Technician or Health Care Professional?

During the weekend of April 25th 2004, I attended a Hands-On Workshop at the University of Toronto that featured the new filling material called Resilon. Dr. Martin Trope (an Endodontist involved in creation of Resilon) was addressing the 75+ (standing room only) assembled dentists that had come to learn about this new Polyester bonded endodontic filling material.
Editor’s Note: As I write the update of this commentary that  I initially wrote some  20 years ago – I note that that this new “wundermaterial Resilon” is now no longer being sold because it was shown NOT to perform as advertised.)

In his opening statements, Dr. Trope said something quite profound. He said that Dentists must now decide whether we are “Technicians or Heath Care Professionals”. The difference, he said, was important in that technicians can be replaced, most often by either machines or individuals trained to perform these tasks in a step by step manner. Health Care professionals, on the other hand, are not simply technicians. Their degree confers upon them the responsibility of diagnostician, health care provider and patient advocate/educator. There is also the responsibility of being current with regards to techniques and the literature. This is how we maintain the state of the art and science of Dentistry and of our practices. It is the sum of all of these obligations that separates us from the technician.

In order for Dentistry to remain a profession, the health care professional must not merely “fix things”. How many of us are stuck in the rut of “finding something to do today on this patient that their insurance company will pay for?” How many of us actually present the optimal treatment plan to the patient and then work backwards? Rather than regarding the patient’s needs with: ” I’m going to do what I think they can afford”, how many of us actually sit down with our patients and truly talk to them about their oral health care needs as we see them?

One of my favorite stories was told to me by a Generalist Dentist colleague who eventually went back to Postgraduate studies to study Oro-Facial Pain as a Specialty. He became frustrated with General practice because he said he could sit down with a patient and spend 30 minutes discussing their oral health needs. He would then present them with a bill which many patients resented. Why? Because he didn’t “DO ANYTHING”.  That same patient could have a small buccal pit amalgam placed on one of their mandibular molars in 15 minutes and would gladly pay the very same fee. Why? Because he “Did something”. Try using that strategy with your lawyer the next time he sends you a bill for that telephone chat, billed by the minute. From the patient’s standpoint, Dentists are paid “to do”, not to think, and that is a big problem.

Proper diagnostic procedures as well as treatment planning, patient education and individual multidisciplinary case management must be part of every day practice. If it is not, then the Dentist IS merely a technician and we should not be surprised when Denturists, Dental Nurses and Hygienists see an opportunity to encroach on this territory. After all, they say that they can obtain exactly the same skills necessary to perform many of these procedures, simply through repetition or the most basic of technical training. Insurance companies, governments and private individuals then begin to look at this option as a feasible way of lowering costs. We need look no further than the companies who are marketiing “Teeth Straightening” direct to patients on the TV. If patients believe that can get the same results, why go to professional who charges more when you can go to a “technician” who charges much less?

In these days of high overheads, there is a tendency to focus on production levels at the expense of comprehensive care. It is tempting to regard patients as “the extraction in Room 2”, the “the crown prep in Room 1” or the “checkup in Room 3”, simply because it requires the least amount of effort. This is compounded by the benefit limitations that are placed upon us by many of our patients. The result is that instead of having a plan for the patient, we merely become the person who “fixes things” when they are broken. We spend a lot of time replacing older restorations that have no longer become serviceable. A simple, “Its broken, I need to fix it”, is all that’s required from us. “OK Doc, go ahead if you have to”, is generally the response. Its easy, it’s covered and it rarely requires any real extensive discussion with the patient.

Marketing of a complete treatment plan is hard work because it requires thought, care, preparation and patient education. In very many cases the comprehensive plan may be rejected, most often for financial reasons. But should that prevent us from formulating such a plan and offering it to the patient along with alternatives?

For example: A badly broken down molar with deep proximal decay requires endodontics for proper post and core crown restoration. Yes, we can perform the endodontics and then struggle with the crown margin preparation that encroaches on the biologic width. But do we not owe this patient the best possible outcome? Crown lengthening should be discussed even BEFORE the endo access is made. Whether you choose to refer the patient to the Periodontist or do the crown lengthening yourself, is this not a necessary procedure? How can we create a margin in an area that can easily be seen in an impression and that is cleansable and manageable, if this is not done properly? Can we not say to the patient; ” Sir/Madam, in order for me to restore this tooth correctly and for you to be able to maintain your investment, I need to be able to see a margin and without this procedure it won’t be possible for me to do my best work for you?”

But that means you have to explain what a margin is and that takes time! Finally, ask yourself ” Isn’t that what I would want done in MY mouth?“

Until very recently, “the marketing of treatment plans”, how to “talk to patients” and “listen to their needs” were courses that were either not offered in Dental School or had very little emphasis. Many of us were too busy obtaining our “requirements”…the minimum number of procedures that were needed for us to graduate. Furthermore, by not focusing on comprehensive treatment plans we regarded the specialties of Endo, Perio, and Prostho etc as separate entities rather than incorporating them into a multidisciplinary approach to care. The worst scenario is when the case is referred to the specialist for expensive complex procedures without a treatment plan. It is then up to the specialist to plan and coordinate treatment and make sure that the case is returned to the dentist ready for proper restoration. This lack of patient preparation is a source of great frustration for many specialists. Your referral specialist never wants to appear to be “commandeering” the case from you. You are the team captain and this is your patient. However, the case needs to be properly worked up before the referral slip is filled out.

There is no question that will be certain cases in which the optimal treatment plan is not feasible financially or practically. This is especially true in less afflent communities. Nevertheless, if we are to remain true professionals, we must NOT prejudge patients and we must provide patients with all the information necessary for them to make an informed decision. This is not only mandated only by ethical standards, it is a legal requirement.

Still, how many of us merely extract a tooth and do NOT explain alternative strategies for treatment at the time of extraction? This may include endodontic treatment (or retreatment); implant replacement and fixed or removable prosthetics? Do we explain the long-term consequences of not replacing the missing tooth (ie/ open contacts, eventually drifting, malocclusion etc.)? I can only imagine what the final judgment would now be should a US dentist prepare virgin anterior teeth (Int’l maxillary #11 and 13 for example) for a bridge and NOT at least OFFER an implant as an alternative for replacement of a missing lateral incisor (#12), REGARDLESS of whether the patients benefits pay for it or not. Not offering valid alternatives can now actually leave you legally liable.

The Denturist “situation” is also somewhat troubling. The gray line that once separated the Denturist from working directly with the Dentist is rapidly dissipating. The public is now saturated with advertisements that tout the implant-supported overdenture as a realistic alternative for patients who are considering whether they should retain those last few strategic abutments. Instead, there is a push toward full clearances, “All on 4”  or removal of “bothersome” teeth in favor of the implant-supported full prosthetics. In the patient’s mind (especially those patients whose dental IQ or oral hygiene may be less than optimal) this appears to be a “no brainer”; removal of the remaining dentition ensures that they will no longer suffer from the discomfort and bother of caries, while at the same time having a denture that is supported by “lifelike” implants that require minimum care.

It is our responsibility as Health care professionals to stay current and to discuss and offer modern treatment alternatives to our patients. Raising the “treatment bar” of our practice from one that basically “fixes things”  ( and hits the production goal  dollar number for the day) to a practice that provides comprehensive care. That means that we must take the time to educate and talk with our patients. We cannot on one hand say ” My patients would never go for that treatment” while on the other hand making no effort to educate them as to the value of the procedure or treatment plan. We must resist the urge to regard these patient discussions as a “waste of chair time” and merely look for “something to do” in this patient’s mouth.  Once patients begin to understand, appreciate and value our professional services, patients will be far less likely to seek assistance from “Technicians”.

The Insurance Dilemma:
Who are we really working for?

Originally Published in the Canadian Dental Association Journal
Vol 67, No. 4 – April  2001

Canadian Dentists face a dilemma on a daily basis. Approximately 70 % of their patients have some sort of private dental insurance (according to the CDA’s most recent figures). Many patients have been conditioned by Canada’s socialized medical system when they consider the financial consequences of any of their Health Care decisions. In most cases, they are not used to seeing a “bill” when they attend the hospital or consult their Physician.

Patients with Dental insurance often expect that dental benefits will work the same way. Patients present with an insurance form and claim that they are “covered”.  If the procedure recommended by the dentist is not a benefit of their plan, they often elect not to have the procedure performed.  That certainly is not the best way to decide on treatment, however for many patients and the dentists that treat them, this is a fact. Regardless of how well the treatment plan is presented or how extraction may adversely affect their oral health, that is the reality in many dental practices.  Work within the insurance benefit limits or lose the patient.

By choosing this method of Health Care planning, the patient is now in effect letting the Insurance Company decide which procedure they will receive.  Dentists know what is best for their patients, rather than some bureaucrat at an insurance agency who knows nothing about the patient’s oral condition and who does not have any personal relationship with the patient.

Furthermore, it is painfully obvious that Insurance companies have been unwilling to modify their plans to accommodate for the increased costs of dentistry.  Many plans with a $1500 limit have had the same dollar amounts for the past 35 years or more.  During that same period, dental fees have had to increase approximately 3-4% per year on average to accommodate increases in wages, technology, supplies, infection control and inflation. It is unrealistic to expect that insurance coverage amounts that were merely adequate a quarter century ago will be entirely adequate today.  Yet patients still do not seem to understand this concept and insurance companies are loathe to do anything about it unless severely pressured by their policyholders.  This situation underlines how dependent dentists have become on the whims of the insurance industry, an industry whose primary concern is focused on providing the maximum profits to its shareholders.

That is a failure of both Canadian Dentistry as a whole and the representatives of its professional membership, the CDA. Why ? Because, the CDA has been placed in the dilemma of officially endorsing a stand that discourages assignment of patient benefits to its members. At the same time it must acknowledge that a substantial portion of its membership relies directly on this method for its livelihood.

While Canadian dentists in most of the country have managed to hold the line against Capitation, this slow erosion of real buying power of dental insurance benefits threatens the oral health of their patients.  As insurance companies continue to make huge profits (based mainly on the fact that only half of their subscribers visit a dentist regularly) they continue to cut benefits, lengthen recognized time between check ups, lower scaling allowances, limit cosmetic, prosthetic and implant treatment and often deny retreatment due to frequency limitation. Yet their premiums either remain the same year after year or increase. Our greatest failing as health professionals has been our inability to convince our insured patients that by partnering with their Dentists, they are more likely to attain optimal oral health. The insurance carrier could care less about the specifics of their case and is interested in nothing more than satisfying the barest of requirements at the least cost. Still, patients continue to make critical oral health care decisions, based mostly on the level of coverage.

As fees increase, endodontic procedures in particular (per tooth) continue to consume higher and higher percentages of patient’s benefits.  With the average yearly benefit maximums in the $1500 CDN range, endodontic treatment and core buildup of one molar tooth in the General Dentists office can now come close to exhausting the patient’s benefits for an entire calendar year. Referral to an Endodontist for that same procedure leaves no benefits for any other routine treatment that may be necessary. This is a definite dissuasion for referral to an Endodontist and an encouragement of extraction. As a profession, this is something we cannot abide.

In areas of affluence or in certain provinces with a totally different attitude toward assignment of insurance benefits (such as Quebec), this does not seem to be a problem.  Dentists have made a decision to simply not take assignment of benefits and their practices may have not suffered.  But in many other areas, more and more patients (many of whom live from paycheck to paycheck) choose a dentist based upon whether the dentist takes direct assignment of their benefits. If the dentist does not, patients often threaten to move to an office that does take assignment.

In some cases, it has reached the point where dentists do not even pursue patients for the 10 or 20% co-payment.  This is not only damaging to patient’s perception of real fees, it is fraudulent and illegal under the insurance benefit guidelines. Nevertheless, some dentists find that “chasing” the patient for a relatively few dollars simply is not economical or they may carry these outstanding amounts on their books in the hope that the patient will pay during their next check up (if or when they ever do return to the office).

Even worse, some dentists attempt to “fudge” insurance claims by submitting for exaggerated covered restorative procedures when placing non-covered restorations of equal value. (e.g./ submitting a claim for a 5 surface composite when a porcelain veneer is placed)  This practice is deplorable but is much more common than we as a profession are willing to acknowledge.  It has occurred precisely because of this insurance “squeeze”.

There is no point discussing the merits or disadvantages of assignment of benefits.  The genie is out of the bottle and there will always be those who will cave into the pressure of the patient who threatens to leave a practice unless assignment is taken. With the advent of EDI, the problems of protracted delays in processing of claims or waiting for insurance monies (from some but not all insurers) may have lessened but have not entirely disappeared. The dental office remains a de facto unofficial extension of the insurer because it is the first place that the patient contacts when any problems occur with insurance claims. Most of us would prefer to deal directly with the patient and would like to eliminate dental insurers from the equation. However, it is unreasonable to expect every employer to dump the insurance company and move to direct reimbursement. We will have to live with this situation for the foreseeable future.

The time has come for organized Dentistry to exert as much pressure as possible and to at the very least demand that insurers increase the routine benefit maximums to a minimum of $2000 per covered individual per year as a start. We must convince our patients and their employers that their benefit maximums are not in step with modern dentistry. They must in turn make their concerns known to their underwriters and demand that increases in benefits be realistic and regularly reviewed.

In the same way that we as Dentists must be current with regards to techniques, training, equipment, wages and asepsis, the insurance companies and their subscribers must recognize their obligation to alter their coverage with the times.  Failure to make this accommodation will eventually result in an untenable situation where Dentists will be asked to work within financial limitations so confining that the best interests and health of their patients are at risk.

In the best case scenario, the continued irrational use of antibiotics as “do something” treatment, contributes to the proliferation of antibiotic resistance. The consequences will probably not be apparent to clinicians in their middle or late career years. The problem will no doubt escalate in the future, as bacteria become more resistant and we are left with fewer effective drugs. Those of us prescribing in a haphazard manner may well be responsible for a situation where our children and grandchildren have fewer and fewer alternatives for treating serious bacterial infection in other, more critical areas of the body.

In the worse case scenario, a patient may undergo an anaphylactic reaction, possibly resulting in death. The chances of this happening are remote. But should that happen to your patient, and you are required to justify your prescription in a court of law, do you want an Endodontist to be forced to tell the court that your prescription was not indicated, ineffective and unsupported by any of the literature?

Responsible use of antibiotic therapy is part of good dental practice. Clinicians who are unwilling to take the time to properly diagnose and treat a problem or who are not able to make a definitive diagnosis should opt for referral. The use of antibiotics as scattergun treatment for problems of unknown etiology is poor clinical practice. Antibiotics are not “chicken soup” and clinicians should not use them in this manner.  They should not be used as a “Do something – dismissal tool” when you are too busy or are unable to make a diagnosis. When in doubt, refer the case to a specialist.