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


Andy Alas said...

Larry, another fine post.

What I don't understand is what happens if you choose not to follow their "recommendations". I assume no one is claiming your Web site is ILLEGAL. It's just that someone doesn't like it.

What do they do? Send you a strongly worded letter? (I have a collection of those in my desk. Perhaps I'll read them some day). Did they literally go in and crash your site? Or, did you take it down?

What happens if your site were to suddenly go back up?


Dr. Lawrence M. said...

Unfortunately, the ADA&C have created nearly unlimited powers. A violation of the Code of Ethics, if a formal hearing is conducted and you 'lose' (no dentist in Alberta has yet to 'win' a Code of Ethics violation hearing), I would have to pay the 'cost' of the hearing which ranges from $25,000 to over $100,000 and if I then do not comply, they have the power to take my license to practice away from me.

Andy Alas said...


Sorry to learn this. I guess things just work a little different in California.

As you've pointed out the abuse potential is huge.


Anonymous said...

great comments Larry. I applaud you for staying so "non emotional" over this issue. Your previous website was informative, entertaining and very professional. There was nothing that would confuse a patient or consumer. What a shame the dentist who reported you is so educated yet so stupid that he or she felt the need to turn you in.

If the dentist who turned your site in, instead put his energy in something positive for the community; like taking a course on communication, empathy or how to improve his technical skills (and ultimately his self worth - to a point he did not have to make himself feel good by squealing on his peers--- It might even be a past or current executive who turned you in for your amazing site! Does this uninformed or scared doctor not realize that they are now forcing patients to go to other states or provinces in search of a dentist with the knowledge they are seeking..... as everyone in Alberta has learned nothing since they graduated... according to our ethics mandate!!
Keep up the good work.

Anonymous said...

I would like to know if Alberta dentists involved with this advertising issue...believe that any harm can come to Alberta residents for advertising? What if a patient is severely harmed as a result of the confusion of a general dentist giving orthodontic treatment, and they only advertise what they do (limited ortho work, for instance) and not tell them to go double check with an orthodontist specialist? What is ethical in your view? Do you want only fair advertising, so as to do and advertise as you like... or do you want fair advertising, which includes telling the patient what other specialties are out there. Please consider and weigh in on this question about patient safety and fairness.


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