Annoying dentist…
On October 5th I appeared on NPR, discussing some of the problems with dentistry.
This was not the first time that I have pointed to problems of conflicts of interests. In the past I have been vocal about conflicts of interests in Medicine and in Banking, but somehow this time I stuck a nerve and as a consequence I got lots of angry emails (see also the comments on NPR).
The basic email I got had the following form:
“Dan, you are an idiot. I am a dedicated dentist who only does what is in the best interest of my clients. But, it is true that there are a few bad apples in dentistry, as they are everywhere”
One of the responses came was from Ronald Tankersley, D.D.S. the President of the American Dental Association. Among other things Ronald Tankersley writes:
Ariely’s assertion that patients stay with their dentists because pain, discomfort and having to “keep your mouth open” causes cognitive dissonance is pure nonsense— he sounds like someone who hasn’t visited a dentist for decades. Modern pain and anxiety control techniques have all but eliminated the discomfort that older patients may have encountered as children. In fact, younger patients today don’t think of dental care as being uncomfortable at all, partly because they rarely get disease and partly because the treatment they do get is rarely uncomfortable.
Particular details of the comments aside, I would like to take this opportunity and clarify my position on the pay-for-service model that we commonly use in dentistry and its effects on conflicts of interests (dentists that get paid for X want to do X), and on the quality of care:
1) I don’t think that dentists are particularly evil, selfish, of greedy just that (much like the rest of us) when they face conflicts of interest they are likely to see the world in a distorted way. They are likely to look, and find, problems that the treatments for are ore lucrative. The same of course applies to bankers, MDs, financial advisors, expert witnesses, etc.
2) The evidence for conflicts of interests is rather staggering, and I suspect that the majority of dentists would agree with me that this is a problem that is hurting their clients and in the long-terms also their profession.
3) One of the hallmarks of conflicts of interests is that people don’t see themselves as being influenced by such forces (“I am always doing the right thing, other people succumb to conflicts of interests…”)
4) I am easily influenced by data, and I would read carefully any study or data that would add to my understanding of this problem – so if you have such data, please send it my way.
5) Rather than dismissing the problem completely, perhaps the American Dental Association should take this as an opportunity to study the standards of care and conflicts of interests in dentistry. On my part, I am willing to help in any way I can. I can help design studies, analyze data, propose ways to eliminate conflicts of interest and get patients to seek second opinion, etc.
It is easy to pretend that world of dentistry is working just fine, and that the error is entirely mine, but I suspect that this is not the right approach for patients, for dentists, or for the American Dental Association.
Irrationally yours
Dan Ariely
The Upside of Irrationality, explores some positive and some negative ways that irrationality plays out in our lives.
Hi Dan
A minor comment: it’s not clear where Ronald Tankersley’s email ends and your commentary begins.
That aside, this is an interesting issue and I wonder how mechanisms could be designed, or a cognitive environment created, which would counter these conflicts of interest. The conventional economic answers to these kinds of problems tend to add overhead and remove some of the benefits of the trust relationships that we want to build with our professional service providers. So a cognitive/psychological/behavioural approach no doubt has a valuable contribution to make.
The power of social norms, combined with the desire to avoid cognitive dissonance, can be a useful contributor here. For example, imagine that dentists were expected to explain to their patients the trade-offs and likely risks that are presented by a given course of treatment or by inaction, combined with a statement that they believe their recommended treatment is in the interest – medical and financial -of the patient. I suspect the requirement to make this statement would in itself provide pressure against many (no doubt inadvertent) abuses.
Leigh
In regards to “For example, imagine that dentists were expected to explain to their patients the trade-offs and likely risks that are presented by a given course of treatment or by inaction….”
Dentist already do this … actually it is a requirement for all medical procedures. ITS CALL INFORMED CONSENT!! Where have you people been? Informed consent is required to have risks, benefits, and alternative to treatment explained. And yes, this does help patients understand what is being recommended allowing them to make their own decisions regarding any recommended treatment
Hi Dane
Fair enough – my experience in the UK is that any explanations of risks and trade-offs is cursory at best. Generally the dentist will tell you: “You need this tooth to be filled, and a root canal in that one”. If you ask more questions, they may tell you that the root canal may not be needed and you can try some antibiotics first, or that a crown will strengthen the tooth but it is possible to get away without one. But if you don’t ask, you are unlikely to find out.
I don’t believe that dentists (the majority) carry out treatment that is completely unnecessary or indeed harmful. But surely they are likely to have a “safety-first” bias and many dentists will want to treat any potential problem, no matter how minor. Even though many cases must be a borderline decision between treating and not.
If patients were made aware in a clear and objective manner of the balance of risks, costs and benefits, they would indeed be able to make an informed decision. But, in the UK at least, the information we are given is very basic. Indeed I would be surprised if most dentists even know the relevant probabilities of different outcomes from a particular diagnosis. But I would make a very different decision with a 10% chance of a problem developing into something more serious, than if there’s an 80% chance.
In fact, younger patients today don’t think of dental care as being uncomfortable at all, partly because they rarely get disease and partly because the treatment they do get is rarely uncomfortable.
Speak for yourself!
yeah, wow. Granted pain from nerves isn’t an issue for me, but pain of holding my mouth open wide, dealing with saliva and the feeling I’m about to choke (even with that suction device) is exceedingly uncomfortable for me. I don’t fault my dentist, but it’s ridiculous to claim that visits to the dentist aren’t uncomfortable.
I stay with my current dentist because he’s the least painful of several I’ve tried.
Wow. So many defensive, “you-just-hate-dentists-shame-on-you!” comments to that NPR interview. The fact that these people seemed to completely miss your point is depressing (but interesting). Are human beings really defensive enough to dismiss criticism (real or perceived) by vilifying the critic? I know it happens, but I never knew it happened so overwhelmingly. (I wonder if they were, in fact, replying to some kind of viral email that took what you said out of context, as opposed to the actual interview?)
Conflicts of interest are one of the important reasons professions develop codes of ethics. I think most professionals are aware of the code that they’re supposed to adhere to, and try their best to follow them (with the possible exception of lawyers). The problem is they may be subconsciously affected by their self-interest when it comes in conflict with that of their clients. When this happen, not only are they unaware of it, they are likely to take umbrage at those who suggest otherwise (case in point). In this case, I don’t think they’re being very fair with Dr. Ariely. I don’t think he thinks dentists are evil (on the other hand, maybe he had a bad childhood experience with dentists). He’s just pointing out how our behavior may be influenced by things we are not aware of (as is often the case).
This warning makes a lot of sense; dentists should take notice, and remain vigilant instead of going on the defensive. It’s probably not possible to determine whether individual decisions are influenced by self-interest, because you can’t really get into someone’s head to figure these things out; however, that doesn’t stop us from trying to figure out whether it’s happening on a systemic basis. For example, if there is substantial evidence that an expensive procedure has no net benefit (for patients), yet dentists continue to use it, I’d say there’s good reason to suspect that many dentists are not ignoring self-interest in favor of patients’ interest. Of course, there can be alternate explanation for this type of finding, but if that turns out to be the case, we need to know so that the solution properly addresses the root cause.
Hey, love the blog. Seconding the comment above that “A minor comment: it’s not clear where Ronald Tankersley’s email ends and your commentary begins.”
In fact I first read the post, thought that the points were from the head of the ADA, and came away *extremely* impressed with his leveled response to your criticism!
Only now do I realize that that was your response, which makes it somehow less impressive, perhaps because I have come to expect that level from you…
Unfortunately Ron Tankersley’s response is not shown in its entirely … it was actually about a page and a half long. Which I can understand why the whole thing was not posted, but to not provide a link to the whole thing for people to read is irresponsible and yet another way Dr. Ariely is trying put the dental profession in a bad light
Dentists in the US need to adhere higher ethical standards, there is no doubt about that. That Americans are bombarded with advertising for teeth whitening, straightening, make your life perfect advertising in their daily lives is beyond doubt. Anyone who thinks it doesn’t happen when someone is put in an especially vulnerable position lying defenceless in a dentists chair is deluding themselves. And that is only the obvious sales pitches. I’m sorry, this is obvious to those of us coming from a different country and using the dental services in the US. (I am lucky to still have teeth as I had specially negotiated expat insurance that covered absolutely everything at full cost and drew bewildered awe from dentist admin). It is just too tempting, Dentists are running a business, they have families, employees and taxes and charges to pay. The hard sell I can appreciate, the hard sell when I am lying splayed like a stranded turtle, not so much.
Dan,
I’m a dentist so I am interested in your NPR piece about dentists.
Please send sufficient information so that I can obtain your reference to the Delta Dental data about the x-ray reading discrepancy.
A pub med search under Dan Airely[auth] did produced 22 reference, but none seemed related to the data in the NRP piece. Please send the reference(s) to your article(s) about the evidence and your conclusions in the NPR piece so that they can be considered. After all, you did say, “The evidence for conflicts of interests is rather staggering, and I suspect that the majority of dentists would agree with me that this is a problem that is hurting their clients and in the long-terms also their profession.”
Your site, The Research, did not produce anything obvious that might support your conclusions. Did I miss something?
Your book Predictably Irrational seems interesting. I’ll read it.
“Your site, The Research, did not produce anything obvious that might support your conclusions. Did I miss something?”
Are you volunteering to have metal instruments stuck in your mouth and then have someone suggest you buy something (that you are unlikely to understand clearly) from them? Please say you are as you seem to be very concerned about experimental procedure and conclusions.
Hair splitting and personal attacks rarely further a cause.
Wasn’t there several Seinfeld episodes addressing this very topic. I know it seems silly to bring Seinfeld into the discussion, but obviously it has been an issue for some time (either real or perceived). Instead of launching a “counter-attack” as it appears the ADA has done here, wouldn’t make more since to launch a massive PR campaign in an attempt to win the confidence of the consumer?
i haven’t read/listened to what you said, but i can imagine that dentists wouldn’t take too kindly to it. they, like doctors, don’t like being questioned.
also, everyone i know hates the dentist, my age (37) or younger or older.
also, i would find it very difficult to treat anyone with respect who didn’t believe in the very real and pervasive conflicts of interest in most/all fields.
i recently discovered a ‘dentist on the radio’ show out here in Silicon Valley/San Jose. it’s awesome, in part, because it actually sheds some light on that shady industry.
What are you an anti-dentite?!
Dan,
I loved the article on NPR because it described my experience with my dentist. I had been going to the same dentist along, with my family for over 20 years. On almost every visit, each of us had at least one cavity, normally multiple. For the last 3 dentist visits, we’ve had a different dentist and not a single cavity has been found in any of us. We haven’t changed anything about how we care for our teeth, except the dentist. I’m pretty sure we all didn’t have cavities that needed to be filled every time we went to the dentist, and I’m also sure that last dentist, in effect, ruined my teeth by drilling and filling so much.
Dentists are no better than auto mechanics or veterinarians.
I would argue that, in responding to incentives, they are no different. Better is a value judgment I’m not qualified to make.
Ponderosa, I direct you to the ADA code of ethics: http://www.ada.org/194.aspx. Dentistry maintains one of the highest standards of ethics for any profession and deals harshly with does who stray. Your comment is unfounded and offensive not only to dentists but to automechanics and veterinarians. What is your profession? Do you have a public code of ethics? Did you take an oath when you received your degree after 8 years of education? How many hours of training in ethics do you have? You are the worst kind of cynic. You probably don’t even trust your own family. By the way, I dare you to tell your dentist, mechanic, and veterinarian that you posted this. You probably aren’t so bold when you need their help.
Totally agree! There are dentists who’s main concern are what’s inside your pockets. To that effect, i suggest looking for an efficient dentist
Hi Dan,
I passed by here, because I found out about your visit to Berlin. Hope to see you there.
The topic puzzles me personally. I find it annoying to be the one who has to choose treatments (e.g. certain types of fillings) though only costs are made transparent to me but utility is kept pretty vague. How am I to choose a treatment, given that set of information? (“Hey it costs you 300 bucks extra, but think about it – you only have one set of (natural) theeth”?) How consciously strategic is such offering by the dentist?
As an option, double-blind revisions of diagnosis (as blindness by the doctor in charge of a second examiner’s id and vice versa) have been around in Germany for a while. In the case of dentists, they are supported by public insurance companies.
How (consciously?) biased are dentists when asked for a second opinion knowing that their opinion on treatment choice has impact on overall per/head dentistry earnings? How would professional diagnostis-only doctors act, if paid / diagnosis, with no direct effect of treatment earnings? It will probably end up depending on how “diagnosis” is defined… At minimum, they would be heavily lobbied.
Anyway, I rely on dentists, who try to give me answers when I ask for specific success variables of distinct treatments (e.g. lifetime of teeth when doing endodontic treatments ceramics vs composite).
However, they never come up with such figures unaskedly and only very few actually go through the “hassle” of providing them (takes me couple of minutes on google scholar).
Someone design, please design an incentive mechanism, which doesnt leave on that chair, thinking I am buying life insurances.
Best
Jan-Paul
This is the “perverse incentive” problem we measurement geeks encounter frequently. Any goal or measurement established influences behavior and pay-for-service is nothing if not a measurement (revenue per patient). This was encountered by Sears when they set a revenue target for each employee in their car care department. Employees, reacting rationally to the incentive, began to recommend the infamous “radiator flush”, unnecessary “procedures” that extract revenue from the “patient”. I’m not implying that dentists are evil or immoral, they’re people, just like the mechanic at Sears, and they respond similarly. The challenge we face is to set incentives so they don’t perversely affect behavior and it’s no trivial challenge. Basing school and teacher evaluation on test scores seems rational but when instituted, teachers respond rationally and teach to the test, perhaps just subtly refining their delivery so that the test material is covered. Is this wrong? That’s not a problem I’m paid to solve but is it inevitable? You betcha….
Still, it is an interesting question, what “evil” and “immoral” as personal characteristic constructs actually are to certain individuals or in certain social groups and how by such means “evil” and “immoral” individuals self select into certain professions, e.g. become a dentist or a pediatrician.
And no matter if its a question of self selection or treatment by profession: May be let the doctors who often impose decisions (with significant financial impact) on clients (e.g. dentists) vs. general practioneers (where in germany, you never actually have to choose / or pay for special treatments) participate in some dictator style games. I have a hypothesis in mind the dentists wont like. Though I am an uncertain if their biases will hold in lab experiments or if they will smell the rat.
I quit going to the dentist for this very reason about 2 years ago. On a go forward basis I plan to go “when I have a problem”. I know one person’s experience doesn’t represent a scientific study, I’ve just suspected this for a while as I know few people who go and the dentist doesn’t try and sell them something.
Here’s a question:
Dentist A says nothing’s wrong… everything’s fine… see you next time.
Dentist B says I would do something about this… here’s what I recomend.
I don’t have research to back it up… but it is my personal experience that when the two are compared… 95% of the time Dentist B will be seen as evil, untrustworthy, only after your money. What do we have to say about the concept of supervised neglect? Where do the biases of just hearing what we want to hear factor in?
Is it possible, even likely, that Dentist B actually cares about the patient, cares about them enough to raise an uncomfortable conversation and possibly risk driving the patient away in order to do what’s right by them? Is it possible that Dentist A just wants to wait until things become more costly to fix, all the while securing your trust so that in 2 years that root canal and crown that’s going to cost almost $3K isn’t such a big deal…. when Dentist B and the $150 restoration seemed evil?
Serriously Dr. Ariely…. I’d be interested in talking more about this with you… and not in an argumentative way. I think there are some pieces missing from your conclusions and I think if we talked we could learn from each other. The dentist / patient relationship and the way the public percieves dentists has always fascinated me.
re what people would think of the question Which dentist (A or B) is more evil?:
I would guess (without evidence) that people are more likely to choose a third option: neither. If most people generally trust dentists, the recommendations of the two dentists would seem equally earnest, even if they are talking about the same patient. People’s explanation for this would be pretty simple: there’s an honest difference of opinion between the two dentists. At that point, the question for the patient then becomes Who is a more competent dentist? When people are selecting their dentist, I think this is the main question they have in mind. They don’t ask Who is the most ethical dentist? I think the reason they don’t ask the latter question is that they dentists generally have high ethical standards.
I would be really interested to see how people would empirically respond to your question; it should also be of great interest to dentistry, but it seems they are not very inclined to entertain the idea that there might a perceived problem with conflicts of interest.
Phillip,
I have to be honest, I love patients like you! My true financial incentive is to somehow get you to ignore my advice for small, inexpensive early intervention, and wait for the big stuff. I guess that is why I don’t understand how Dan thinks that dentists have a conflict of interest. If I was following the money, I would tell everyone to wait till it hurts. That is much more profitable for my business. Of course what a wretched existence that would be….somehow need to find a way to bury that little voice that nags. Maybe I can get in bed with delta dental, because everyone knows that if a patient wants great care they should look to the insurance industry to be the gatekeeper.
That the fee-for-service (FFS) system of reimbursement results in overtreatment is hardly earth-shattering news in health economics circles. Neither is it news that the most common alternative–capitation, which typifies managed care plans–provides an incentive for undertreatment. One way around this apparent dilemma is to pay health professionals a salary. Do that and the incentives for over- and undertreatment disappear.
Except that “incentives” don’t disappear. What has largely been ignored in all of this discussion is the fact that dentists like most normal human beings consciously or unconciously avoid conflict where possible. Telling someone bad news is stressful – trust me on this one. I don’t do it unless I think a patient really will benefit from treatment. There is just so much dental need out there that there is no real incentive for “creating” work to do. I find it somewhat amusing and naive that so many people think a dentist’s prime motivation is greed. There are so many other – better suited – professions for people who are solely or mostly interested in making money. Dentistry done right is challenging. It means communicating the complexities of therapy to patients and helping them to make good treatment decisions for themselves. Those who choose to take advantage of what dentistry has to offer, do so. Those who do not are hopefully well informed.
Paying a salary vs FFS really does little to change the human dynamic. In fact, it probably doesn’t matter what economic model is used. There will be good caring dentists in any system and others who are not so much of either. I actually think that successful dentists tend to be the ones who are honest and who care about their patients. They have the best reputations and they are in demand, sought after by patients. The other ones develop a poor reputation in the community and their practices are less successful. I tend to see these dentists finidng another line of work after a while, something better suited to their talents, interests and abilities.
There are a number of models for salaried dentists, the VA and Indian Health Service for example. In the these environments there are just as many good, bad and indifferent dentists as in private practice. (I have worked all three at one time or another) What matters is the individual clinician and perhaps that is why there are so many angry dentists writing in. Broad statements like the ones made on NPR are as thoughtless as those made to support ideas like racism and sexism. No one likes to be identified as potentially unethical based solely on his profession.
I am a dentist and a professor of dentistry. I can tell you that disagreements of what treatment is necessary and what is the “best” alternative are a constant source of debate in our college.
I would suggest that anyone and everyone get at least one second opinion for the need for invasive dental treatments, if not a third opinion.
That’s an interesting piece of advice, but I’m not sure if it’s entirely practical; multiple consultations ain’t cheap. Unless the procedure is particularly risky and/or the condition is particularly serious, I can’t imagine people (and their insurance) going for that. There’s also the problem of people wanting to trust their dentist. After all, you have been allowing him or her to poke around the inside mouth all this time already. Seems like it would be a big source of cognitive dissonance for patients. Perhaps the cognitive dissonance issue is cultural, and people need to get over it?
I’m also wondering what would happen to the notion of “my dentist” if getting multiple opinions became a regular thing for people. Seems like people would not have the same kind of relationship with their dentists if they made it a habit to ask other dentists for their opinions to compliment or supplement that of their “regular” dentist.
Dear Dan
The conflicts of interests are everywhere and as you mentioned one is not often aware of the influence they have on his/her decision making. Perhaps some of the readers are taking your analysis a bit too personally than it is intended.
I am undertaking a project which is closely related to this subject and one of my case studies has been the NHS Dentistry. I have been using your book (Predictably Irrational) as one of my references. The objective of research in this area is to understand human behavior and propose plans to transform the social structures to be as neat as they can be in achieving their social mission. It’s obviously not a way to insult people in a specific profession.
Kind Regards,
Maryam
Super interesting topic! It’s being discussed on the dental sites all over. I’m a dental hygienist and can bring a little different perspective to the discussion. All of what Dr. Ariely said is true. And the ADA representative missed the boat entirely.
When one dentist decides to “fill a tooth” based on an xray and another doesn’t it’s because they are not using a diagnostic tool other than their bare eyes. That bent wire they’re using to “detect decay” on the tooth was perfected in 1880s and the science behind how to use the information gleened from the wire is about that old.
So, if the ADA representative had asked me to proof his letter, I would have assured readers that the ADA was actively working to make this problem go away by getting behind new technologies that help clinicians avoid this conflict. Alas, he didn’t and the ADA doesn’t, he predictably went to fluoride and toothbrushing.
I’d also like to toss another example into the fray. Dentists over-see dental hygienists. California is the only state where dental hygienists have their own state board. Dental hygienists are in charge of helping people avoid dental disease, avoid cavities, avoid periodontal disease, however, they must work under the supervision of a dentist who makes a living treating dental disease. There is another huge conflict there.
The ADA is the accrediting authority of the dental hygiene schools. Except in New York and Alabama, a dental hygienist student must pass an accredited program before sitting for the National Board Examination which is required for application for licensure. There are 300+ such dental hygienist programs, there are only 50ish dental schools. Where are those new hygienists going to work? They cannot. The wages of dental hygienists are plummeting and the job outlook is bleak, with 50 or more applicants for each opening. The dirt goes deeper and deeper. Thanks for allowing a little light into this mushroom bed.
for a while i’ve been thinking of hiring one dentist office to keep my teeth clean and another to fix them to reduce the incentive of finding needless repairs.
You aren’t a car, you are a person! So it wouldn’t be a “needless repair” it would be an unethical mutilation of the human body! The majority of dentists take this very seriously, and all dentists are held to a standard of care. The best advice I can give you is find a dentist you trust. The best way to do this is to ask friends who they go to and trust. If you flat out can’t find anyone to trust in your life….well that would be unfortunate.
I will point out that it is my experience that more dentists UNDER DIAGNOSE problems than over diagnose. Most do this out of fear that the patient will not accept the treatment. This presents It’s own set of disadvantages. If you are under diagnosing small cavities, you can always catch them when they are medium sized (if the patient is regular on their visits which most are NOT). If you under diagnose medium cavities, and the patient misses just one appointment, those cavities can become much more of a problem and much more expensive to fix.
Most dentists are committed to preventative care, and are attempting to essentially put themselves out of business with prevention. Of course they need not worry about putting themselves out of business because the majority of Americans DO NOT do the preventative visits. The ADA which is 100% funded by dentists, actually has an agenda that if the American people followed, honestly could change the role of all dentists. They have been prevention minded for decades. They have certainly made a dent in dental disease, however there are still plenty of people that don’t go to the dentist until it hurts, don’t think there is a problem until it hurts, and don’t do any preventative steps. They actually take better care of their car than they do themselves. It’s like exercise, we all know it’s good, but most people don’t do it.
My final advice is if you wait to trust your dentist until it hurts, it is going to cost you. If you think you don’t have a problem until it hurts…..It is going to cost you. Cavities DON’T hurt, until they are HUGE!
“it would be an unethical mutilation”
Just because something is unethical doesn’t mean people won’t do it. Unethical behavior is exactly what we’re talking about here. The fact is that it’s very easy for a dentist to perceive that “mutilating” someone is in their self-interest. Most of the time, that perception is subconscious i.e. they don’t realize it, but their self-interest is influencing their decision. When that happens, we don’t call them evil; just human. This leaves us with a very difficult problem: What do we do about it?
Apparently, the dentist persona that Dr. Ariely describes believes we should all stick our heads in the sand and do nothing about the problem; however, it’s probably safer to assume that dentists are not a super breed of human beings who are never influenced by their subconscious. Ideally, we should find a way to eliminate conflicts of interest; as some have suggested, perhaps salary pay would be better than the pay for service model. At the very least, we have to recognize the mental hazard created by conflicts of interest.
Thank you for your in depth research due in part to the Delta Dental Insurance company. If you would please support Dan and his informative discussions by purchasing his books or hiring him for a lecture on his witty observances it would be greatly appreciated. It seems that dentists are not the only ones out for a dollar.
I would agree with you except that Dr. Ariely hasn’t made attacking dentists the basis of his success. If you had read his books, you’ll notice that he doesn’t talk about dentists in either Predictably Irrational or The Upside of Irrationality. This is probably the first time he’s mentioned dentists on his blog or on NPR (and yes, he has appeared on NPR before). In that case, you really can’t make the case that he is exploiting dentistry for his own benefit, because his success so far has little or nothing to do with pointing out the fact that dentists face conflicts of interest in the pay for service model. If anything, he probably _deserves_ a few dollars for trying to improve the situation by raising the discussion.
Correction: He talks about not using Novocaine at the dentist on pages 161-162 in the Upside of Irrationality.
Look the reason dentist are up in arms is because he has provided no study for his “view” that he is belaying as a scientific authority. Furthermore what he portrays as his thoughts and concerns on this blog DOES NOT reflect what was said or how he said it on the NPR show. The words “conflict of interest” were never brought up on the show. It was literally an attack on the profession … it wasn’t a scientific discussion, it was comical rhetoric. He is now back peddling on this blog with more dignified remarks when he really just needs to say: “I was a jackass, I’m sorry, this is what I really meant”
So I hadn’t heard the NPR interview until now. I went and listened to it expecting to hear something completely different from what’s on this blog post (based on what dane004 and others have said). I’m not going to claim that I’m objective (e.g. I’ve made many comments supporting Dr. Ariely all over his blog, have read his books, and even paid to see him in person) but I don’t see the huge chasm that dane004 and other claim exists between this post and the episode of NPR.
On the other hand, dentists should realize they can’t be objective about this either (probably to an even greater extent). For example, dane004 was very willing to take the “hazing” remarks very out of context. Although that probably wasn’t the best choice for an example, the point of it is something Dr. Ariely can speak to with authority as a professor of psychology: enduring pain and discomfort in the dentist’s chair makes you more loyal to your dentist. If he were really cynical about dentists, he might claim that dentists have designed a painful patient experience in order to exploit this phenomenon of human behavior, he’d have a much harder time claiming that he doesn’t think dentists are evil.
Another thing that surprised me while listening to the interview was that he talked about a study (from Delta) about how cavity identification doesn’t line up between dentists. Based on comments that I’ve read here, people were making it sound like Dr. Ariely was just mouthing off with NO studies to back his claims up. You might question the quality of the data based on your doubts about its objectivity (since it came from an insurance company), but you CANNOT say Dr. Ariely didn’t use data.
I’m really not impressed with the fact that “conflict of interest” was never mentioned on the show. Why should I be? Again, I won’t claim to be objective, but now that I’ve actually heard the show, I do not see this post as backpedaling over what he said on air.
@allyourcode,
The trouble is that Dr. Ariely is referencing a study by Delta Dental that doesn’t seem to exist. I linked to this earlier, but the comment by Chris Pyle, Delta Director of Public Relations says he does not know about the study Dr. Ariely is talking about.
http://www.wired.com/wiredscience/2010/10/why-do-we-love-our-dentists/comment-page-1
Several readers did searches of studies of dentists by Dr. Ariely and could not find it. Until there is any evidence such a study exists besides a single sentence from Dr. Ariely, there is no data worth discussing.
Brad Smith nailed it, so I will keep my comment short and sweet – Dan Ariely, you are a giant douche bag. Carry on.
I bet there is a “50%” chance you have a really filthy mouth that needs some work. Please go see a damn dentist and stop with this irrational dentist are evil car mechanics thread. Life is short. you should enjoy it with your natural teeth so stop being such a cheap bastard.
I really liked the piece, and it of course fit in well with your other TED Talks I have seen and various papers read. Once again, you really make me think about people’s motives and actions in situations that would typically never occur to me.
My wife had Delta Dental 7 years ago. She went to the dentist and was told she needed 4 teeth drilled. She didn’t like the guy and we asked to switch. When we got a new dentist he too said she needed 4 teeth drilled. An ENTIRELY DIFFERENT four teeth.
It’s now 7 years later… and she has had none of them drilled. I, myself, have not been to a dentist in 20 years.
Aside from Dan’s great books, you might also try WRONG by David Freedman about how experts aren’t always what we envision them to be.
Dr. Ariely,
If you’re “easily influenced by data” where is the data? You have provided no information where others can read about this study. I’ve done searches and at least one other of the above commenters has done a search and can find no such study linked to your name. On another blog post regarding this work:
http://www.wired.com/wiredscience/2010/10/why-do-we-love-our-dentists/comment-page-1
The comment at: CPyle | 10/11/10 | 9:45 am is a representative from Delta Dental’s director of publications who says he knows of no such study using dentists in their network. Where is this study listed so that readers can assess the accuracy and honesty of your data. I also am easily influenced by data, but “50% of dentists can’t agree on cavities” seems unbelievably high unless you’ve used some non-standard definitions of agreement or used only a subset of x-rays.
Dan, as I asked in my email to you the other day, there are still several unanswered questions, hence the “cognitive dissonance”:
1) Can you please tell us where you were trained in radiologic interpretation so we know your background in evaluating any references?
2) Can you please discuss the “conflict of interest” that exists in the “research” provided to you by Delta Dental, a FOR-PROFIT insurance company that makes its money by…….wait for it…….DENYING PAYMENT ON DENTAL TREATMENT! The things that make you go Hmmmmmm????
3) Can you please share with us any other data that may have contradicted the “research” provided by Delta; if there was any, please tell us how you determined it to be less valid than that provided by Delta? If there wasn’t any, can you then please explain the cognitive/logical dissonance inherent in a one-sided, necessarily biased result?
4) Can you please cite the literature on how dental appointments can be related to the Stockholm Syndrome, in which hostages are held for extended periods of time (not just an hour or 2, like most dental visits)?
5) If Delta Dental’s Director of Publications doesn’t know of such a study, can you please tell us where you found it so we can, too?
6) Can you please explain how a psychologist apparently has no bias in keeping his/her patients “sick” in order to keep earning money, because after all, the patient is already on the sofa and you can’t make any money if you send him home, so it sure SEEMS like there would be a conflict of interest there.
7) Instead of saying, “Oh, look, I hit a nerve so I must be on target,” maybe you hit a nerve because you flat out LIED about a subject about which you know jack-shit ’cause you haven’t done any such research, but hey…..YOU’VE GOT A BOOK THAT YOU WANT TO SELL, SO MAYBE YOU’RE WILLING TO SELL OUT TO MAKE A BUCK, EVEN AT THE EXPENSE OF AN ENTIRE PROFESSION.
“Conflict of interest,” my ass. It’s YOUR conflict of interest that needs to be discussed. Moron.
Any time money changes hands, a conflict of interest is created. In my industry, financial planning, I have found the planners that beat the drum of “fiduciary duty” and “always putting the client first” are the ones most abusing the client.
One should never blindly trust anyone, irrespective of their profession.
Keep up your enlightening work, Dan. I continue to learn from you!
Dr. Ariely,
As a wet-fingered dentist, i regularly see no destruction of hard tissue on visual, tactile and radiographical examination on folks who keep up their six month check-ups. On the occasion I find a cavity, it’s usually small. People who aviod the dentist until something occurs is when it gets very expensive to treat.
On the delta dental front, and probably fits into your topic, is beginning in January 2011, delta will pay dentist monetary incentives in addition to its typical insurance payment. I’d be suspect of the data you obtained from delta.
everyone want to earn a living, you, me and delta. I’m just a dentist on a blog with no connections to the media, like you, nor a very large pile of money and a cast of attorneys like delta. So while I want to applaud your piece on dentistry, how about looking into how dental insurance truly works,or doesn’t. Patients usually recieve about a $1000/year. This amount hasn’t changed in 40 years. Imagine what a thousand bucks bought back then?
Most dentists are kind compassionate and look out for patients better overall health. I think your conversation with Robert Seigel could have much better with input from the dental profession. I kindly would like you to remove the quote above saying this is the typical response of the blog. My comment surly isn’t, but it makes you sound just like the remark you you poke fun at.
This is really difficult to read as the NPR story was difficult to listen to.
This is the same information problem that I run into when I have my oil changed. It seems that there are always services that my car needs on top of the oil change, yet when I choose not to do them, my car still seems to do O.K. Do I need these services? What will happen if I don’t do them? I don’t know much at all about how a car works. I also don’t have a real relationship with the oil change place. So I almost always feel burned when I choose the “needed” extras.
Are the oil change guys always upselling? I’m not sure. I always wonder if this is how they take care of their own car.
I understand that the car/oil change analogy isn’t a perfect one for dentistry. I never realized that patients felt this way about the dentist.
I make an effort to show my patients what I’m seeing and explain why I believe in a treatment. I try to give them options. I also realize that simply by saying this, I sound defensive.
I’m not sure there is a solution to this information problem. I would encourage those that feel like their dentist is trying to sell them things that they don’t need to have a conversation with their dentist. Explain how you feel at the oil change place and how the dentist’s office makes you feel the same way.
Also remember that your dentist put their pants on the same way as everyone else.
I often apply the saying “If all you have is a hammer, everything becomes a nail”.
Dentists drill, surgeons cut, internists prescribe, chiropractors ‘snap’….etc.
I believe many patients have benefited greatly from multi-disciplined practice groups (herbalists, massage, traditional medicine, chiropractic, etc)
If the medical establishment gets a bigger tool belt – patient treatment may be optimized.
The same can be said of education, financial planning, etc
I just experienced a pretty hard sell for some additional dental services from my dentist’s new hygienist. I dismissed the recommendations (and don’t even remember what they were now), but that would have been difficult had it been my actual dentist, with whom I have a more trusted relationship. The existence of the conflict acts on him in the same way, of course, but he’s been consistently less alarmist in the past.
Ad-hominem attacks…. Shoot the bearer of bad news…. Dan, you’ve arrived as a blogger!
Dan, you rock!
Get multiple opinions if you don’t trust what you are being told. If you are getting the hard sell at your dentist you might want to look for a dentist that gives you options without the sell.
If you are worried about getting different opinions from different dentists…realize you are not a machine, you are a human, and some dentists recognize that different humans are at risk for different things. I evaluate my patients for a variety of risk factors, and higher risk patients are given recommendations that fit their situation.
Sometimes I get a patient that feels like we are selling them something. My response is always, “I am mandated by the state I am licensed in to tell you what problems you have, and the options for treating those problems. You can do all, some or none of what I suggest, but the standard of care and conscience mandate at a minimum that I inform you. I will not prejudge how or what you will do with that information. I consider it a success if you understand your problem, even if you choose to do nothing about it.” The success is in the patients understanding. People I have this conversation with are those that I have not been able to build an adequate trusting relationship with, yet. Of course because I have dental experience and most patients do not, sometimes understanding is not enough, sometimes the patients wait until they have an “I told you so” moment. This is when I tell a patient they have a problem, I tell them it will eventually hurt and possibly become infected if they do nothing. They wait, it becomes a problem, they come in and tell me, “doc you told me 6 months ago that this would hurt, remind me again what we need to do” I compassionately handle the patient, and I NEVER say I told you so, but they always tell me Doc, you told me! Unfortunately for some, we must have the I told you so, and the pain before the trust. Tougher life for them, but that is what makes them comfortable.
A couple of comments for some of the previous posters:
Christian,
An acquaintance of mine bragged to me at a party that he has been dentist free for ten years, said things never felt better. He really kind of ruined the night, and I thought it was rude of him to make those comments. 2 months later he was in my chair with an emergency. 6 teeth were hopeless, and infected, one had to be removed to save him from a serious infection that was entering his neck, and he had put himself seriously at life threatening risk. 4 other teeth required extensive treatment, and he required gum surgery to keep the remaining teeth. His treatment topped 12 thousand dollars. He values what dentistry, especially preventative dentistry has to offer. If you value your oral health and your overall health being “away” for 20 years is not wise. Being away from the dentist for 20 years pays off in only the rarest of individuals. I hope for you Christian that you are one of those rare individuals.
Brenda,
Unlike most of the services you pointed out, dentistry is very preventative minded. We seek to get patients to buy into the prevention side of their health. Most choose not to. So to say that we have a hammer and that patient is a nail, is not very accurate. Again, if your dentist doesn’t give you options, including the option of taking ownership of your problem and doing nothing, maybe find another dentist.
Brad’s approach sounds ideal to me. I hope that most dentists are just like him; if so, then the problem Dan has identified must only be with a few of them.
Ok, well this is a long post and I contemplated not even posting it. My goal isn’t to fuel the fires here … even though some of my comments are quite spirited. But so many people are saying the dental profession is missing the point. I’ve listened; I’ve read; and I just don’t agree … I am objective in my profession, it’s what I was trained to be and I don’t think my disagreement means I’m blind or ignoring some problem. So here it goes:
Dear Dan,
I am a dentist and I don’t consider disagreeing with you a defensive position as some of the bloggers claim. I actually find your blog response “defensive and annoying.” You have provided no scientific study for your remarks on NPR. That’s why so many dentists are up in arms! Your “view” gives no insight to any research on the subject. What I don’t understand is why the reaction from the dental community is a shock to you? Come on! You even state in your blog: “I am easily influenced by data … so if you have such data, please send it my way.” WHAT?!? You’re begging for data now? How about doing your own research before you go inventing a problem and shooting your mouth off about something you know nothing about? I can admit when I’m wrong. Why can’t you? Maybe you can write your next book on the irrational response of the male ego when presented with the conundrum of being even the slightest bit incorrect, if not completely incorrect and uninformed in this case. Ok, that was a little harsh and I am sorry about that, but in all fairness you did compare my profession to “hazing,” which I find completely offensive considering I have spent the past eleven years devoted to the practice of dentistry and improving people’s oral health. How did it make you feel when Tom Cruise called psychology a pseudoscience? Well that pretty much sums it up for you and dentistry: An uninformed celebrity commenting as a scientific authority about a profession that he is not qualified nor well informed to comment about.
I will agree with part of your blog response: Yes, a “conflict of interest” can be observed in my profession. However, “observing” the obvious isn’t really some scientific breakthrough … its common sense. In fact, a conflict of interest not only exists in all medical professions (as you rightly stated in your blog), but in ANY profession where money is exchanged for goods or services. Furthermore this conflict has existed since the creation of these professions. Since you stated you are interested in improving the effect of this conflict of interest, I would also like to take the time to inform you of the ways many of my colleagues and myself are already doing so. We have made significant technological advances to better educate our patients and thus make them a more informed consumer. Just two of these technologies include digital x-rays and intra oral cameras. Both allow me to show you what I see in your mouth on a large TV screen. I propose treatment for any pathology I see (which the patient can also see) and I have a written consent form that reviews the risks, benefits and alternatives to any procedure before the procedure is done. This is called INFORMED CONSENT and it’s required. You act like American consumers are stupid and dentists can magically force patients into treatment. I can’t change what I see and if a patient doesn’t like what I have recommended, they are free to go get a second opinion or … wait for it … do no treatment at all! I often tell my patients doing nothing is always an option, it is just not necessarily a good option as all dental disease usually worsens if not treated. In regards to a second opinion: Just because two recommendations differ, doesn’t mean that one is right and one is wrong. It is usually means there are two different philosophies on treatment … and that’s ok! It is the patients’ responsibility to find a dentist whom they agree with in regards to health care philosophy.
The real question is: If you feel so strongly about this conflict of interest and your desire to improve it, then why didn’t you mention it on NPR? On your blog your words are quite dignified and you act like you provided some tactful and insightful constructive criticism on NPR … that’s not how it went down. This is why the dental community is annoyed at you. The words “conflict of interest” never came up, not once. There was no scientific or professional discussion. Instead, you made snide and ignorant comments, which did nothing to help anyone. Well, I suppose they did help you. You are, in fact, the one with something to gain: the promotion of your book. Talk about an obvious conflict of interest. Perhaps this is why you refuse to recognize the ignorance of your remarks: the pure infamy of it. Even negative publicity is good publicity, right? Good strategy.
Well Ryan, anyone who can’t counter with at least a semblance of decorum is either really young, very rude or simply immature.
To make your case by stating D. Ariely to be a’giant douche bag’ says you are all three and yet probably a dentist replying like that simply because you can do so anonymously.
So daneoo4 as you make this personal, even though this wasn’t about Dentists being evil, but rather about having a captive audience of reluctant patients for a specialized area of the body,
As ‘devoted to oral health’ and to making prevention so important that you are putting yourself ‘out of business’, you feel that you are always doing the right thing by patients. Very noble statement, but is it true?
BUT what Dr Oreilly is saying is that we are likely not the loving and devoted fans of your profession that you think we are. (or is that should be… as one dentist said above we no longer feel pain! *laughs*) We are not as devoted to a certain dentist because we like you, but we are likely to trust your judgment more then we should, simply because we feel we must to placate ourselves and keep returning.
if I had pulled the 4 teeth earlier that needed pulling done, then I wouldn’t have such horrible pockets on the next teeth, for example. I was told pulling teeth is NOT what the dental profession is for and I would have to leave if I made that decision… and yet 2 years later they were pulled, even though I care for my teeth 3 or more times daily as I have to pick, have 3 month visits and have a specialized cleaning for my gums.
I have one tooth that has had flap graft, then a bone graft implant (no not that new implant) which became infected and when I told him so, he left it for nearly 2 years… saying it was fine. Finally after my gums were one huge blister he stuck a cone in it and drained it and said it was fine. (periodontist and procedure were 60 to 100% paid by insurance) He and my dentist loved saying how I paid for their vacations and houses and for one, a renovation. (they are in same office)
When the pain came back, I visited a new dentist, who was of course horrified I was being treated like that, he would be better, got a root canal in same tooth BUT had to leave there because I asked the dentist to be kind to my 4 year old son as he didn’t like anyone doing things without saying what they were doing. After being assured, the hygienist shoved her hands into his mouth to start cleaning without warning him (I was right there watching)and was upset when he cried…. I complained and asked for a gentler person next time, and I was told to leave (by the dentist there)if I didn’t like it. Of course I did…
On to the next dentist and specialists where my same flapped tooth was considered a failure and she could do it better. So of course her flap failed too, but was I reimbursed? no It got infected again, and this time the hygenist agreed that it needed to be looked at, but guess what …all is fine.
Then the dentist said it needed capping and although the gums were so sore, I felt he must know what to do as this is an incisor and I need it. He was right in there and yet I had the infection and gum swelling yet he continued with the procedure.
Return to the periodontist (they are in same office) said it was fine, until it was so infected the gums blistered again. I saw a new dentist because after 10 years there they thought I had never been there before. First visit , gave prescription, second visit, did MRI and 5 of the Doctors looked at it 9including my own) while I was trying to tell them I think I have a systemic infection as I felt better then I had in years… after taking the antibiotics. hello hello, nope they were all too fascinated with the MRI to hear me.
What was wrong with the tooth now? I don’t know . they told me to come back for the consultation for the next procedure and not even with my own dentist! I was being sloughed off to another one… and although I asked to see my own dentist, desk said oh yes fine we will call you and never did. maybe she lost my chart again!
Yes I am beeching as this just happened. What the dental profession seems to be preventing me from is having much money left in my pockets even though they are aware insurance covers only half the cleaning now and little else…
We aren’t stupid, we just trust you all too damn much to actually do the right thing… even though we ‘sense’ that isn’t always the case and are aware that we are being irrational. And I will have to trust another new person to discover what is now wrong with my $9.000 tooth!
PS: I grew up going to dentists that drilled through my gums, broke teeth (neither even told me… I found it out later) and later when I had 100% coverage at my job decided nearly every tooth needed capping. I have had 2 offices lose my files 4 (oops 5 now) times, lose my sleep guard which cost a fortune and there is much more but … this was supposed to be about irrational behaviour of patients and I have made this all about dentists… so sorry! I contemplated not posting mine as well Dane…*sends*
My heart goes out to you hsv kitty for your bad experiences with dentists. Might I suggest that you try a dental school near your area? It might take slower than an outside dentist but at least you will know every aspect of your health will be analyzed and addressed.
Come on Doctor Ariely, please, this is not funny. Both NPR and Delta Dental distanced themselves from you this afternoon. Delta flat-out denied that they supplied you with any data. You seem to be completely unable to believe that a human can be ethical when money is involved, Makes me wonder about your upbringing. Two Points as stated by many on the NPR site: 1. Even if you are a person that thinks every thing is about money (how sad), you cannot deny the facts. Doing procedures is not profitable. Diangostic and Prevention are profitable. The last thing most dentists in a modern practice want is to find mmore work. Procedures take up too much time and take away from the less stressful, more enjoyable, and yes, more profitable aspects of the practice. 2. There is so much dental disease out there, we don’t have to “make up cavities”. This is the biggest inside joke in dentistry, that dentists “make up work” so they can get the money for the procedures that follow. It just doesn’t happen that much. Come down to Batesville, MS and I will let you stand next to me in the O.R. as I treat, under general anesthesia, 4-year-old after 4-year-old with at least 12 cavities each. I’m not kidding, doctor, you can stand 18 inches away and I will show you the cavities.And then we can go out and see their 17 year old mothers and examine them and we will find that each has at least 15 cavities, and periodontal problems, impacted teeth, etc. Doctor, you are wrong as wrong is wrong. Just admit it. You owe it to your sizable following to correct your errors. But I guess its not as much fun to say that most dentists do the right thing most of the time without some sort of mysterious subconsious conflict of interest. Also, please doctor, would you post the entire letter from Dr. Tankersly, not just the smallest, least critical part of it that you could find. What are you trying to hide. Admit you are wrong, there’s nothing wrong with it, and your fans will respect you more.
Bill Neely
Dept. of Dental Surgery
Tri-lakes Medical Center
Batesville, Ms
ive enjoyed reading this blog, the readers may use enjoy my blog http://www.entertainingeconomics.com please comment and let me know what you think
Hey- tangential thought. Look at _how many_ dentists are listening to NPR!!! New market niche…eh public radio???
Just when I thought all professionals were conservative.
Dan,
Could you comment on this? http://n.pr/b8y5YS
“Finally, we heard from the dental insurance company Delta Dental, which Dan Ariely cited in his interview. Company spokesman Chris Pyle writes: We’re normally fans of Dr. Ariely’s work, but he should not have made reference to Delta Dental when stating that 50 percent of the time dentists will interpret X-rays differently.
Delta Dental has no data that could lead to any such conclusion. Delta Dental processes 84 million claims a year for 54 million customers, so obviously we’re interested in making sure those claims are accurate.
That’s why we employ dentists throughout the country to review claims for accuracy. Still, he writes, we understand that conclusions made in the medical arts, like other arts, are prone to some degree of subjectivity and interpretation.”
Dan,
I agree with the numerous comments which have called your data into question. Its not that I doubt the existence of your data, or even its accuracy. Its simply that you never gave us the opportunity to be “easily persuaded” by data. Instead you invited us to be persuaded by your rhetoric about the importance of data. You even went to the humorous, ironic and possibly hypocritical extent of inviting (ostensibly) Mr. Tankersly to share his data. Does this smack of “I’ll show you mine if you show me yours first”?Not a very high academic standard.
I have read your books with enjoyment, amusement and stimulation. But not entirely with absolute acceptance. And neither your original interview, nor your blog addendum have influenced my position.
Separately, you made a point in your interview that I’d like clarification on:
“And it turns out that the more time people have seen the same dentist, the more likely the decision is going to go in favor of the dentist. People are going to go for the treatment that is more expensive but has the same outcome. More out of pocket for them, more money for the doctor. So in this case, loyalty actually creates more benefit for the dentists.”
Is it at all possible that this is true because trust is built over time? I, personally, am likely to be more skeptical of my new dentist than the dentist with which I have had a relationship for ten years. That skepticism will manifest itself in my hesitation when the new guy recommends significant (in terms of cost, pain or outcome risk) services. The trust built over time with my old dentist will manifest (conversely) in a higher acceptance rate of his recommendations.
Isn’t this rational?
If the ADA were really interested in making sure that the patients got the best service at the best possible price, then it would support the elimination of medical licensing.
Contrary to so-called conventional wisdom, medical licensing exists to enhance the pay and job security of licensed individuals, NOT to protect patients. It was the AMA that vigorously promoted licensing laws, not the unwashed masses who were afraid of getting taken advantage of by “quacks”. Consumers like to have choices about what type of professional they patronize and there are private methods for certifying the qualifications of would-be providers; there is no need to rely upon the notoriously poor oversight of government panels.
Medical licensing has a great deal to do with the outrageous expense of our current system. It also has the unfortunate effect of hampering innovation, as innovative dentists need to be worried about losing their licenses for actions that threaten the status quo, not the patient.
Free up the profession and it will find ways to provide better services at lower prices.
Absent the ADA’s monopoly on dental practice, dentists undoubtedly would have eliminated mercury from their fillings long ago and stopped doing so many root canals, after Weston Price’s research came out.
Not that I am holding my breath that Ronald Tankersley would support such a real measure to improve the quality of dental practice.
Dan, thanks for the correspondence. Good journalism examines both sides. Is there a conflict? Sure. Is there a conflict in almost every profession, including yours, but we’re not discussing your conflicts here…..that could take years. As a somewhat biased practioner, it is my opinion that most dentists do what is good for their patients. Some don’t, but we spend much more money on auto mechanics and I don’t see a move to clean up their ethics. So, why pick on dentists? Ethically, you should do an article on how well dentists are doing, despite this ethical dilemma. Now wouldn’t that be the ethical journalist’s thing to do?
Still looking for rationality…….
Obviously, you hit a nerve. Sorry. Me thinks they doth protest (way) to much.
Our view is that the status quo is effectively impossible to change and our minds and institutions will fight change to the death.
We did read that any kind of change is coded by our brains as taking food out of our mouths. That makes sense. Or did.
Dan, this is a comment on the current survey. (I couldn’t find an e-mail address for you.)
In answering the “all about Music” questions, I’ve excluded all instances of perfectly legal transfers, e.g., my friend giving me a recording of his most recent composition, as played by himself, or me sending a copy of my own music to my family. I also excluded works involving public domain materials. I don’t know if that’s what you wanted me to do, though. The second set of music questions might benefit from more clarity about whether you’re interested solely in music that is copyrighted by a third party.
Dan I’m surprised you got a denial from Delta Dental so fast, usually takes us dentists 4-8 weeks to get a response from them.
I will be blunt. Put up or Shut up. Provide the references to your allegations that there is a 50% accuracy between operators in diagnosis of xrays. As a PHD and a journalist you must have cross-checked your data. I doubt you can produce a double blind peer reviewed published study that backs up your assertions. Prove me wrong.
Modern dentistry has all but eliminated pain? ha ha ha. Even if there is no pain, holding your mouth open for 45 minutes with a stranger 3 inches from your face isn’t exactly a positive experience.
A letter to NPR’s Robert Siegel and CC to Mr. Ariely:
October 13, 2010
Mr. Robert Siegel, Host
All Things Considered
National Public Radio
635 Massachusetts Avenue
Washington, D.C. 20001
Re: Half-truth and misleading opinion on dentists by Professor Dan Ariely
Dear Mr. Siegel:
Professor Dan Ariely got statistics from Delta Dental Insurance showing that only 50% of accuracy rate in predicting dental caries (cavities) using X-ray images only. He then quickly concluded that dentists are money-driven and eager to perform drilling and billing regardless of the caries existence. He further characterized patients who are loyal to their dentists, as having behaviors of “Stockholm syndrome”. There is no proven link between the two dots, simply based on a piece of statistics.
In dental practice, X-ray is only one of many tools to aid diagnosing tooth caries due to its limitations in oral anatomy. For example, the healthy side of a permanent molar may block a carious other side on an X-ray film. So, dentists routinely use a metal explorer or probe to survey tooth surfaces in an oral examination. This physical examination is more important to detect caries on the occlusal (bidding) surfaces, which cannot be detected by X-ray films, particularly when caries is in its early stage.
Therefore, the low rate of caries shown on X-ray films reflects a problem of false negatives, and less of false positives. We routinely rely more on physical examinations and take limited X-ray films for each patient, and even start treating caries based on convincing physical findings before X-ray film developed! In support of this practice, a group of dentists used probes and mirrors, but not X-ray, to study tooth caries in a group of 569 school children aged 4-14 years old1. They have found no (0%) false positive and 2.75% false negative rates. This suggests that physical examination reduced chances of false negative and false positive if X-ray were used alone.
Nevertheless, X-ray still plays an important role in detecting certain caries that beyond reach of a probe, e.g., contact surfaces between two teeth and under the surface. X-ray is also critical in evaluating gum infections derived from deep caries, and loss of bones surrounding teeth due to periodontal diseases.
The high false negative rate of caries prediction from X-ray films is not unique in dentistry. Similar situation is seen in X-ray-based mammography in detecting breast cancer, with a 29-38% false positive, and a 10% false negative rate2. There are some voices concerning about both unnecessary and invasive surgeries or missed deadly breast cancers. However, no one questions physicians who perform mammography on women, out of doctor’s greediness or conflicts of interest.
A bigger issue that has been missed by Mr. Ariely: dentists were often denied payments from insurance companies, especially government programs such as Delta Dental-managed Denti-Cal in California, simply because of a “lack” of X-ray evidence. Small private offices like us, cannot afford the new electronic submission of X-ray images, and have to spend time and money in duplicating them. Submitted films were often “unclear”, “not received”, or “lost”, leading to treated caries unpaid.
Should greediness is a driving force for dentists as Mr. Ariely alleged, and then filling tooth caries is not the most profitable practice. Dentists should have instead waited and left those caries un-treated and later performed more expensive root canal treatment followed by a crown.
Mr. Ariely profits from selling his books on irrational thinking, and may have used NPR platform to promote his popularity, with groundless speculations and allegations on dentistry. Unsuspected NPR listeners may perceive his biased opinions as “facts”, as Mr. Ariely is also a psychiatry professor at renowned Emery University. He might have also used it as an unusual way of attracting the attention of dental society to help him getting funded for actual studies.
Whatever reasons there were, Mr. Ariely’s irresponsible allegations seriously damaged the good reputations the dental professionals established over the years. It is also harmful to people who are financially disadvantaged and especially those who are odontophobias (fear of dental care). The dental professionals try hard to educate the general public to routinely seek dental maintenance care (examinations and cleaning), as a way of preventing deleterious, painful, and costly consequences of untreated caries and periodontal diseases.
On the other hand, some of his suspicions may exist at a very small scale and need to be investigated as unethical acts by respective professional board and associations. Criminal charges should be filed against those who intentionally perform unnecessary procedures and profit from such unlawful acts, if proven.
In his personal blog3, Mr. Ariely responded to criticisms of his NRP talk, and attracted some feedbacks. A dentist named Richard Furze, searched Pubmed under Dan Airely and found 22 references. None of which, however, seemed related to the “data” claimed in his talk. We expect to see his rationally designed scientific study, preferably in a peer-reviewed scientific publication.
As an unbiased and educational radio station, NPR should follow up this issue, on All Things Considered, in its future broadcasting, after reviewing responses from all sides, to minimize the damage.
Thank you very much for your attention.
Sincerely yours,
Ke Hu, DDS Ke-Wei Zhao, PhD
Member Acting Manager
American Dental Association
Cc: Ronald L. Tankersley, DDS, President, American Dental Association; Mr. Dan Ariely
References cited:
1Abdul Haleem, Ayyaz Ali Khan, Muhammad Irfanullah Siddiqui. A simplified dental examination for detection of cavitated carious lesions in school setting. Community Dentistry and Oral Epidemiology 37 (3): 276-283, 2009
2Ivo A. Olivotto, Lisa Kan, Andrew J. Coldman. False positive rate of screening mammography. New England Journal of Medicine 339:560-564, 1998
3Dan Ariely’s personal blog. http://danariely.com/2010/10/11/annoying-dentist%e2%80%a6/#comments
Docsoc put up or shut up… And to all of you dentists, know that some really can be evil masochists who don’t have a clue what they are doing and still charge a fortune when they break a tooth or leave you suffering with infections for years… TWICE!!!!
I may very well have a systemic infection that was caused by 2 dentists not doing their job and misdiagnosing me as needing bone grafts and root canals which only exacerbated it. I used to say to my ex that I felt as though my mouth was rotting. Now I see that it is. I trusted Docs and paid a lot of money for care.
I am saying all that… Dan Ariely isn’t saying anything nasty@ You are all so huffy you won’t even try to understand what he is saying. He never called you evil. He said dentists should understand more about behavioral science and that sometime the patient feels trapped and obliged to take the recommendations and makes bad choices because of it.
His own experience with pain left him wondering why a patient cannot make recommendations and be heard and why the professionals will sometimes dismiss a patient because ‘Doc/dentist/nurse’ knows best.
And so we cave to your professionalism and skills. Why else would I listen to dentists and have 2 failed flaps, bone graft, root canal… and now a crown in the same tooth, when both he and I know the gums were badly inflamed and I was crying in pain. When he showed the crown deep into the gums he said the inflamed tissue would grow over my tooth. Well it did, with the infection inside. I have since had severely infected gums and paid almost a thousand dollars for that privilege.
Dan Ariely isn’t demeaning your profession, you dentists are by coming here to whine and blame when you should be asking if you are really there to help us when there is much money to be made. The number of dentists who wrote in was alarming. You all made yourself sound like elitists whiners…
Also none of the 5 dentists who looked at my MRI has called me back with a follow-up. I am still woozy, having trouble sleeping and difficulty speaking and with comprehension. I am reluctant to go see my Physician because I usually get sick if I take antibiotics too close together.
I made an appointment with a dentists for weeks from now. Lovely that I have to start all over again. I wonder how much bone is deteriorated from all this mess? And I truly wonder who the hell care but me. I wonder what he will recommend… take off the new crown, I am sure and probably another root canal.
BUt you go and complain at convention… pat yourselves on the back that no one ever feels pain and that we are all happy to have you in our mouthes because you are not there to make money but for prevention.
I am pretty verbose at the best of times , but very bitchy right now as you can see and head achy and sick! So I am sucking it up…YOU all suck it up and perhaps look the the other research Dan Ariely has done so you can better understand your patients and both your and our irrational behavior.
hsvkitty,
You DO realize that one of the problems is that they’d be more than happy to look at the data if Ariely could provide it, right? So far, there doesn’t seem to be a source for the survey that he cited in the discussion, and at least some of the dentists here cannot find it. Additionally, another post has clearly pointed out that X-rays are not, in fact, the primary way of finding cavities anyway, and I do quite remember all of my dentists spending more time probing my mouth than staring at X-rays. So there may be mitigating factors, even if that survey existed. And the insurance company denies having such data, which is the purported source of it.
All of this even ignores the underlying issue with Ariely’s hypothesis that dentists may recommend more expensive treatments as that benefits them which is that there may be other, counter-balancing biases. For example, I can’t imagine that doing a root canal or a crown are fun, and they do seem to be labour intensive. How many dentists don’t recommend them even when they would be of use simply because they think “Ah, man, but then I’d have to do one … let’s see if it can recover without it”? We don’t know, and we’d need more studies to find out.
As for your personal case, it’s unfortunate, but no one said that dentists never make mistakes and that bad dentists don’t exist. Ariely seems to be hinting at a systemic problem, and that’s what at least some of the comments are acting against.
Ultimately, speaking as someone who is not a dentist and has no particular loyalty to any dentist — my current dentist is the one closest to my work — it’s clear that Ariely really needs to show his work, If it is somewhere and I missed it, then someone please point me to it. But right now this claim looks like dataless speculation, and no one really need take that sort of speculation any more seriously than my speculation above.
firstly i would like to say that always it depends on your own personal satisfaction. how you feel as a result of going to your dentist. having lived in many locations over my 58 years i have been to many. my current dentist and all of the staff make me feel good when i walk into the office and i feel good when i walk out.
secondly: i can only think of financial advisors, financial planners when i read this blog and all of the comments. regardless of the institution they represent, they are motivated firstly by thier profit and (hopefully)secondly by your satisfaction.
Lynn, those things are not, in fact, mutually exclusive. Ultimately, at the end of the day, their at least mid to long-term profit depends entirely on your satisfaction. If they mess up and tick you off enough, you will leave and you will have other choices, so at least making it look like it was in your best interests is in their best interest.
We still have no data or retraction of dan’s statements.
As for the problems with fee for service models, this is nothing new. We have other payment models but they have just as many flaws. HMO’s or capitation models pay based on a head count. The critics say they tend to do the least amount of work needed to fulfill the contract. If you have thousands of dollars of needed work do you think the Dr is going to do it all or rapidly when he is paid only $25/month? HMO’s are the way insurance companies pass all the risk to the dentist. We are not insurance companies. We do not analyze risk but we are expected to pay for it. Some Dr’s have been able to make this model work and good for them. In the end, all business models can have criticisms brought against them. You just have to trust who you see or move on to someone else.
Several comments; Now Dr. Ariely..you got Delta Dental, a dental insurance company (of which I am a provider) to be objective about dentists’ accuracy. Tell me now..you wouldn’t suppose that there might be any possibility that it is in their best financial interest to question the validity and therefore the cost to them for any dental treatment? Most of us try to catch small problems before they get bigger. An example is grafting an extraction site to avoid more expensive grafting later for dental implants.
Now I will poke the soft underbelly of your own profession. Are there psychologists who keep seeing (and keep billing) clients long after they could release the client from counselling. It IS a business and you do bill clients for each session that they see you for, correct? Do psychologists also make clinical diagnosis mistakes that other psychologists would have diagnosed differently? Maybe we should have a study done on a “fake” client and have them go from psychologist to psychologist and see what diagnosis is made with the same script from the client? Now that would be some real food for thought.
Scott Noren DDS
Honest to goodness real Oral Surgeon who tries to do the right thing by patients and isn’t just out to “make a buck” on them
Unbelievable! The dentists who responded in an defensive way are unbelievable.
What Mr. Ariely says is true, two dentists looking at the same xray will often treat the lesion differently. Because xrays are only one way to determine the need for treatment, surgical treatment. You don’t need a study to tell you that and you know it. Where are your studies to prove differently? I didn’t see anyone post anything to counter his argument. And his argument is that there’s a conflict of interest, and if it’s not you, doctor, than it’s your neighbor. Ask a hygienist who works for two or more dentists, she’ll confirm this problem.
There is a conflict of interest. Dentists get paid for surgical procedures, period. The third party payment arrangement doesn’t pay for preventive services. Not many dentists include their hygienist in the treatment of early enamel lesions, most dentists don’t know anything more about prevention or non-invasive enamel restoration that this whole thing thread is laughable.
The term ‘restoration’ in the hands of a dentist is a misnomer from the beginning. They approximate the dimensions of the tooth with a prosthesis, pure and simple.
The restoration is in the hands of a dental hygienist, who is overseen by a dentist in most states. Now there’s the biggest conflict of interest!
Shirley, What irritates me is that he said two dentists have a 50% agreement on “diagnosis” and a study to prove it. Please go back and listen to what he said. While I agree that two dentists could “treat” multiple ways, diagnosis is different. I would like him to back up his claims or retract that part of the statement. Is it so much to ask for truth in reporting? The second part of your post pertains to your own personal agenda which it seems is independant hygiene practice and/or expanded function dental hygiene. I understand that you are passionate about it, but it is veering off topic.
Here is a radical idea – how about throwing some science into your “behavioral science” and back your claims with some empirical data rather than making broad generalizations as a form of mental masturbation in support your hunches. I thought people in academia knew better than to assume. Sad for the students that are paying for a semester full of this tripe.
Why dont dental radiologists who do not have an immediate financial incentive to see “cavities” read dental x.rays, just as medical radiologists and pathologists read all diagnostic data related to medical procedures. It seems this is a clear solution that would mitigate the concerns regarding conflict of interest. Why are dentists not held to the same standard as physicians??
Anna,
The reason that the dental radiology analogy doesn’t work is because radiographs are only a part (and frankly a small part) of dental diagnosis. Medical radiology is often the linchpin of a medical diagnosis because you are viewing a radiograph of a part of the body that cannot be viewed or palpated directly. Dental radiographs are hardly ever the definitive diagnosis because dentists can actually see and touch the teeth and gums directly.
Dan Ariely’s position on radiographs is so oversimplified that it is laughable. Except that 1) no one knows where his data came from and 2) there was not anyone trained in dental diagnosis consulted for the story. Can you imagine a similar story about cancer diagnosis not asking an oncologist for an opinion?
The more I think about this the less regard I have for NPR and Dan Ariely.
Dera Alan and other whiny dentists above,
The more we read your vitriol the less people will think of you.
Any people reading can feel my pain if they have had any procedures and been poorly cared for. They are more likely to identify with me rather then yourselves (especially those calling Dr. Ariley a douchbag, moron and idiot…) even though you have convinced yourselves procedures are pain free and your demeanor and actions exemplary.
May I ask how many of you told a patient that you were wrong when you were? How many of you have made decisions that were plain wrong, and the results proved it, and refunded the money and made attempts to correct the wrong? (Shall I guess none because they signed a waiver and not under any duress or nudging or subconscious/conscious manipulation from the dentists ever, right?)
How many of you have followed procedures that were hyped at a convention, even though you didn’t see great results in your own patients?
How many of you did follow up care after surgery and made sure the patient wasn’t just cowering at home wondering if they should even call or go back to you because they were in such dire pain or mental confusion because you said this was the right path to take?
How many patients have disappeared from your practice that you never followed up on and who voted with their feet to never return? Do you in fact care or even know? If you don’t know why some are leaving, what makes you think you know why they are staying?
Dentist’s comments that they are right, Dan is totally wrong, the patient has no pain, that they are in preventative medicine not there to make a buck only proves what Dan Ariely was saying and none of you even get it, because you are caught up on the xrays … search for my MRI results and followup and how it turned out to see what I mean… Hello? hello? Is anyone home? Do you actually care about the patient and outcome as much as you THINK you do?)
Patients are your captive audience and although you are working hard to regain confidence that dentists always do what is right and what is good for the patient, that is your own hype. Having convinced yourselves first and having been manipulated by the Dental Industry yourselves first and foremost you lead the patient subconsciously or consciously to make decisions.
Right now, the televisions at the dentist, in the reception and rooms all show ‘dental TV’ with constant repeated messages of the newer and much hyped procedure of using dental implant/screws.
I was told that was my next step, but of course I need bone grafts to fix the deteriorated bone so the implants can be secured and last (but no guarantee it will be successful or last even though those words were used) so another 4000 I do not have.
However I prefer to clean up the mess made previously, so perhaps root canal and bridge instead. No one offered that as a choice, so I am going to another Dentist to see what options they give me. Thanks Dan Ariely for I should not ever sit idly and just take the word of one dentist when there is money to made from the major decisions.
And to any dentists replying, each time an insult to Dr. Ariely is added, I feel a need to add more lovely anecdotes for the readers to balance the ‘discussion’. Thus far I have only concentrated on the $6,000 (and counting) tooth… next I will discuss how my treatment (of me and my tooth) changed when I no longer had 100% insurance…
I think I also had repressed memories going on, to placate myself. My memory is returning, and I owe it all to the Dentists here who came to berate, rather then learn and discuss!
“Man will become better when you show him what he is like.” Anton Chekhov
Dan, thank you for showing us what we are like. Naturally, some of us will not be able to accept the way we are.
hsvkitty,
Please note that I have not called anyone names. I disagree with name calling and mindless defensiveness. Dan’s point about the dental industry could have been better made with transparent and accurate data. Dentistry is far from perfect, but I believe we try to improve. Dan is allowed to have an opinion and a point of view, but he isn’t allowed his own facts. Delta Dental flat out said that the data that Dan referred to in this radio story doesn’t exist and Dan did not clarify his position on this data. That doesn’t make me whiny, that only means I want the facts straight.
I did an in-chair whitening procedure on a patient yesterday and neither of us were as happy with the outcome as I had hoped. It happens. I didn’t charge her. Is that “admitting I was wrong?” I’m not sure, but I communicate with my patients and treat them like I would want to be treated. I think that should be the goal.
Yes Alan, i was rather hard on you. I understand that you aren’t happy with Dan, but I am not presently happy with dentists, so my behaviour is irrational. I am always thrilled when Dan explains my irrationality, but in this case I know from whence it comes.
Rather then take for face value that Dan had his hands on some data (which perhaps he feels in hindsight he shouldn’t have used; perhaps it was given by a friend who now might be in trouble who knows) you are going to pursue it doggedly.
I am willing to be as kind in turn, simply because I am still feeling the pinch in my pocket book for unwarranted procedures and lack of proper care. BTW I was sent a bill in the mail yesterday, even though I stopped in 2 weeks ago to ensure I was paid up to date. I had also of course paid immediately after my last cleaning, but they still managed to find something I owed!
Guess what… it was sent from a collection agency! How about them apples! No written notice from the office, plus I was at the desk twice since the cleaning! Gotta love the money grubbing aspect of your profession!
The fact I am complaining here makes me a whiny person…I admit it. You didn’t get what Dr. Ariely was saying because you are so danged focused on the xrays.
Do YOU think not charging your patient was admitting you were wrong? Hardly. It was an admission that the procedure didn’t work as well as it should have. Does that make you a better dentist? You would have to ask the patient.
Treating patients the way you would like to be treated is certainly a start. Being you would be upset to be charged for useless procedures and whitening that didn’t work, perhaps make an appointment with a dentist who doesn’t know you for your next procedure and a different perspective.
Superb write-up, I’ve saved this blog so ideally I will discover much more on this subject in the future!
Nice work you have done and good going….Hats of to your work…
A smile says a lot about a persons personality. Its the first thing people notice about others. White, even teeth are indicators of your overall health. Many people with stained, discolored or crooked teeth are self-conscious and avoid smiling and socializing.
I heard your interview on NPR; and I really liked it. It seems obvious to me now, but I had never thought about the possibility that a dentist might be biased. I was so interested in the information that dentists don’t find cavities in the same teeth more than half the time that I immediately grabbed a copy of, “The Upside of Irrationality”. I loved the book and now all of my co-workers are reading it!
Danielle, you have come into this post rather late and must have missed a very important point. What interested you, the dentists not finding the same cavities, is not supported data. Dan has not produced any studies, reports, or names of the researchers responsible for that statement. Dan has not bothered to retract the statement even though Delta Dental has said they have no data to support the claims Dan made. I hope you reread Dan’s book with that in mind.
Dentistry is a very nice profession,It’s not about gaining money but it’s all about helping people having dental problems.
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