Sunday, January 24, 2010

Finding a Good Dentist

Finding a Good Dentist

- OR -

The Death of Professionalism.

Finding a good Dentist these days is a daunting task, and not because there is a shortage of them. On the contrary, we are awash in a sea of Dentists in this country and have many to choose from.

So, one would think, with the law of supply and demand and all, that with a surplus of Dentists to choose from, we would have competition forcing down prices and also providing top notch service. And yet, the opposite is true.

What do I mean by this? And why has this happened? Well let me explain the first part, and they we will examine how this has happened to the Dentistry business as well as a lot of other professions.

Despite the paranoid claims of the John Birch Society, fluoride, in our drinking water and toothpaste, has done wonders for American teeth. The incidence of cavities has dropped significantly. If you were exposed to fluoride as a youngster, chances are, you have pretty good teeth. So the need for a lot of traditional dental work (filling cavities, the bread and butter of the business) has dropped off markedly in the last few decades.

At the same time, enrollment in dental schools has climbed. Why this is so, I am not sure. Perhaps Dentistry is viewed as a less risky (from a malpractice standpoint) and more lucrative profession. We are also seeing a lot of recent immigrants getting into the business. Many thought that this increase in the number of Dentists would result in better service for undeserved rural areas, where there is indeed, a shortage of dentists (which explains teeth problems in West Virginia). But as one blog notes, the resultant increase in Dentists meant only an increase in the number of Dentists in highly profitable urban and suburban areas.

So we have a surplus of Dentists in urban and suburban areas, and still a shortage in rural areas. Why hasn't the "free market" fixed this problem?

The short answer is that the free market IS at work here. Newly minted Dentists are going where the money is - to urban and suburban areas, where people are more likely to spend money on their teeth, are more likely to have money, and better yet, are more likely to have Dental insurance. You'd go broke opening a practice in a rural area, where people have horrible teeth, can't afford to have them fixed, and moreover don't care.

So the young professionals move to the urban and suburban areas. And increasingly, the practice of Dentistry is becoming a money game, where the name of the game is to sell as many services as possible to the customer. The old days of doing X-rays, filling cavities, and bi-annual cleanings are old hat. Today, we need to sell cosmetic services, such as tooth whitening and repair, and even teeth straightening (braces for adults). We are sold "mouth guards" to prevent us from "grinding our teeth". We are told, with regularity, that we need to have our jaws broken and re-set, to repair "manibular dysfunction" or "TMD" or some other major surgery. And even if you have healthy gums, you are plopped down in the chair for a half hour with each visit to have a computerized "gum recession check", regardless of your real risk for periodontal disease.

Now, don't get me wrong, there are people with real Dental problems, who need root canal or periodontal treatments. And there are some people whose jaws are so badly formed they need corrective surgery. But most people have perfectly healthy mouths - and yet are still told these things. The practice of Dentistry has become, in many quarters, an utter sham - where the name of the game is to "sell" as many services as possible to the client.

The problem with this model, is that many people have an undue respect for professionals, and will take whatever the Dentist says as the word of God. So if the Dentist says you need your jaw broken, it is very easy to convince yourself that he is right.

I went through this with one Dentist, who suggested jaw surgery. After explaining all the benefits of this painful, protracted process, she mentioned that it would cost $10,000 or more, but that "my Dental Insurance would cover it". When I explained that I did not have Dental Insurance (and didn't have $10,000 laying around), she said. "Oh, well, then you really don't need the surgery."

Huh? Did I miss something here? The need for surgical procedures is based on your ability to pay? This, in a nutshell, illustrates what is wrong with insurance-based health care. If someone has insurance (or medicare), procedures are recommended that are not recommended for the uninsured or under-insured.

For example, my neighbor and I both have Diverticulosis, which can flare up into a painful and dangerous condition known as Diverticulitis. Since she is on Medicare, when she has an attack, they put her in the hospital for eight days. When I have an attack, I am sent home with antibiotics. The 80% medicare reimbursement for an otherwise empty hospital bed is just too lucrative for the hospital to pass up. But my private insurance wouldn't cover it, so, I don't get it.

Funny how that works, eh? And maybe you understand better why medical care in this country costs 2-3 times that in other industrialized countries.

But getting back to Dentistry, the same effect occurs, which is why Dentists want to locate where the money is. Trying to sell TMJ surgery to someone in rural West Virginia with no money and no insurance is a sure way to go broke. But in the Suburban New York City area, there is money to be made.

This trend has been commercialized in the form of chain Dental Offices. Overnight, it seems, a new chain of Dentist Offices has sprung up. This chain promises to examine your teeth and do an x-ray, for free! It sounds too good to be true, and of course, it is.

People going to the chain stores report a typical scenario thusly: You go in for your "free" exam, and they tell you that you have periodontal disease, or need four teeth extracted, or need 8 fillings, or need complete dentures. The "patient" is then lead from the examining room to the business office, where they are harangued for money. Do you have insurance? A credit card? Money in the bank? Home Equity Loan? Parents you can borrow from? If you don't have the money, the price of some of the services changes. They claim they can "cure" periodontal problems with one "deep gum cleaning", which of course is costly.

Disturbingly, some report that, after getting a second opinion, they discovered that the chain Dentist was proposing drilling or extracting perfectly good teeth. If these reports are true, it is certainly beyond disturbing. Remember the Hippocratic Oath, "First, Do No Harm"? Apparently these folks have forgotten.

These chain Dental stores have completely commercialized the practice of Dentistry. The patient is viewed as a cow going to the slaughterhouse, and they are picked clean and sold whatever services they can pile on. If you are foolish enough to go along with the program, shame on you.

(Whenever I see an adult wearing braces - and adult with perfectly good and straight teeth, I always get a chuckle. That Dentist was a good salesman!).

So what has happened to Dentistry - and the professions in general? We also live in a glut of lawyers today, but good luck finding one that is reasonably priced and honest.

The problem, I believe, is what I call the "death of professionalism", which has occurred in the last two decades. At one time, being a professional - Doctor, Lawyer, Dentist, etc. was a position of status. You made good money, true, but not a killing. Doctors drove Buicks, not Mercedes (Buick's tag line used to be "The Doctor's Car"). You were comfortable enough in your profession that you could afford to make judgment calls based on actual client needs, and not whether you could make a mortgage payment that month.

And that to me, is the definition of professionalism: The ability to discern the difference between your own self-interests and the interests of your client, and advising your client what is in their own best interests, not yours.

Today, that definition is lost on an entire generation of professionals. The name of the game now is billing, billing, billing. In order to keep a practice afloat these days, you have to bill each and every person who comes in the door. Why? Because there is so much competition, that there are fewer customers for each practitioner. The "free market", instead of providing better services and lower prices has done just the opposite. We now have higher prices and worse services. Funny how that works.

So, how can you find a good Dentist? It ain't easy. Word of mouth (if you'll pardon the pun) is probably the best way. But beware - a friend who is serially addicted to medical procedures is probably the worse referral there is. And there are such people - who enjoy the attention they get from doctors and professionals and will seek them out repeatedly (adding to the cost of medical care for all of us). If your friend recommends Doctor X, and then recites a litany of treatments they have received over the last year, well, chances are, Doctor X is going to recommend the same treatments for you, too. Get a referral from a different friend - 0ne with healthy teeth.

And once you find a good Dentist, hang onto them. A good Dentist is one who is in the business because they enjoy their work, and oh-by-the-way, they make a living at it. So the Dentist with the flashy, expensive office is least likely to be the one you want.

And yet, many people assume that the Dentist with the flashy office is "successful" and therefor must be "good". For the same reason, people will drive by a locally owned diner that makes excellent gourmet food at cheap prices, and eat instead at McDonald's - because the McDonald's is shiny and new and flashy, and obviously successful. So it must be "better", right? (This effect is prevalent in any industry, and probably the subject for another article).

I have had two good Dentists, and both were ex-Navy men with small practices. They do the usual cleanings and X-rays and generally don't try to suggest jaw-breaking on a regular basis. One of them started to go down that road once, after taking a seminar on the profitability of offering these sorts of services. He also said I needed to wear a "night guard" to prevent me from "grinding my teeth". I asked him, point blank, if my teeth would last another 30 years.

"Of course," he said, "you have really good, strong teeth! They should easily last another 30 years!"

"Oh, good," I replied, "because that's about as long as I plan on using them."

You see, once I put that into focus - whether the teeth would last my expected lifespan - the speciousness of the ancillary services became clear.

Re-drilling cavities is another area that Dentists like to visit. My Dentist of 20 years told me once that I needed to have my cavities re-done, as "whoever did these, did a hack job". I thought about it briefly, and said, "Didn't you do these 20 years ago when we first met?"

After consulting his chart, he turned beet red and said, "Well, what I mean by 'hack job' is....."

I eventually got them re-done, and sometimes that is necessary, as amalgam fillings do expand and contract and tend to crack teeth (don't chew ice!). And I eventually had them re-filled with this new fiberglass stuff that doesn't show as a filling. But I am not sure that was not just a cosmetic cure (My latest Dentists claims that the amalgam scares are much over-hyped. People are having perfectly good fillings removed for no reason).

My latest Dentist is an older man with a modest practice. He enjoys his work and makes a living - not a killing - at it. He has some of the best advice I've ever gotten from a Dentist: Floss More, Brush Less.

You see, periodontal disease is one of the more common problems people have with teeth, or more specifically, gums. And one reason is that most people do not floss enough. We are bombarded with advertisements on the television for toothpastes and toothbrushes, as these are wildly profitable items which can be continually re-worked with gimmicks and gimcrackery.

But Dental Floss? There is no money in that. There are no Patents to enforce. No special formulas or designs. There is no brand name loyalty, even. So we tend to think about Dental Floss as an accessory to brushing, which is the main event. But brushing without flossing is really a bad idea, as all you are doing with the toothbrush is forcing things further down your gums.

It seems like simple advice, and sometimes the best advice is simple, and free. If you take care of your teeth, you'll have fewer Dental problems. But of course, there is no money in that, is there? So most Dentists prefer you come to them for expensive procedures.

Lest you think I am picking on Dentists, the thrust of this article can be applied to ANY profession. I am using Dentists only as a simplified example. The problems in our health insurance system and in our legal system are caused by the same root problem: The Death of Professionalism.

I am not sure how we can re-instate what are essentially moral values, into the professions again. However, as a consumer, you can take note and not fall into the trap of treating professionals like the Gods they once were. We no longer deserve such treatment. Be skeptical, shop around, get a second opinion.