Friday, October 17, 2014

The Ethics Conundrum

People younger than age 40 are pretty extraordinary. I have always thought of myself as a bit of a geek; I’m pretty computer and smart phone savvy. But I am still all about personal relationships—direct people contact, and opening my mouth and having words come out. I talk so much, my team has a system to get me to stop talking and get back to doing dentistry. 

My teenage daughter was telling me about the friends she has been “talking to.” The thing is, not a single word emerged from her mouth or her friends’ mouths. For my daughter, “talking” translates to “messaging.” It could be instant messaging, Facebook messaging, tweets on Twitter, posts on Instagram, Tumblr, and more. They don’t “talk.” I find that weird, but I also am finding that it’s really common.

When I see young people out together, I often notice they are not talking to each other; instead, they are on their smart phones or tablets interacting with something else—or someone else—not physically with them. I have asked many of them, in different situations, if that lack of direct human conversation bothers them. They look at me like I am from a different planet. It is their normal.

For many years, I had an innovative and different website. It had animation, it had Flash video, it had an interactive map to show from where in the world people have come from to seek my services (more than 40 different countries!), testimonials, before/after photos (set to music) of the work that I have done, and more. The site was fun, it was interactive, it was informative, and it was, in my opinion, professional, humble, and ethical. It was about me and my amazing team, and it offered the opportunities of what might be possible. It displayed my quirky personality and was never about how great we are, but how much fun we had and how much we liked practicing dentistry in our wonderful profession.

In Calgary, according to the Calgary Chamber of Commerce, the average age of our city residents is younger than 38, and we have the largest number of professional engineers in Canada. It's a large, well-educated, computer-savvy population. My office is in an area filled with young professionals.

Many of my new patients came to me as a result of my website. They would be texting their colleagues and friends and, many being new to Calgary, they would ask about a dentist. Some of their friends—who are patients of mine—would text back with a suggestion to see me and they included a link to my website. The referral all happened in a matter of seconds and it all happened electronically. The concept of “word of mouth” is rapidly transforming into something different.

But now my website has been shut down.

I have a ton of questions. I don’t have any good answers.

Many years ago, the Canadian Dental Association published a report stating that the public trust of dentists had slipped considerably. As a response to this, a call to action was made. In Alberta, in 2007, a Code of Ethics was published. It discussed a number of items, including how we communicate directly to our patients, how we build and train our team members, the kinds of dentistry we do, and more. It contained very commonsense applications of good ethics. It is generally a really good document.

In a subsection about marketing, it mentions that we should not state that we are better than other dentists via statements of superiority, publishing credentials that we pay for as a member, and more. I agree with the concept that I should not state that I am better than my neighboring colleague because I am not better. I work hard to be the best dentist that I can be and I am proud of the work that I do, but I am not better than anyone else.

After the publication of the Code of Ethics, nothing much happened. My colleagues and I paid attention to this important document and conducted ourselves well. In the years following, I am humbly honored to report, I have been nominated and awarded fellowships in the Academy of Dentistry International, the International College of Dentists, and the American College of Dentists, the latter organization being the ethical conscious of dentistry.

In 2010, the Executive Director of the Alberta Dental Association and College (ADA&C) noted that the general public was not complaining about dental websites and marketing. So the ADA&C began encouraging dentists to complain about other dentists. In Calgary, four dentists have been responsible for complaining about more than 100 dentists and their websites (there are approximately 2,700 dentists in Alberta). The ADA&C states that they do not have the time and resources to examine everyone’s websites, so the only ones who are forced to comply with the “rules” are those who have had complaints issued against them.

The ADA&C has published broad statements in the Code of Ethics about what we should not say, but the details are lacking. Compliance and acceptable verbiage, photographs, and content are decided upon by one person: a Complaints Director who is a lawyer (not a dentist).

According to contact with colleagues who have had complaints issued against them, we now cannot have web domain names that include the name of our city, as it denotes geographic superiority. Our domain names cannot have the words spa, studio, cosmetic, and other words that may denote superiority. One dentist was told he could not publish that he served our country and retired with a specific rank, as it denoted the possibility of claiming superiority. Another dentist was told to remove all links to dental organizations, including the Academy of General Dentistry, because stating that we are a member of these organizations may be construed as a statement of superiority. We also have been told that we cannot have testimonials on our websites as they are unverifiable and those who are not happy with our services cannot have their statements posted on our websites. We have been informed recently that they have now decided that before and after photographs are not in compliance with the Code of Ethics, but the reasoning behind this decision has yet to be communicated to the dentists in Alberta. Some of our general practice colleagues have narrowed their scope of practice, preferring to do more orthodontics, endodontics, or pediatric dentistry. However, we also are not allowed to inform the public via our websites that this is our preferred area of practice, the education in that area of dentistry that has led to our expertise, and more.

Let’s just examine the subject of testimonials. If testimonials are biased on our websites, where can someone go to get independent unbiased views? What about reviews of MDs? I personally had four positive reviews removed because they were labeled as “positive spam” even though I personally witnessed all four people posting those reviews on their computers. What about Yelp? I have one positive review from someone whom I know, but Yelp stated that it is hidden because its algorithms flagged the comment as not legitimate. So there are no websites that offer independent, verifiable reviews of dentists that are accurate.

Since the modern application of our Codes of Ethics and their vociferous application (which is based on personal interpretation of the Code by a small number of people in our regulatory body) regarding how we market seems to be a knee-jerk reaction to the declining public attitudes toward dentists, is having positive testimonials on our practice websites really so damaging or unethical? Personally, I think that good testimonials may help our image in the public eye by having something positive being said about us, since this is not occurring in so-called independent review sites like Yelp and MDReview.

I have asked my College and the Complaints Director a few questions. How can we improve the public trust by withholding valuable information about what we know, what we do, and how we do it? How can the consumer’s desire for more information be fulfilled if our websites are limited to our location, contact information, hours of operation, and a list of procedures that we do? The general population is now going to the Internet first for all of their information. They choose almost everything they can—from cars to restaurants to health care providers—based on what they can learn about them online. How can we provide this information without running afoul of our regulatory bodies? We need to reach an emotional core for people if they are to pick up their e-devices and contact us to become patients. We need to do the same in order to keep our existing patients engaged, informed, and entertained. But how can we do this without running afoul of the Code of Ethics? The response I received was, “We will not write your website content for you.”

I love what I get to do, each and every day. Dentistry is a profoundly satisfying profession for me and I want to continue to enjoy it, and to let others know how much I enjoy what I do, too. We, in dentistry, need all the “cheerleaders” for dentistry we can get, so that we can improve the public image and opinion of dentists and dentistry in the future. With my 27 years of experience, honored by my peers with three Fellowships, and more, I believe that I can play a significant role in this effort. (Excerpted from a letter I wrote to the ADA&C).

Christie Blatchford, a nationally prominent newspaper columnist wrote, “There is a real danger for those who embark upon self-regulation and often, so keen do such groups become to avoid attracting government attention or censure that they make decisions so utterly dopey even the fussiest and most conservative governments would not have made them.”

I was forced by my regulatory body to shut down my website due to its interpretation of the Code of Ethics as it applied in my case. My neighbor does not have to comply with any of this and has before-and-after photos, testimonials, and more, all part of an emotionally satisfying, informative website. 

I have been encouraged by my College to complain in an effort to make my neighbor’s site “equal” to mine. I find that attitude deplorable, detestable, immoral, and unethical. I refuse to behave in an anti-collegial manner toward my esteemed and honorable colleagues and neighbors.

I am concerned that this is just the tip of the iceberg. I am concerned that what is happening in Alberta will spread across North America in an attitude of witch hunts that encourage dentists to compete with each other. We need to rally to communicate better with each other and to tell our regulatory bodies that we need clearer guidelines on what we can say—not just what we cannot say. We also need mechanisms for everyone to comply, or the unequal application of the rules becomes a serious financial burden to the few of us who have been targeted.

What do AGD members think? What do American College of Dentists members think about this application of a Code of Ethics?

I invite you to leave a comment and let’s get a dialogue going on this subject.

Warm regards,

Larry Stanleigh, MSc, DDS, FADI, FICD, FACD


Monday, October 13, 2014

Do You Groupon?

A little disclaimer for this blog entry, folks: It may (actually, it does) include some ranting. If you’re OK with that, I think you’ll really enjoy the read. If you need to take a blood pressure pill first, you have 5 minutes and I expect you back in front of your computer. GO…!

…Welcome back!

Today’s topic is access to care. From the moment we entered dental school, it was stressed upon us that access to care was a critical concern for the field of dentistry in the coming years/decades. We learned that it would quite possibly be the most serious issue we’d ever face in our profession. And it most definitely is.

On one side of the coin, there is a shortage of dentists in this country. According to the Health Resources and Services Administration (HRSA), we had a shortage of 4,000 dentists in 2010, and every year there are more dentists retiring than graduating from dental school (wrap your head around that). On the other side of the coin, 130 million Americans are without dental insurance, including 40 percent of adults in the U.S.

In addition, many government-supported dental plans (i.e., Medicaid) have very low reimbursement rates for the general dentist, and thus very low participation rates among dentists. Add in the lack of dental education among the general public and you get an outrageously large portion of the American population not seeing a dentist regularly.

So they end up in the emergency room, where the scope of treatment options is limited and dental problems often are misdiagnosed and/or incompletely treated. The physician prescribes a pain medication and antibiotic if infection is present and kindly refers the patient to a dentist. Then it’s in the patient’s hands to follow up with the dentist—which often doesn’t happen—and the cycle repeats itself. This whole process costs nearly 10 times what it would be in a dental office!

But for some, it’s the only option—or at least appears to them as such. This is where we as dentists come in. We signed an oath as professionals to treat people—to heal people. With that comes an obligation to the community to help combat this access to care problem. I have worked at free clinics, gone on mission trips, done discount and free dental services—all of which help a lot of people and provide my coworkers and me with wonderful opportunities to treat people who need it most.

But I also run a business that has to support five doctors, 25 staff members, and three offices. As such, we've developed a model of “organized care”  in our practice that limits the barriers to entry in coming to see the dentist: namely, taking nearly every major dental insurance plan; offering significantly reduced-cost exam/cleaning/X-ray packages through discount sites like Groupon and LivingSocial; and offering free or reduced cost services when deemed necessary. This allows us to run a business and help people to get the care they need at the same time.

And this, friends, is where my blood pressure rises and my rant begins. At last month’s Virginia Board of Dentistry meeting, the board members voted on and began the process of outlining regulations to outlaw fee-splitting programs, namely Groupon. They seem to be concerned with the ethics of splitting the fee with a marketing company (Groupon) for a “health care service.” But that sounds pretty similar to participating in an insurance program, doesn’t it? Or, maybe they are worried about the fact that it low-balls the fee that other dentists charge in the area for the same exam. Or, possibly, they are worried about the legality of Groupon being liable if something goes horribly wrong during the dental exam. All of these are viable reasons for the board members to vote the way in which they did—even if they’re a bit of a stretch—but my guess is that it’s simply a misunderstanding: They truly just don’t know what Groupon is and how the process works. Nonetheless, let’s look at the facts.

I’ve been participating in these programs for two years now, and we’ve sold 800 of these offerings. Let’s get it straight right off the bat: We don’t make any profit from the Groupon sales; we actually lose money on each one. But we’re OK with that. It’s a form of marketing, and one that breaks down the barriers to entry for many patients. The majority are young adults who are uninsured and haven’t visited a dentist in some time. Many of them have significant dental needs that, maybe without this program, would have resulted in toothaches, trips the emergency room…and the cycle we just talked about.

So what gives? Are we here to continue the status quo, or are we called to improve the landscape of dental health? When I see these adults and children coming to my chair for the first time in years, using their Groupon promotion, I get the opportunity to educate them. We are able to do small-scale preventive dentistry: cheaper, better for the patient, easier for everybody. And we’re seeing a population base that may otherwise not see a dentist. To me, it’s a win-win. I can honestly tell you that it’s reaching a population base that truly needs to be reached. I will continue to offer, promote, and graciously accept these discount dental exam programs for as long as I’m legally able to. It is my pleasure, and my duty.

Donald Murray III, DMD


Friday, October 10, 2014

Icebreakers

Every day most of us have the same conversations, over and over again: “What brings you in today?” “How was your weekend?” “How about this weather we’re having?”

I was lucky to work with a colleague whom I called the “patient whisperer.” He always seemed to know the right thing to say. When patients would ask if we could put them to sleep, which we didn’t offer at our office, he would say, “We have a sledgehammer in the back. Otherwise you would need to go somewhere else for that.” He also had a very contagious laugh that got him out of trouble if he ever said anything that could be taken the wrong way.

I am a people person, but knowing what to say doesn’t always come so easily to me. After thinking about it, and a few trials and errors, here are a few icebreakers that I think anyone can implement to make their days a little less monotonous.

1. This first list is to be used with new patients only. Once you have a bit of a relationship with someone, it’s usually much easier to jump into things. Also, I do not recommend extending small talk if someone is in obvious pain. In these cases, the patient wants to get to the treatment just as much as you do. But for the nonemergency new patient, here are a few questions to break the ice:
  • What kind of work do you do?
  • What do you do for fun?
  • How long have you been retired?
  • Do you live near here?
  • What’s your favorite subject in school?
  • Do you play any sports? 


2. For established patients, you’ll need to rely more on memory, or a helpful assistant, but patients love to talk about their children, grandchildren, pets, or vacations. Try:
  • How was your trip?
  • What are your kids doing this summer?
  • How was your golf game last week?


3. When finishing up an appointment, it’s nice to get feedback and see where things can improve, so always make time to discuss the day’s treatment: 
  • Is there anything we haven’t covered that you would like to discuss?
  • Have I answered all of your questions today?

4. Patients with special needs should be treated like everyone else. I always speak directly to the patient, even if it is fairly obvious that the caregiver will be making the decisions; I want the patient to feel important. Patients with Down syndrome, for example, seem to respond well to the tell-show-do technique. I like to show them my “squirt gun and straw” before we “wash away the cavity bug.” A classmate of mine also showed me that the matrix band could be presented as a “bear-hug squeeze” as it does squeeze a little bit when placed. 


When in doubt, I try to emulate my friend, and smile and laugh as much as possible.
  
Sarah Meyer, DDS




Wednesday, October 8, 2014

Latex Allergies in Dentistry


In the past few weeks, we have had two latex-related incidents at our office.

The first was when one of the hygienists used latex gloves for part of a cleaning before she realized the patient had an allergy. The patient was 19 years old and she had a mild dermatitis reaction. Her medical history did note that she was allergic. The patient’s mother was quite upset and asked to speak to me, since I had done the exam. I am not the owner of the practice and have no real power when it comes to office management, but the mother wanted me to promise that our office would get rid of all latex products. I told her I would speak with the owner but that it wasn’t really my decision to make. I did speak to the office manager, but apparently most of the staff hates the feel of non-latex gloves.  I was willing to switch, but my voice was only one in an office of three dentists and three hygienists. We are currently still using latex gloves. The cost of nitrile gloves is higher, which is another thing to consider. We did update our policy to always have a pop-up warning on any patient with a latex allergy; every time the chart is clicked, the warning shows up.

The second issue was with a patient who is not allergic; she is a nurse and is afraid that she will become allergic to latex from exposure over time. She needed a RCT No. 19 and asked that we use only latex-free products. We discussed that we can do a latex-free rubber dam and use latex-free gloves. The patient also was highly concerned about the gutta-percha, as she learned it was form of rubber. We discussed at length the history of gutta-percha as an RCT filler and that there are not a lot of good alternatives. After she left, I tried to research cross reactivity of latex-allergic patients and gutta-percha. Everything I read seemed to indicate that there is no evidence of any cross reactivity. I also discussed the issue with an endodontist, who confirmed that there is no known cross reactivity and that the subject has been studied extensively. 

The moral of the story is that latex allergy is a very real thing, and that it is important to be aware of our patients’ allergies and always get a good medical history. Gutta-percha, however, is completely safe.

From time to time, we are all going to get patients who read too much on the Internet, and it is nice to be ready for them.


Sarah Meyer, DDS

Latex Allergies in Dentistry


In the past few weeks, we have had two latex-related incidents at our office.

The first was when one of the hygienists used latex gloves for part of a cleaning before she realized the patient had an allergy. The patient was 19 years old and she had a mild dermatitis reaction. Her medical history did note that she was allergic. The patient’s mother was quite upset and asked to speak to me, since I had done the exam. I am not the owner of the practice and have no real power when it comes to office management, but the mother wanted me to promise that our office would get rid of all latex products. I told her I would speak with the owner but that it wasn’t really my decision to make. I did speak to the office manager, but apparently most of the staff hates the feel of non-latex gloves.  I was willing to switch, but my voice was only one in an office of three dentists and three hygienists. We are currently still using latex gloves. The cost of nitrile gloves is higher, which is another thing to consider. We did update our policy to always have a pop-up warning on any patient with a latex allergy; every time the chart is clicked, the warning shows up.

The second issue was with a patient who is not allergic; she is a nurse and is afraid that she will become allergic to latex from exposure over time. She needed a RCT No. 19 and asked that we use only latex-free products. We discussed that we can do a latex-free rubber dam and use latex-free gloves. The patient also was highly concerned about the gutta-percha, as she learned it was form of rubber. We discussed at length the history of gutta-percha as an RCT filler and that there are not a lot of good alternatives. After she left, I tried to research cross reactivity of latex-allergic patients and gutta-percha. Everything I read seemed to indicate that there is no evidence of any cross reactivity. I also discussed the issue with an endodontist, who confirmed that there is no known cross reactivity and that the subject has been studied extensively. 

The moral of the story is that latex allergy is a very real thing, and that it is important to be aware of our patients’ allergies and always get a good medical history. Gutta-percha, however, is completely safe.

From time to time, we are all going to get patients who read too much on the Internet, and it is nice to be ready for them.


Sarah Meyer, DDS

Friday, September 19, 2014

Never Say Never

When I graduated from dental school, I made two promises to myself: never establish a home office or specialize in orthodontics. But never say never. As a general dentist, I’ve enjoyed incorporating orthodontics into my practice, which is—you guessed it—in my home.

After commuting 40 minutes to an hour and a half, depending on traffic, to my high-rent suburban D.C. office, my home practice has been a delight; the coffee pot is my only distraction on the way to work. I thought there might be a problem with drop-in patients, especially on weekends, but I live in a rural area, which is not conducive to folks just sauntering over unannounced.

My wife manages the office, and the worst drawback for her has been people giving her payments when she’s not at work. They might call three months later, upset that the payment was never recorded. Later, she would find the crumpled check buried in her purse along with her two wallets, numerous loose bills, assorted change, expired credit cards, a coin purse (containing more change), lipstick, eyeliner, emery boards, nail clippers, wadded facial tissue, ancient MasterCard receipts, scraps of paper containing historical grocery lists, and—well, you get the picture. She no longer accepts payments at the grocery store or on the alley on bowling night.

I’ve loved incorporating orthodontics, which I once condescendingly referred to as “wire-bending.” It has allowed me to more closely track my ortho patients’ oral hygiene and diagnose caries development early. And the meticulous treatment planning, which predicts a two or more year regime, has spilled over into other aspects of my general practice. The treatment plan contains a list of dos and don’ts that the kids and parents are supposed to follow. Those instructions, however, seem to be forgotten at Halloween.

And incorporating this aspect of dentistry does add to the mix.

I’ve spent a lot of time performing dentistry overseas with different charitable organizations. One time when I was far away, a mother, who didn’t want to use our on-call dentist, phoned my wife, who told her to bring her son right over. The boy was in braces, and a wire was poking him. He arrived at the house with blood and muck all over his face, more than just a wire poking his cheek. With the mom looking on, horrified, my wife took him into our kitchen—practicing dentistry without a license is not on the table, but being a good neighbor is—and proceeded to wipe him off with peroxide. There was a minor cut on his lip and straw caught in his braces, which, it turned out, were not loose. He had fallen face-first out of a hayloft and into a horse stall. The muck my wife had just wiped off was not just dirt.

On another occasion, when I was in town, a school nurse phoned our office. She sounded frantic. A young orthodontic patient needed to be seen right away. I’d once been told by an orthodontist that there was no such thing as an orthodontic emergency (which was the main reason he’d chosen his specialty), but this particular call sounded like one, although the nurse wasn’t very clear about the problem. When the young man entered the waiting room, I heard my wife crack up laughing. She was almost in hysterics as she came back to announce his arrival.

I couldn’t imagine what could be that funny about a patient in distress—until he was seated. When the boy turned toward me I saw a ballpoint pen clipped to his upper wire. It was firmly pressed against his lips and chin, while the “clicky” end was wedged far up his nose. A telltale bulge revealed that it was pressing hard against the inside of his nostril. The school nurse had attempted to dislodge it, to no avail. I tried to be nonchalant and asked him how his day was going. He just shrugged.

As I took the wire off, the pen fell to the floor. I should’ve taken the time to snap a picture of it jammed up his nose. I asked if I could have his pen as a souvenir, after my assistant had wiped it clean, but the kid said he needed it for school.

There some are days when I just love my job!

Orthodontics and a home office have been a great way to expand my general dentistry practice.

Best thing I ever did.

Jim Rhea, DMD

Wednesday, September 17, 2014

RE: Exit Interviews


This blog entry is inspired by Larry Stanleigh’s great post on patient exit interviews. One of the rewards of reading and writing for this blog is that we are constantly learning from one another.  Sometimes, when I read one of my fellow blogger’s entries, it inspires me to write. Thank you, Larry. 

I look at the problem of learning why patients leave a practice from a different angle. Instead of asking patients why they left my office, I ask them why they left their previous office. Patients (and dentists) often are more comfortable with this approach. I find that patients are more forthcoming because they don’t feel that they will hurt your feelings. You’ll get a greater number of honest answers. Believe me, you’ll learn what NOT to do in your practice. They’ll tell you things they would never tell their previous dentist.

I usually say something benign like, “What brings you here?” or “Tell me about your last dental visit.” or “Who was your last dentist?” I’m not a big fan of scripts. Just ask in a manner that seems natural for you.

Sure, you’ll get the usual responses, like how the patient just moved to your area. Some responses, however, have surprised me. My favorite is when patients tell me that they just absolutely loved their previous dentist. They tell me about how great he or she was, how their kids loved that office, and how caring the staff was. They brag about how the dentist just about walked on water. My question naturally is, “Then why are you here?”

Are you ready for the response? C’mon, you can see it coming. You’ve heard it many times before! “We had to change offices because my dentist no longer accepted my insurance.” Man, I could write a whole blog on this one alone!

Sometimes the patient responds that the dentist became very involved in the local dental society, or that he or she became a busy lecturer. The biggest complaint from the patient, then, is that the dentist was never in the office.  Let’s face it: Patients want you to be available when they need you. Sure, they are happy for you when you move up the political ladder, but they’ll soon be looking for a new dentist. Lecturing across the country? Patients think that’s cool—and they’ll be happy to brag about you to their new dentist.

Another reason I’ve heard is that the practice was sold because the dentist retired. I get new patients from that, too. Believe me, I make absolutely no effort to bring those patients into my practice. Ideally, patients will stay with the new dentist. However, I usually hear the same concern: The dentist who bought the practice is just too young. I can really relate to this since I, too, was once a young dentist. But the good news is that, over time, that problem corrects itself. If you observe most practices, the average patient age tends to be close to that of the dentist. If an older dentist sells to a much younger dentist, there will be some patient loss.
  
Some of the above reasons are not ones that patients may want to tell you. How many times have you told someone they are too young or too old to treat you? Not many, I bet. You just quietly move on. 

I agree with Larry that exit interviews can prove valuable in the rare cases in which people
 actually will be honest with you. I have found that learning why people are now in your office can prove to be just as informative.

Andy Alas, DDS

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