Business, ethics and over-servicing

A recent article has highlighted public concerns about over-servicing. It's important that we don't bury our head in the sand.

Put the interests of your patients first.

A recent article on over-servicing in dentistry seems to have hit a nerve in the profession, with many concerned about the negative portrayal of dentists and the impact that will have on their reputation. The author wrote that they felt they were pushed into treatment that was not necessary, and that having recommended their dentist to a friend, they were horrified to learn the same thing had happened to them:

Not long after this ordeal, I ran into the person I’d recommended Digger [the dentist in question] to. The friend had recently been to see Digger, and what he recounted made me feel queasy.

Digger had drawn up a treatment plan for him that bore an uncanny similarity to the work I’d recently had done, including the replacement of old fillings. All up, the work would cost my friend $5000. The friend then took Digger’s plan to two other dentists for their opinion where, upon inspection of his teeth, both dentists could find nothing wrong. One of the dentists, particularly horrified at the treatment plan, said dentists like Digger were a disgrace to the profession.

For the cost of $200 and two dental visits, he was able to confirm that Digger was a dud.

And lest we think that this problem is overblown or perhaps the poor characterisation of dentists is without merit, there are egregious examples of significant overservicing. In 2012 a Sydney dentist was fined $1.7 million by the NSW Supreme Court for providing nearly $75,000 worth of dental treatment despite knowing it was both unnecessary and would be ineffective. And in 2013 a Sydney dentist was found guilty of five counts of assault in providing crowns to elderly nursing home residents, some who had dementia, to exploit a government funding scheme.

First do no harm.

Fee-for-service is the predominant payment system in dentistry. This type of arrangement make good sense for apple pickers, but perhaps not so much for healthcare providers. Incentive based payments work when it is easy to measure outcomes (how many apples have been picked); compare the output of various workers; or when there are few opportunities to game the measurement system and there is little risk of the incentive diverting attention from other productive behaviours. Conversely in healthcare, it is difficult to measure outcomes or compare clinicians, and there are incentives to provide more treatment than is necessary, as these previous cases demonstrate.

Since the majority of dental practices also operate as small businesses, there is naturally a tension between the delivery of healthcare and the imperative to maintain profitability. It (should) go without saying that a private business must be profitable, since it cannot continue to operate at a loss – since that will ultimately harm patients too. And there is no doubt that ethical practice is good for business. Practitioners will be aware of this at the micro level – reputation and word of mouth are key to a successful business in any sector. If patients perceive that you do not have their interests front and centre, they will go elsewhere – and a bad online review can be damaging. It is equally important at the macro level, as the erosion of trust in the profession as a whole will also have negative consequences.

Although dentists are in the top group of trusted professions and occupations in Australia (ranking 5^th in ethics and honesty behind nurses, doctors, pharmacists and teacher in 2021), the proportion of people giving a score of high/very high has declined from 79% in 2017 to 71% in 2021. Chipping away at public trust makes it harder for health professionals to connect with their patients and work with them to improve their health. Patients become sceptical of the treatment options suggested, or perhaps they simply cease attending regularly.

But we need to be careful in our haste to denounce such stories, because they do highlight that there are issues that must be addressed. Patients expect the dental profession will circle the wagons and pretend that there is no problem. It is important that we are able to acknowledge that these problems do exist and work hard to promote high standards of ethics and professionalism if we want to maintain public trust.