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”.