(Editor’s note: This article is the follow-up to “Selling Dentistry: Ethics or Income, and Other Choices Dentists Must Make.”)
In my last article on ethics in dentistry, I wrote about the ever-present lure of selling dentistry and the need for some sort of oversight and/or guidance. I concluded that article by proposing that aligning ourselves with a proven CE organization would hopefully lessen the temptation of wrong-doing and poor decisions that lead to wrong-doing.
Ethics start in dental school
The oversight at the level of private practice might still be avoided or at least lessened if the foundation for values-driven ethical decisions were addressed much earlier (in dental school) and if the system for training healthcare providers (professional/dental school) did not exacerbate the likelihood. Winkler and Gruen, in the Journal Healthcare Management, state that the principles of organizational ethics in healthcare are to provide care with compassion, treat employees with respect, act in public spirit and spend resources reasonably.1 If this were taught and emphasized in dental school, students would be specifically exposed to shared decision making using clinical ethics via trust, compassion and competence within the caregiver/patient relationship.
Similarly, dental students would learn specifically about business and workplace ethics via fairness, empowerment and participation within the dental practice employer/employee relationship. They would identify political ethics via common good and community benefit within the citizen/community relationship. And finally, they would learn about distributive justice via investors, insurers and the public through the manager/patient relationship.
The true irony, I would submit, is that a large portion of the concerns and possible solutions stated above – and in my previous article – could be avoided if dental students were not forced into a position to be tempted by false insurance claims, over-treatment or disregard of the truth. The reasons that most people pursue dentistry are not congruent with the system in which they learn it and the system in which they practice. The financial burden and debt that students face due to the high cost of professional education coupled with false assumptions and preconceived notions that private practice will guarantee financial security, autonomy and happiness is the epitome of the perfect storm.
Survey says …
A survey of graduating seniors in 2009 showed that 69 percent of the graduates said the decision to go into private practice, as opposed to public health, teaching or specialty school, was influenced “very much” by educational debt. Thirty-five percent of the new dentists said the primary influence on choosing dentistry was awareness of dental market trends. The same year, 76 percent said the reason why students pursued a career in dentistry was control of time, while 47 percent said income potential.2
Further, Okwuje’s 1996 article in the Journal of Dental Education revealed that in that year 7.3 percent of graduating dental students had debt of $150,000 or more. Only 10 years later, in 2006, that figure was up to 53.5 percent, and in 2008 it was 69.5 percent of all graduates. In 2009, almost 20 percent of new dentists had educational debts of $250,000 and above.3
The reality of life after school and the likely difficult ethical decisions are not part of the curriculum or at least not dealt with at a deep enough level. In Peltier’s article, “Some Observations on Truth Claims in a Profession,” reviewing the third dental ethics summit, he noted that many participants recommended the strengthening of ethics teaching in dental schools.4 We need to “get at” dental students, to challenge their professional identity. Did they come to dental school to become a merchant? A beautician of the mouth? A small business person? A successful amateur golfer? It is hoped that most came to learn how to become a doctor, with a capital “D.” We have to strengthen that desire, introduce it and shape it in those who don’t have it, and model what we think to be important. If we reinforce the notion that money determines who wins, that doctors should weed challenging or difficult patients out of their practices, and that the business of dentistry is a business, we will reap what we sow. When dentists become merchants, patients will become customers, and the truth will be the loser.
The financial burden coupled with the daily, unforeseen difficulties in private practice can be more than burdensome. There is evidence that the bad habits may be cultivated early in professional education. In a 2002 article in the Journal of the American Medical Association, Spickard suspects that there is ample evidence that physicians are caught in a web of pressures including financial deficits, Medicare/Medicaid audits, concern over fraud and abuse, and malpractice suits in which they perceive little control. He argues that the seeds of burnout may be sown in medical school and residency training, where fatigue and emotional exhaustion are often the norm. By mid-career, the momentum of burnout is maintained by the subtle reinforcement of the esteem and recognition of one’s peers for being a hard worker and placing service to others before self-care.5
The frequency of poor decision-making might be partially explained by burnout, defined by the “index of the dislocation between what people are doing versus what they are expected to do.” Burnout represents a deterioration of values, dignity, spirit and will. Deterioration of physician well-being from excessive stress has been described as the silent anguish of the healers. Workers who are burned out find their work unrewarding, experience a breakdown in community, believe they are treated unfairly and are confronted with conflicting values. The influence of healthcare organizations on physician well-being has been reviewed, and external factors, such as payment reduction, regulation, and business practices of insurers, were found to contribute to physician stress.5
The combination of an unrealistic perception of the profession, coupled with unreasonable debt, lack of formal ethics education, non-existent ethics systems and oversight seems like an almost insurmountable battle. Physicians must be guided from the earliest years of training, Spickard argues, to cultivate methods of personal renewal, emotional self-awareness, connection with social support systems, and a sense of mastery and meaning in their work.5
Maintaining these values is the work of a lifetime. Systematic understanding and review of organizational ethics should be mandatory in dental school and every type of dental practice, from hospital based clinics like Kaiser to the smallest one-person practice. The secondary goal should be avoiding burnout, which only aggravates the potential for poor choices by all healthcare providers, including dentists.
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Kevin Kwiecien, D.M.D., M.S., Spear Faculty and Contributing Author
- Eva C Winkler; Russell L Gruen; Andrew Sussman, First Principles: Substantive Ethics for Healthcare Organizations, Journal of Healthcare Management; Mar/Apr 2005; 50, 2; ABI/INFORM Global pg. 109
- American Dental Education Association , Senior Survey, 2009
- Okwuje,I. Annual ADEA Survey of Dental School Seniors: 2009 Graduating Class, J Dent. Educ. 74(9): 1024-1045, 2010
- Peltier, B. Some Observations on Truth Claims in a Profession, Journal of the American College f Dentists, Vol 71, No.2, 2004
- Spickard, A, Gabbe, S., Christensen, J. Mid-Career Burnout in Genralist and Specialist Physicians, Contempo Updates Linking Evidence and Experience JAMA, September 25, 2002—Vol 288, No. 12