Conflicts of Interest in Dentistry
According to a recent SmartMoney article, as many as 48% of U.S. dentists have seen their profits plummet thanks to the recession.
In and of itself, this isn’t a particularly remarkable statistic – after all, most of our wallets have taken a hit this past year – but what follows is an interesting discussion: how are dentists coping with this drop in income? Angie C. Marek reports a variety of tactics in her article (including lowered rates, freebies, eliminated IOUs, etc.), most of which benefit the patient – but they don’t all. Rather, some dentists are softening the financial blow by upselling and overtreating patients.
One example is a woman who, upon switching cities and dentists, was surprised to learn that her hitherto problem-free mouth was suddenly a danger zone: several cavities required coatings, and two veneers needed replacement. Or so her dentist told her. In fact, though, this turned out to be just another case of overtreatment.
The problem here is conflicts of interests (COIs). These are instances when professionals are pulled in two directions, torn between personal gain and the good of the patient. And the sad news is that when faced with COIs dentists (or physicians or cardiologists or other MD) often ends up going the self-interest route, and this can have undesirable consequences for the patient.
Not just a product of the recession, COIs have been a problem for some time now, and are actually very pervasive; you’ll find them everywhere in medicine. There’s the doctor who at once accepts consulting fees from a drug company and studies their drug, and the doctor who prescribes what a drug rep pushed on him the week before over a free lunch, and even the doctor who urges a treatment on a patient mostly so that he can use his costly new medical equipment.
But this isn’t to say that these are dishonorable people who only see dollar signs and say to hell with the patient. Rather, COIs can deeply color the person’s perception, and thereby end up influencing even the most upstanding citizens astray, and this happens often.
So, next time you are at the dentist – think about your dentist’s conflicts of interests.
This is a HUGE problem–the one of the biggest obstacles to meaningful health care reform. I’m a radiologist, which means I interpret diagnostic tests but have no power to actually order them. Even when I suggest additional tests, I am in a 17-doctor group employed by a hospital, so my personal economic gain is minimal.
However, a gastroenterologist in solo practice has the choice of whether to diagnose and treat a patient in the office (for around $65) or to perform an endoscopy, possibly helpful and almost never harmful (for many hundred dollars), and no one, other than an insurance company, has any oversight!
We need to allow highly-trained, hard-working doctors and dentists to achieve an income commensurate with their education and comparable to their peers in law, finance, etc. But we need to eliminate conflicts of interest in individual patient interactions, perhaps by aggregating physicians into larger groups, insisting that doctors refer patients to colleagues for the actual procedures, or similar measures.
Interesting observation.
I wonder how much of a problem this is. Also, how would you design a social system which is more resistant to such conflicts of interests?
Years ago I switched dentists (due to a move) and the something similar happened. He claimed I had a mouthful of cavities. I got a second opinion (I drove back to my old dentist) and discovered everything was fine.
I bet you get tons of comments where people report similar things.
What I’d like to know is this. At the time I thought the “You need eleven fillings” dentist was a shameless crook. Now I suspect it may have been a case of someone seeing what they wanted to see.
I had this same problem when I switched dentists. I moved from Michigan to Boston. The dentist I found there suggested full deep cleaning on all 4 quadrants of my gums, a small filling, a mouthguard & teeth whitening. Total bill: $3000+. I of course didn’t go back, which is too bad since I should’ve gotten that filling.
I moved back home a year later and told my old dentist about it. He laughed and said I didn’t need any deep cleaning and if I have no problems, a mouthguard is unneccesary as well. Teeth whitening is obviously optional, but this guy just wanted my money.
I just heard precisely this on a podcast of This American Life on NPR, but with doctors.
I think our society overvalues the ethical level of doctors and dentists to the point that even them stop evaluating their practices.
I hate how this works! The same happened to me… except in the process of the new dentist fixing tiny cavities that didnt need fixing, he created small cracks on two of my teeth, which grew to the point that I needed two implants.
The worse part is that fellow dentists would not admit that is what happened, until I moved away and another dentist admitted the greedy dentist had made a mistake.
Agreed.
There are many other examples.
For example, there are medical devices and procedures done in this country but not done in other industrialized countries because they are ineffective or because, in about a year, a different procedure will have to be done anyway if the problem increases (or what sometimes happens is that the problem goes away.) So, what happens in the US. Well, there is a DRG for the procedure and there is a device in the doctors office (and don’t forget the disposable) which if the doctors uses, he gets paid for the use of his device and for the procedure. In Europe, the device has no market for the device–because the states will not fund the procedure because if you wait, you will find out in a year if you need surgical intervention or it will go away or you can take a pill.
A good subject for research is comparative care which will reveal more of your conflict of interest problems.
Here’s another one.
A doctor friend of mine used to work at a very renowned clinic before getting his MBA and doing something else.
When things were slow at the Clinic, doctors “trolled for moles”–managing to find more suspicious skin conditions requiring biopsy.
It would be interesting to look at the frequency of trolling for moles based on doctor capacity utilization.
This problem exists in many business relationships. Your car mechanic makes more money, the more he/she talks you into “fixing”. Many financial advisors make money from your transactions (whether or not you make money on the transactions), and others are paid a part of the management fee from whatever you invest in (again, independent of your return).
The answer is to give MDs salaries so that they are paid the same salary, no matter what treatment they give. Not doing this is the single biggest flaw in the British National Health Service. Most people don’t know this. They think their doctors are employed by the NHS but actually, they are private businesses that have contracts with the NHS. Because of the COI you so eloquently describe here, doctors didn’t agree to be past of the NHS when is was established.
I hate how this works! The same happened to me… except in the process of the new dentist fixing tiny cavities that didnt need fixing, he created small cracks on two of my teeth, which grew to the point that I needed two implants.
The worse part is that fellow dentists would not admit that is what happened, until I moved away and another dentist admitted the greedy dentist had made a mistake.
Dan,
Think also the other way round. We, as pacients, are more inclined to believe the specialist who gives us the good news.
There is a pre-stage to any cavity, called marmorations, when the tooth enamel is altered, yet not broken. Some dentists are keen to eliminate these marmorations as well, while some don’t consider them as cavities. As everywhere, there are perfectionists and laissez-faire types of guys. So, it’s not always a matter of money
On the other hand what would one expect, when one asks a second opinion to the same, previous, dentist, the one who actually didn’t take care (enough)?
As some have noted, the Problem is not confined to dentists. It’s the problem of a lack of professionalism, applying for example to professors of economics (I’m one, too), who if they lack professionalism can slack off and make more. The solution is to stop imagining that incentive systems solve everything, and that we don’t need ethical conversations. We need to be telling people in dental schools (and graduate schools of economics) that they are acquiring a professional identity, and therefore an ethical responsibility to their client/student/customer. If we professor of economics keep telling people that Incentives Are All (they are something: just not All)we are poisoning the well.
Another elephant in the room, moreover, is the framing of dentistry as somehow “quasi-medical” with its own (typically inferior) insurance systems. Perhaps that offers its own culture/flavor to the business/medical
model.
Ironically, poor dental health is considered a marker for systemic medical issues.
I am now ready to rinse.
Thanks for your sharing.so wonderful!wish you have a lovely day and Happy New Year.
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Hi Everybloggie,
Hmm…this seems to be the way some cowboy dentists work. This happened to me when our family relocated from California to the east coast. I call it the ” Dental New Mercedes Purchasing System”. I would never go back to the crooked dentist ~ and my husband and I took our family to another dentist recommended by friends and neighbors.
“By word of mouth ” is by far the best way to find honest doctors, dentists…and plumbers !!
Went through the same upsell routine with 2 dentists. I had both of them claim that less than optimal oral health could lead to complications of general health. May be true, but I question just how perfect it needs to be. I’m over 50, so some of my dental work is older, but symptom-free. Does it need replacing? Doubt it!!
The addition of cosmetic services further clouds credibility for me. Question on my intake form for present dentist: Rate your smile on a scale of 1-10!!!
I’m a librarian who manages a large budget at one of the (very) top university libraries in the United States (I can’t be more specific than that, otherwise you’d know which one). Since I began I’ve been extremely uncomfortable by the freebies given to libraries by corporate (Lexis, Proquest, Gale/Cengage) sellers of large, uber-expensive databases. They give free lunches and dinners – expensive ones at that – and all other manner of soft incentives. People are well-aware of this system in medicine, but I suspect that even academics who are affected by the vendor/librarian relationship have scarcely a clue about the nonsense taking place in large academic libraries with COI.
As a few commenters have pointed out, this has nothing to do with dentistry. Does this exist in dentistry? Yes. Does it happen to MD’s? Yes. Does it happen to Politicians? Yes. Does it happen eaters at a restaurant? Yes. Most people in a job that has something to do with sales get put in this position of upselling. “The more I sell, the more I make.” Now you say it’s a bigger problem in dentistry because you are jacking up peoples health care (very coveted in our culture as it should be), but an honorable dentist will treat you well, just as an honorable insurance salesmen will only help to sell you something if you NEED it. But, more often than not we see insurance agents trying to sell you flood insurance when you live on a plateau. The problem is honesty in society, not honesty in dentistry. So, next time you go to the dentist and he tells you that you have a cavity, don’t go getting all skeptical. How about you find a trustworthy dentist before you go to one, then you will know that what he tells you will be truthful. And make sure that you do this for your mechanic, and your server, and your accountant, and your Senator, and your wife…
I have worked in the dental industry for 15 years. I’m sure there are dentists who “up-sell”,just as there are MD’s, financial advisors, carpenters, plumbers, car salesmen, waiters, ect….. My point is, that the more educated you are about your health the better. Each Dr. I have worked for has a different opinion about treatment options for any given patient. Even Dr.’s in the same practice. Some want to tackle problems while they are small and inexpensive to fix, others take a “wait and see” approach. IF you have unanswered questions about a treatment plan, ASK! With x-ray and digital intraoral pictures, you no longer just have to take someone’s word, they can show you the treatment that is needed and explain why it is needed. The dentist’s that I currently work for are very conservative, but also want to take care of the “small fillings” before they become larger treatment. As Hilary said, The BEST Way to find a Dentist is word of mouth – ask your friends or family for referrals to health care providers and other professionals that they trust!
This definitely happened to me. I didn’t get the surgery, and two years later, I’m fine. They still hassle me about coming back.
This is true….
Secretary at anesthesiologiests’ office sees a notation of every operation done at the local hospital. She notices the Ear, Nose and Throat doctor is taking out lots of tonsils lately.
She runs into a secretary from the Ear Nose and Throat doctor’s office and says it must be the season for sore throats.
Oh, that’s not it! The secretary from the Ear, Nose and Throat doctor explains what’s really going on:
The doctor recently divorced, and married his pretty, young receptionist, and she is thrilled to be a “doctor’s wife.” She’s done all the arrangements for a vacation, and it’s going to be really, really expensive.
The doctor didn’t want to appear cheap, so he said OK to the expensive vacation plans.
Now, when kids come in with a sore throat, all of a sudden most of them need their tonsils out. That’s how the doctor is going to pay for the vacation….
This account is absolutely, 100% true.