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COMMENTARIES
LETTERS
J
ADA welcomes letters from readers on articles that have appeared in The Journal. The Journal reserves the right to edit all communications and requires that all letters be signed. Letters must be no more than 550 words and must cite no more than five references. No illustrations will be accepted. A letter concerning a recent JADA article will have the best chance of acceptance if it is received within two months of the article’s publication. For instance, a letter about an article that appeared in April JADA usually will be considered for acceptance only until the end of June. You may submit your letter via e-mail to [email protected]; by fax to 1-312-440-3538; or by mail to 211 E. Chicago Ave., Chicago, IL 60611-2678. By sending a letter to the editor, the author acknowledges and agrees that the letter and all rights of the author in the letter sent become the property of The Journal. Letter writers are asked to disclose any personal or professional affiliations or conflicts of interest that readers may wish to take into consideration in assessing their stated opinions. The views expressed are those of the letter writer and do not necessarily reflect the opinion or official policy of the Association. Brevity is appreciated.
SHOW, DON’T TELL
As a dentist and a coach, I think the answer to the question that Dr. Roger Levin received in his March JADA column, “How Clear Communication Can Improve Practice Performance” (JADA. 2015;146[3]:211-212), was embodied in the question itself. The question was this: “I tell my staff what I want them to do, but the message does not seem to be getting through. What am I doing wrong?” Perhaps because the focus was on improving performance metrics, as it often is with practice management experts, the issue of linguistics and the form of communication often gets lost. I am reminded of the Pogo cartoon where he says, “We have met the enemy and he is us.” My point is that the dentist should not tell staff members what to do; rather, the dentist has to show them what to do. The dentist has to demonstrate proper communication skills (both verbal language and body language) and—what is important and mostly overlooked—has to take into consideration the issue of tone. The way we say something either demonstrates weakness or power, and the dentist has to teach that. I suggest that role-playing in staff meetings may be one effective way of doing this sort of coaching. High-pitched and
squeaky tones are a sure-fire way of diluting the message; ergo, poor practice metrics are sure to follow. Alan Goldstein, DMD New York, NY
http://dx.doi.org/10.1016/j.adaj.2015.06.012 Copyright ª 2015 American Dental Association. All rights reserved.
provides an opportunity to connect with the patient, offer superior customer service, and build value for continuing (or beginning) a relationship with the practice. But scripting only works, as he mentions, when team members practice through role-playing. Running through the script repeatedly allows staff members to grasp its underlying concepts and gradually learn how to make the necessary points using their own words, as well as the appropriate body language. In the process, they gain confidence and the ability to stay on message. Again, I appreciate Dr. Goldstein’s letter expanding the discussion on the importance of communication, which cannot be overemphasized. Roger P. Levin, DDS Founder and Chief Executive Officer Levin Group Owings Mills, MD
http://dx.doi.org/10.1016/j.adaj.2015.06.013 Copyright ª 2015 American Dental Association. All rights reserved.
DENTISTRY IN THE MODERN ERA
Author’s response: I thank Dr. Goldstein for his thoughtful comments on my article. I could not agree more that effective communication between the dentist and the team requires both telling and showing. Dentists should not only clearly convey their expectations to each staff member but also demonstrate the professional demeanor that the team should emulate. By exhibiting the following behaviors, for example, practice leaders guide their team by setting the tone for the practice: - remain calm when confronted with unexpected challenges; - treat patients and team members with respect and consideration. As Dr. Goldstein mentions, how we say things requires careful attention as well. That is why I have long recommended that all practice– patient interactions be scripted for effectiveness. Every conversation
I am writing regarding Dr. Marko Vujicic’s March JADA article, “Of Lawyers, Lattes, and Dentists” (JADA. 2015;146[3]:208-210). Although his article does touch on some key points and sheds light on some data that need to be recognized and understood by dentists, I find that there are a few things that were not addressed that ought to be in order to put the downturn in dental spending into context. First, from an historical perspective, dental spending has had less than a century of growth from levels that were, at one time, much lower than they have been in past decades. One hundred years ago, most people did not even brush their teeth. Excellent quality dentistry was available, and there was affluence to support it, but people chose not to have it. The public interest in spending on dentistry in the 20 or so years leading up to the 2007-2009 recession was more of an historical
JADA 146(8) http://jada.ada.org
August 2015 567
Descargado para Anonymous User (n/a) en ClinicalKey Espanol Colombia, Ecuador & Peru Flood Relief de ClinicalKey.es por Elsevier en mayo 04, 2017. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2017. Elsevier Inc. Todos los derechos reservados.
COMMENTARIES
anomaly than anything else, fueled by an economy boosted largely by borrowing. Second, many of us who are practicing in real-world dental practices have come to see a strange dichotomy of themes in our profession. On one hand, we go to meetings and are told that we need to have hundreds of thousands of dollars of esoteric equipment and digital imaging technology and to do the sort of dentistry that will pay for all those costs on each and every patient who walks into our waiting room. On the other hand, we also are being lectured by academicians and public sector dentists about the lack of access to health care for anyone who is not wealthy, and that we must address that issue by lowering fees. When you add the cost of a dental education to this, can you expect a young person to deal with the cognitive dissonance this situation presents? Is it any wonder that we are now seeing the rise of corporate dentistry and a rising level of overtreatment? Drs. Cummings and Vergo, in the benchmark article “Traditional Dentistry Versus Retail Dentistry: A Sociological Pilot Study of the Dental Profession,”1 published in 1985 before the high growth occurred in the dental economy during most of the years from the mid-1980s through 2007, showed conclusively that this is not the model patients want for their dental care. Finally, the health care industry needs to recognize that although we care a great deal about health care, the American public does not. The reason there is support for government intervention in medicine is not because the public thinks that health care is important; it is because they do not, and they take it for granted. In a free society, people can spend their money on what they want. Dentists need to make peace with that notion. To the extent that dentistry can do something about this, we need to have a more coherent vision of
568 JADA 146(8) http://jada.ada.org
what dentistry is as a profession. Are we a boutique industry composed only of those who can afford an overpriced education and treat only those who want cutting-edge treatment? Are we to be largely welfare providers who put out lowest common denominator restorative treatment? Or can we cobble together something like what we were before the big buildup and bust—practitioners who could address the needs of many in the same office with highquality, predictable care for the bulk of our patients, regardless of what their specific priorities are about dentistry? That is our challenge. Robert K. Thompson Jr., DMD Cohasset, MA
http://dx.doi.org/10.1016/j.adaj.2015.06.014 Copyright ª 2015 American Dental Association. All rights reserved.
1. Cummings J, Vergo TJ Jr. Traditional dentistry versus retail dentistry: a sociological pilot study of the dental profession. Quintessence Int. 1985;16(9):651-655.
ETHICAL DECISION MAKING
In Dr. Don J. Ilkka’s May JADA Ethical Moment, “Keeping Skills Current” (JADA. 2015;146:[5]:352-353), the question posed concerned a pediatric dentist who, after a few years of administering conscious sedation, hired an anesthesiologist to perform the task. Then, 20 years later, he decided to resume sedating. Because sedation is allowed with proper permits, is it ethical for this dentist to administer sedation without an anesthesiologist being present? Although this is hardly a significant ethical dilemma and so long as the pediatric dentist is capable most would reflexively answer “yes” to this question, the article goes on to cite the principle of Nonmaleficence as embodied in the American Dental Association (ADA) Principles of Ethics and Code of Professional Conduct, carefully explaining the word means “do no harm”1 to indicate that the practitioner should not injure.2
Not satisfied, the reply goes on to cite the principle of Beneficence, affirming that this means “do good,” clarifying an ethical demand that patients are entitled to competent care. This well-meaning article clearly demonstrates the misapplication of ethical decision making and inherent weaknesses in the ADA’s Code of Conduct. Usually, it is only when recognized principles are in conflict that ethicists are called on for their expertise and thereby play an important role in decision making. For example, Beneficence means doing good for the patient. Veracity asks that we tell the truth. An insured patient is desperately in need of prosthetic replacement of his maxillary anterior teeth but cannot afford the copayment. It would be a beneficent act to forgive the copayment. However, truth would be compromised by dishonest reporting to the insurer. Which is the appropriate ethical choice? Autonomy respects the participation of the patient in treatment planning decisions. A patient presents with an obvious need for significant dental care. A full series of radiographs is proposed to the patient and refused. Without the series of radiographs, proper care cannot be rendered. Although it is possible to take care of the readily apparent problems, major difficulties will remain. Do you help the patient wherever you can, or do you dismiss the patient? Another patient says he “hates his teeth” and asks that they all be taken out. An inspection reveals no indication for removal. Beneficence and Nonmaleficence conflict with the principle of patient Autonomy. Do you extract? Major religious philosophies— Judeo-Christianity, Buddhism, Confucianism, Islam, Hinduism, and even Wicca—have a central thesis of, “Do unto others as you would have them do unto you.” Also called the Golden Rule, it embodies respect for others, being good and not bad, fairness, and truth telling.
August 2015
Descargado para Anonymous User (n/a) en ClinicalKey Espanol Colombia, Ecuador & Peru Flood Relief de ClinicalKey.es por Elsevier en mayo 04, 2017. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2017. Elsevier Inc. Todos los derechos reservados.
LETTERS
J
ADA welcomes letters from readers on articles that have appeared in The Journal. The Journal reserves the right to edit all communications and requires that all letters be signed. Letters must be no more than 550 words and must cite no more than five references. No illustrations will be accepted. A letter concerning a recent JADA article will have the best chance of acceptance if it is received within two months of the article’s publication. For instance, a letter about an article that appeared in April JADA usually will be considered for acceptance only until the end of June. You may submit your letter via e-mail to [email protected]; by fax to 1-312-440-3538; or by mail to 211 E. Chicago Ave., Chicago, IL 60611-2678. By sending a letter to the editor, the author acknowledges and agrees that the letter and all rights of the author in the letter sent become the property of The Journal. Letter writers are asked to disclose any personal or professional affiliations or conflicts of interest that readers may wish to take into consideration in assessing their stated opinions. The views expressed are those of the letter writer and do not necessarily reflect the opinion or official policy of the Association. Brevity is appreciated.
SHOW, DON’T TELL
As a dentist and a coach, I think the answer to the question that Dr. Roger Levin received in his March JADA column, “How Clear Communication Can Improve Practice Performance” (JADA. 2015;146[3]:211-212), was embodied in the question itself. The question was this: “I tell my staff what I want them to do, but the message does not seem to be getting through. What am I doing wrong?” Perhaps because the focus was on improving performance metrics, as it often is with practice management experts, the issue of linguistics and the form of communication often gets lost. I am reminded of the Pogo cartoon where he says, “We have met the enemy and he is us.” My point is that the dentist should not tell staff members what to do; rather, the dentist has to show them what to do. The dentist has to demonstrate proper communication skills (both verbal language and body language) and—what is important and mostly overlooked—has to take into consideration the issue of tone. The way we say something either demonstrates weakness or power, and the dentist has to teach that. I suggest that role-playing in staff meetings may be one effective way of doing this sort of coaching. High-pitched and
squeaky tones are a sure-fire way of diluting the message; ergo, poor practice metrics are sure to follow. Alan Goldstein, DMD New York, NY
http://dx.doi.org/10.1016/j.adaj.2015.06.012 Copyright ª 2015 American Dental Association. All rights reserved.
provides an opportunity to connect with the patient, offer superior customer service, and build value for continuing (or beginning) a relationship with the practice. But scripting only works, as he mentions, when team members practice through role-playing. Running through the script repeatedly allows staff members to grasp its underlying concepts and gradually learn how to make the necessary points using their own words, as well as the appropriate body language. In the process, they gain confidence and the ability to stay on message. Again, I appreciate Dr. Goldstein’s letter expanding the discussion on the importance of communication, which cannot be overemphasized. Roger P. Levin, DDS Founder and Chief Executive Officer Levin Group Owings Mills, MD
http://dx.doi.org/10.1016/j.adaj.2015.06.013 Copyright ª 2015 American Dental Association. All rights reserved.
DENTISTRY IN THE MODERN ERA
Author’s response: I thank Dr. Goldstein for his thoughtful comments on my article. I could not agree more that effective communication between the dentist and the team requires both telling and showing. Dentists should not only clearly convey their expectations to each staff member but also demonstrate the professional demeanor that the team should emulate. By exhibiting the following behaviors, for example, practice leaders guide their team by setting the tone for the practice: - remain calm when confronted with unexpected challenges; - treat patients and team members with respect and consideration. As Dr. Goldstein mentions, how we say things requires careful attention as well. That is why I have long recommended that all practice– patient interactions be scripted for effectiveness. Every conversation
I am writing regarding Dr. Marko Vujicic’s March JADA article, “Of Lawyers, Lattes, and Dentists” (JADA. 2015;146[3]:208-210). Although his article does touch on some key points and sheds light on some data that need to be recognized and understood by dentists, I find that there are a few things that were not addressed that ought to be in order to put the downturn in dental spending into context. First, from an historical perspective, dental spending has had less than a century of growth from levels that were, at one time, much lower than they have been in past decades. One hundred years ago, most people did not even brush their teeth. Excellent quality dentistry was available, and there was affluence to support it, but people chose not to have it. The public interest in spending on dentistry in the 20 or so years leading up to the 2007-2009 recession was more of an historical
JADA 146(8) http://jada.ada.org
August 2015 567
Descargado para Anonymous User (n/a) en ClinicalKey Espanol Colombia, Ecuador & Peru Flood Relief de ClinicalKey.es por Elsevier en mayo 04, 2017. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2017. Elsevier Inc. Todos los derechos reservados.
COMMENTARIES
anomaly than anything else, fueled by an economy boosted largely by borrowing. Second, many of us who are practicing in real-world dental practices have come to see a strange dichotomy of themes in our profession. On one hand, we go to meetings and are told that we need to have hundreds of thousands of dollars of esoteric equipment and digital imaging technology and to do the sort of dentistry that will pay for all those costs on each and every patient who walks into our waiting room. On the other hand, we also are being lectured by academicians and public sector dentists about the lack of access to health care for anyone who is not wealthy, and that we must address that issue by lowering fees. When you add the cost of a dental education to this, can you expect a young person to deal with the cognitive dissonance this situation presents? Is it any wonder that we are now seeing the rise of corporate dentistry and a rising level of overtreatment? Drs. Cummings and Vergo, in the benchmark article “Traditional Dentistry Versus Retail Dentistry: A Sociological Pilot Study of the Dental Profession,”1 published in 1985 before the high growth occurred in the dental economy during most of the years from the mid-1980s through 2007, showed conclusively that this is not the model patients want for their dental care. Finally, the health care industry needs to recognize that although we care a great deal about health care, the American public does not. The reason there is support for government intervention in medicine is not because the public thinks that health care is important; it is because they do not, and they take it for granted. In a free society, people can spend their money on what they want. Dentists need to make peace with that notion. To the extent that dentistry can do something about this, we need to have a more coherent vision of
568 JADA 146(8) http://jada.ada.org
what dentistry is as a profession. Are we a boutique industry composed only of those who can afford an overpriced education and treat only those who want cutting-edge treatment? Are we to be largely welfare providers who put out lowest common denominator restorative treatment? Or can we cobble together something like what we were before the big buildup and bust—practitioners who could address the needs of many in the same office with highquality, predictable care for the bulk of our patients, regardless of what their specific priorities are about dentistry? That is our challenge. Robert K. Thompson Jr., DMD Cohasset, MA
http://dx.doi.org/10.1016/j.adaj.2015.06.014 Copyright ª 2015 American Dental Association. All rights reserved.
1. Cummings J, Vergo TJ Jr. Traditional dentistry versus retail dentistry: a sociological pilot study of the dental profession. Quintessence Int. 1985;16(9):651-655.
ETHICAL DECISION MAKING
In Dr. Don J. Ilkka’s May JADA Ethical Moment, “Keeping Skills Current” (JADA. 2015;146:[5]:352-353), the question posed concerned a pediatric dentist who, after a few years of administering conscious sedation, hired an anesthesiologist to perform the task. Then, 20 years later, he decided to resume sedating. Because sedation is allowed with proper permits, is it ethical for this dentist to administer sedation without an anesthesiologist being present? Although this is hardly a significant ethical dilemma and so long as the pediatric dentist is capable most would reflexively answer “yes” to this question, the article goes on to cite the principle of Nonmaleficence as embodied in the American Dental Association (ADA) Principles of Ethics and Code of Professional Conduct, carefully explaining the word means “do no harm”1 to indicate that the practitioner should not injure.2
Not satisfied, the reply goes on to cite the principle of Beneficence, affirming that this means “do good,” clarifying an ethical demand that patients are entitled to competent care. This well-meaning article clearly demonstrates the misapplication of ethical decision making and inherent weaknesses in the ADA’s Code of Conduct. Usually, it is only when recognized principles are in conflict that ethicists are called on for their expertise and thereby play an important role in decision making. For example, Beneficence means doing good for the patient. Veracity asks that we tell the truth. An insured patient is desperately in need of prosthetic replacement of his maxillary anterior teeth but cannot afford the copayment. It would be a beneficent act to forgive the copayment. However, truth would be compromised by dishonest reporting to the insurer. Which is the appropriate ethical choice? Autonomy respects the participation of the patient in treatment planning decisions. A patient presents with an obvious need for significant dental care. A full series of radiographs is proposed to the patient and refused. Without the series of radiographs, proper care cannot be rendered. Although it is possible to take care of the readily apparent problems, major difficulties will remain. Do you help the patient wherever you can, or do you dismiss the patient? Another patient says he “hates his teeth” and asks that they all be taken out. An inspection reveals no indication for removal. Beneficence and Nonmaleficence conflict with the principle of patient Autonomy. Do you extract? Major religious philosophies— Judeo-Christianity, Buddhism, Confucianism, Islam, Hinduism, and even Wicca—have a central thesis of, “Do unto others as you would have them do unto you.” Also called the Golden Rule, it embodies respect for others, being good and not bad, fairness, and truth telling.
August 2015
Descargado para Anonymous User (n/a) en ClinicalKey Espanol Colombia, Ecuador & Peru Flood Relief de ClinicalKey.es por Elsevier en mayo 04, 2017. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2017. Elsevier Inc. Todos los derechos reservados.
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