Recently, while participating in a group interview of a candidate for a leadership position at our dental school, the question was asked, “What value(s) would you want to see in your dental graduates?” The candidate's answer was simply, “The Primacy of the Patient.” He went on to explain how placing the patient's needs first in the planning and delivery of care will always be the right decision. I thought to myself, what a perfect answer!
Putting one's patients' interests before one's own is certainly not anywhere close to a new concept. Hippocrates preached it in his time about 400 BC and most graduating physicians and dentists pledge to follow this creed, or a modern version of it, in their careers. Dental schools usually teach the primacy of the patient either overtly or via cultural indoctrination and role modeling. Dental students seem, for the most part, to innately know that the patient's interests are supreme. This is certainly true early on in their clinical education when the students themselves are closer to being a patient than a full-fledged dentist. Many students are thankful anyone would agree to have irreversible, potentially dangerous procedures done by a novice like themselves. Students bend over backwards to make sure patients fully understand what is happening and that their patient is happy at all times.
However, things begin to change, tipping the balance more and more towards the needs of the care-giver rather than the care-receiver. Why does this occur? Well, it comes in a few stages. In dental school, it begins for many students when they fully grasp that they cannot graduate unless they become competent in a large and specified variety of procedures. It takes students varying periods of time to come to this realization, commonly explaining why some do not graduate on time, while others in the same program finish their competencies early in their final year.
The need to become an accomplished dental student before graduating creates a self-interest in performing procedures. Doing various dental procedures enough times to be considered competent may, on the surface at least, appear to align the patient's and student's interests. Yet, in too many cases, many of the procedures a student needs are not needed by their family of assigned patients. Likewise, many things a patient may need in the way of oral health care are not “needed” by their particular student doctor; this is particularly true for straightforward or more common patient needs that students usually master managing early in their time in school. This includes procedures such as dental prophylaxis, topical fluoride treatments, and certain operative procedures.
When these needs, the patient's and the student's, begin to diverge, educational and ethical dilemmas emerge. Schools commonly recognize this phenomenon. Many attempt to combat it by mandating “comprehensive care” of all student patients. While this sounds good and would seem to protect the patient's interests, there are many ways for students to game the system since in the end they are usually judged on procedures mastered (at least to the degree of competency), and not solely by patients comprehensively managed. Point systems that give students some flexibility in procedures to be performed help, but do not usually replace the need for procedural numbers in all areas of care. It is a help when schools allow patient care to be delivered by teams of students so it can spread the more commonly needed aspects of dental care more evenly across a class or school. But in the end, no system I've seen in a dental school restores the patient to the position of being supreme given that there is a misbalance of the types of procedures patients commonly need with the types of procedures students need to perform to graduate. I know some schools have moved to simulated procedures performed on patient simulators. Perhaps this is educationally sound, but I've yet to see scientific proof validating this educational practice in creating or evaluating clinical competency.
The final burden we place on most dental students is charging them an arm and a leg, and in some cases, another leg or arm, to get through dental school. They are then expected to repay those loans back over a few years (unless they have wealthy parents or enter some form of public service), while at the same time opening or buying into a practice. This makes it tempting for new graduates to try to sell more dental care to patients than the patient actually needs. This doesn't explain why many practicing dentists closer to my age do not put the patient's interests above their own, since even at my expensive private school I was able to pay off my student loans without much trouble, even on an academician's income.
The next stage at which a patient's needs are not considered supreme usually comes when a student must take a state or regional board examination. In this case, the group that is by law set up to ensure the primacy of the patient, the state dental board, puts candidates into ethical quandaries. This is by typically requiring the demonstration of competency on a live patient. And not just any kind of patient is satisfactory; no, the student must find the goldilocks of patient needs. Those are dental problems that are not too severe or not too easy to manage. They must be “just right;” that is the “just right” amount of caries, or of plaque and sulcular “pocket” depth. This requires many students to “sit on disease;” namely, not treat a patient in need until it is time to take the board exam. Plus, by requiring amalgam instead of tooth-colored materials on many exams, patients are often coerced into a material they do not desire. This entire process then puts the board candidate's interests above the patient's. While I personally agree with a board's right and duty to make sure someone is competent to do clinical procedures before licensure, working with schools to observe students treating their regular patients is a better way to protect the patients' interests and accomplish the boards' task. Another strategy boards could use in adopting the simulated or OSCE model used successfully by the Canadian Board of Dental Examiners, and just recently adopted by the Minnesota Board of Dentistry. Sure, this is not the traditional or most expedient way to give these exams. It would make board examiners have to change and maybe be more flexible. But if examiners value the patients' interests, and even the candidates' interests, above those of the examiner, perhaps such a change makes perfect sense.
So, in the final stage, we come to practicing dentists. How well do we value the primacy of the patient? I'm not sure. With our experience in dental school and with board exams as a groundwork, it is no surprise that many dentists are confused by who's interests win out, their own or those of their patients.
I am chagrined by how much of our local and regional continuing education offerings relate to practice or wealth management training. Granted, some practice management education does focus on how to make patients the kings or queens of the dentist's office. However, most focus on profitability and how to maximize the doctor's interests. Many practices that adopt these practice management strategies do little or no pro bono work or see a fair share (or any) of Medicaid patients. Yes, they'll say they do, but in most cases their “pro bono cases” were retrospective write-offs of uncollectibles and not intentional. The most popular of the other continuing education offerings seem to be those focused on what I'll call “luxury aspects” of dental care. Those are procedures designed to make perfectly sound teeth look better. Some of these courses characterize procedures as essential and encourage and teach dentists how to sell these procedures, even when a patient has to go into debt to afford them.
I feel professional associations like the American Dental Association (ADA) should have an expressed intent to protect the public's interests. However, the major avenue of communicating to the public, the ADA website, does not make it clear that the association and its member dentists put the patient's interests above their own. The mission statement mentions the public, but makes no illusion to the primacy of the patient. (The American Medical Association's mission statement does a much better job of this.) In its current form, it's not even easy to find the ADA's mission statement on the website (it's not in the “public” part of the site). The website should scream that the ADA and member dentists are all about the primacy of the patient.
Does dentistry have an image problem? Probably not in the eyes of most patients able to find and pay for care. But what about the estimated 130 million plus without adequate access to care, and their government representatives at the state and federal levels. We dentists say “one cannot be fully healthy without good oral health.” But for some in our profession, our own self-interests to make a very healthy income too often take priority over our patient's health needs and interests. This manifests by sometimes overselling care, or even providing unneeded care. We provide care that sometimes has no scientific basis like replacing amalgams due to unproven mercury fears. Some of us provide care in our office that should be done by other dentists with greater skill and experience with those procedures. (I've personally seen that often with patients needing alveolar cleft grafting.)
In the end, I've observed over my career, that most of those I consider to be the most successful of my colleague dentists do have a “patient first” philosophy. They usually accept a fair share of Medicaid patients, and see “sliding-fee schedule” or “pay over time” patients who cannot afford to pay full price or upfront. They also do not overtreat patients, or do procedures they have not adequately mastered. They attend continuing education programs regularly to maintain and improve their clinical skills. These same people are commonly active in serving in their communities in non-dental ways, and are often a participating member in organized dental associations and societies. And you know what, they are all financially very successful; and happy with their careers, and lives in general.
I don't have any grand solutions for the student vs. patient interest misbalance in dental school (and even residency training for that matter). Perhaps we just need to make patients more aware of the situation and pay private dentists to come to the school to give patients the care students do not need to provide to become good dentists. I already mentioned ideas on managing the ethical problems with board exams. But for practitioners and their professional associations, I believe more of us (hopefully all of us) should adopt the primacy of the patient as our top mission. All else that is needed to take care of our truly important interests and those of others who are not our patients will follow. I worry that it is all too tempting to let our personal interests rise to the top. So this must be a conscious effort to make certain that by intent and action we do the best we can to always look out for what best serves our patients.⁎
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