the subject of public and media mockery. Dentists already dislike the use of dental vignettes in humor, and we despise the seemingly unjustified criticisms of investigative journalism. I for one would loathe seeing the profession become the target of even more serious media criticism.

The message is simple. Behave as a profession and the world can see us no other way. Behave as a professional and the world can see you no other way. Each of us can evaluate and improve our business practices, our marketing practices, the training and education of our staff, our personal appearance and that of our office staff and environment, our financial practices, our diagnostic and treatment presentation methods, our professional demeanor with patients and in the community, our communication skills, our commitment to education and research, our active liaison with our alma mater or local dental institutions, and our commitment to personal and professional growth.

There is nothing we can do as an organization to change the behaviors of others. We cannot institutionalize professionalism and ethics any longer. The Federal Trade Commission won't let us because professional rules of conduct always seem to border on how the FTC defines trade-related issues. We can only overwhelm the negatives by greater insistence on uncompromised professionalism as individuals and among our friends in dentistry. And nothing stops you from picking up the phone and expressing your personal displeasure when you or a family member receive some cheesy bulk mail solicitation from a colleague, or a patient brings one in for you to see. If a doctor gets seven or eight spontaneous calls from peers for actions that demean us collectively, he or she may get the point.

Let's raise the bar and reach for a higher standard of individual professionalism. Then let's tell the public about dentistry.

Author/Jay M. Hislop, DDS, is currently President of the San Joaquin Dental Society. He is a management consultant specializing in critical issues analysis, strategic assessment, planning and goal-setting, and practice systems and operations.

Editorial Note:
AB 1116 (Keeley) had several components to it, only one of which was the provision allowing graduates of non-accredited dental schools who are currently licensed in California to use the DDS degree. The most important provision from the association's perspective was the elimination by the year 2003 of the restorative technique (bench test) mechanism through which graduates of non-accredited schools have qualified to take the California licensure examination. CDA's support of AB 1116 centered around the objective to require standardized educational achievements from all licentiates in California.

With the passage of AB 1116, graduates of non-accredited dental institutions will be required to either graduate from a U.S. accredited dental school program or a two-year program for international graduates offered by California dental schools. Beginning in 2003, all applicants for licensure in California must have participated in an accredited dental school educational process, either in another state or in California, and they will be required to hold a DDS or DMD degree, which is awarded upon completion of the educational program.