Yeah, I said it. I wrote that title. I stand by it, because it’s true. The corporate interests in Dentistry are a scourge to quality, patient-centered care. When non-dentists are running the show and dictating treatment plans, it’s not a good thing for patients. And, that IS what is happening.
Along came Bobby (not his real name)…
This week, a new patient came to my office. He had a terrible toothache. His partner told me he was up all night curled up in a fetal position. The patient has early-onset dementia, and his partner is his advocate and caretaker. The patient was quite lucid in our conversations, though he’d repeat himself a bit. So, here’s the story…
The patient presented with a number of obvious dental issues. But, he was in severe pain. He had a missing bridge (left it at home), leaving his upper anterior teeth as exposed crown preps. He pointed to the upper right premolars (his most posterior teeth on that side) as the source of pain. I tapped on his teeth, and he winced in pain with all of them in the upper right quadrant all the way to the central incisor (#’s 4 – 8). He explained he was certain that it was #5 by pointing to it. I palpated along the vestibule and the area of the apex of #7 elicited a response. The x-ray confirmed there was a large diffuse lesion over the apex of #7.
This is how the patient presented. The missing bridge was left at home. He reported it had come out a long time ago, and he would stick it in with denture adhesive.
While the other teeth MAY be causing problems (see #6, for example), I diagnosed an apical abscess #7 as the culprit for his current pain. After discussing the pros / cons and risks / benefits, the patient agreed to root canal therapy for #7.
I opened the tooth and pus came pouring out steadily. Sorry, I didn’t get a photo of that. I know some of us LOVE seeing that! I admit I do, because I KNOW the patient is going to feel much better. The pus continued to drain for quite a while. I instrumented with hand and rotary files under a rubber dam. I decided to leave it open for 24 hours. We made an appointment for the patient to return the next day to place a temporary restoration in the access. I didn’t want to leave it open over the weekend. The appointment went very well.
I prescribed PenVK 500-mg qid with a 2-gram loading dose, for 10 days.
I went back out to tell his partner how things had gone. I asked about his health history indicating his current meds included Amoxicillin. And, that’s when he told me…
He went to McDentist.
It turns out the day before, the patient had been to a local corporate chain dental office. They had prescribed three days worth of Amoxicillin. Mind you, I understand I’m getting the patient’s side of the story, via his partner. As to protect their identity as much as I can, I won’t say what the partner’s occupation is. But, I will say that he is a credible and qualified witness.
For simplicity and anonymity, I’ll refer to the corporate office as, “McDentist.” At the McDentist office, the patient was told he needed two root canals. The also handed him a treatment plan for additional treatment for $9,000. Presumably, the $9,000 treatment plan was for restorative-prosthetic services. They asked for $1500 right away, and they would refer him to their endodontist…. at another office in a town 31-miles away. The patient’s partner felt uncomfortable with the experience, so they left with only the prescription for 3 days of amoxicillin. He also told me that the root canal part of the treatment plan did not include #7. Again… due to his occupation, his story is credible.
They went home, and his partner went online to search for a dentist. He found my office in a Google search and looked at my reviews and my website. He then made an appointment online for the next day.
Day 2.
I texted the patient that night, and he was doing great. Feeling much better.
He returned the next day, my last day of the week. I irrigated the canal, dried with paper points, and sealed it with a dry cotton pellet and some cavit. He brought his bridge this time to see if I could put it back in.
This was once a single splinted piece. The connector between 9 and 10 fractured. #’s 12 and 13 are cantilevered pontics. Yeah…. that’s not going to work.
I couldn’t recement the bridge. But, it occurred to me that I could “tack” it in with some TempBond and take an impression for a provisional to be made later. I can at least give him some teeth to smile with.
The bridge “tacked in” for an impression for later use in making a provisional.
The patient will be returning next week to complete the RCT #7 and a comprehensive exam. Then, as I explained to the patient and his partner… I would not have a treatment plan at the time of the exam. I would have to “sit down and review my findings, the x-rays, and photos.” Then I would formulate some treatment options. Perhaps “Plan A” and “Plan B,” and even “Plan C.” Then we would meet and discuss those options. Then we can decide the best course of action for the patient.
They told me on Day 2 that McDentist had called asking if they were coming back for treatment. Ummmm… no.
What’s bothering Dr. MacGyver?
What I find bothersome is that McDentist presented him with a big restorative / pros treatment plan at the emergency visit. It’s not that it was an additional $9,000. The fee isn’t the issue. I expect mine will be higher. I doubt VERY much that they did a comprehensive examination. And, even if they DID (they didn’t), it had to be a harried effort to put it together, considering the extent of the dental issues present. Furthermore, pressuring a patient, who is under duress (PAIN), to accept a large treatment plan at the first emergency visit is ethically dubious at best.
I’ve been told by dentists who have worked at corporate practices, that some of them have big screen monitors in the back that list the dentists and hygienists along with their production for the day. A “scoreboard,” if you will. I’ve also heard from these dentists that the office manager either pressures them with “suggested” treatment plans, or that the manager actually creates the treatment plans.
This patient’s story would reflect those claims. He was in excruciating pain (from ONE tooth) and he was pressured to accept a $9,000 (presumably large restorative) plan. I would loved to have seen the actual treatment plan, but they threw it away.
Hold the pickles, hold the lettuce. Special orders don’t upset us. Have it your way…
No doubt, McDentist is a growing trend. My plan is not to compete with them. I won’t compete with them on their terms, which are: (deceptively) low fees and being on all the “insurance plans.” Rather, I will market myself as the OPPOSITE of McDentist. In my practice, they’ll see the same dentist every time. I will be the only dentist that sees them, and they will be the only patient I’m seeing during their appointment. I don’t chair-hop. Personalized private care. While a lot of people see dentistry as a commodity and seek the lowest cost option… I believe some people still see the value in personalized private care. I hope I’m right!
PS… I get emails from Indeed (jobs website) listing the local dental jobs. Month after month after month, year after year… it’s the SAME corporate clinics perpetually hiring associates. They’re always hiring. Which can only mean dentists are leaving. Patients have told me that they’ve never seen the same dentist twice at these places.
Stay tuned! I’ll update this article as the case progresses! Feel free to add your comments below!
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I couldn’t agree more Mike. That’s why the following, of all my google reviews, is my favorite: “The office is a perfect example of why I prefer individually owned dental offices vs large corporate owned ones…”
Though I preach your message all the time, I didn’t coax this particular patient at all. She just got it!!!
I’ve recently been approached by several large corporate groups to buy my practice, but the only people I’ll sell to are my associates.
Excellent Mike! Having worked, and even “owned,” a number of corporate practices (and determining that I wasn’t ever going to bend to their way of doing, “business,”) I’m thankfully in private practice exclusively now.
With student loans out of control, for many young dentists, corporate practice is their only option. So they become indentured servants to these assholes with AA degrees that think they know dentistry better than doctors. It’s criminal…and many of those docs have the social skills of a yam, so they’ll cow to the corpos, and do their bidding for money. It’s bullshit.
I wish that there was more guys like us, who’ve seen the, “Dark Side,” of the Evil Empire, to keep providers away from corporate practices. However, the ones in my area do a pretty good job of pushing patients to me, and as you did in this case; it isn’t hard to see why they suck so badly.
We just had a big, national chain office close here, about 8 miles from my office. Fuck them! One down, 4 more to go. They’re crooks, all of them.
You’re my personal hero. I could have said it better myself.
Hi Mike. You, me,Dr. Stivers, and many others will agree all day long on this topic. I’m afraid we are preaching to the choir. The root cause of the problem is bigger than all of us. And it begins at the student level. I’ll visit student blogs to get a feel for what’s happening today at that level and it looks quite bleak. It really is disheartening to hear from many, at the student or recent grad level, that are already soured and discouraged with the profession. Not all of these individuals are just malcontents.
Corporatization would not exist if there wasn’t a need – just like the sex industry, illegal drugs, or any of a multitude of “services” that flourish today. We may not like it, but it fills a need. All of us are culpable, directly or indirectly, whether we like it or not. Idealistic students rack up massive debt to become doctors, only to be thrown out into a system that is not really working well in the private sector. Dentists in our age bracket are working longer into our careers and many are not hiring associates. What are these poor grads supposed to do? There’s your “need”. Dental schools let representatives from corporate come in and court impending grads.
They are organized, and have a crap ton of money behind them to sustain this effort. What are we doing? Nothing. Just bitching on a blog. Our profession is so disorganized and fractured, that we are too busy fighting with each other to give a damn about recent grads. Organized dentistry is impotent politically, never strapping on some balls because some attorney shouts “anti-trust”.
The end result? A flood of new grads, year after year, mired in debt, with scarce private sector job opportunities. Enter corporate, which produces your hi-lighted patient with a fucked up treatment plan. We’ve all seen it way too many times and it’s sickening. But if we can’t collectively figure out a way to organize and inject a healthy dose of ethics back into our once noble profession, then dental professionals and patients will continue to suffer the consequences.
I completely agree with Brian when he says that, “All of us are culpable…” Most of us who are old were so poorly treated in dental school that we vowed never to put a foot in the door of the school once we graduated and we can all understand our vow. Unfortunately, that gave schools permission to mistreat following generations of students and none of us stood up…Sad. What that also did was to permit the schools to teach the same information to students for the last 45 years; teaching the Krebs Cycle was useless 45 years ago and it is STILL useless. More importantly, the schools have failed to adequately teach diagnosis, treatment planning, occlusion, function, esthetics and implant restoration all which would be more important than the Krebs Cycle. When I went into practice 40+ years ago insurance paid up to 92% of my fee; today it pays 20 % and that is why I have been insurance independent for 25 years. Why is this important? Because the parents of kids who want to go to dental school remember when older dentists did extremely well financially and they are willing to pay any price for tuition so that their children will be successful which is why dental schools are able to charge so much. Something has to change but it will not change unless successful older dentists are willing to step up to make it change. The leadership of the ADA has traditionally been between 60-70 yrs old while todays average dentist is ~42 years old. This too must change. We need professional leadership and the ADA is not it. These are just some thoughts for discussion; there is no right or wrong.
Bullshit. I reject the notion of collective guilt or “it takes a village” crap. That you believe stepping foot back through the doors of the dental schools would change them is naive. It’s the same canard about “getting involved” in the dental association to change it. Been there. Done that. Got the plaque with the little gavel on it. It doesn’t work! I got involved, and it changed NOTHING, despite my efforts. The traditions and polices of such institutions (dental associations and dental schools, alike) are FAR too entrenched to be changed by simply “getting involved.” The BEST way to change them is to REJECT them. To NOT get involved and LEAVE those organizations to languish by diminishing membership and MONEY.
Joining them is tacit approval of what they have been doing and continue to do. One person…. two people… twenty people joining with the intent of changing them will do nothing. The poor treatment is the VERY BASIS of their existence. We aren’t going to change it by joining them. They will either change or DIE when we REFUSE to join them.
The ONLY thing dental schools want from alumni is their MONEY… not their opinions.
Your suggestions are pollyannish at best, or naive (which I don’t think you are). But, given your experience I would have expected you’d have figured it out. I did.
No. The BEST thing I can do is post articles like this one: Dental School Still Sucks 25 Years Later. It’s my third most popular article, with over 44,000 views, and the bane of dental schools. I’ve been told the article has been printed and circulated at dental schools to the chagrin of the faculty.
I did something similar many years ago, before I had a blog. I wrote a letter to the editor of the ADA News. It was in response to a report about the lack of faculty and former students not coming back to the schools. The report concluded that it was because the schools didn’t pay as much as private practice. My letter argued that it was the way we were treated in school. I was very specific and even called out my school by name. It got published in its entirety. And, it caused a firestorm! 🙂
The best thing I can do is use my platform to EXPOSE them for what they are. Fuck them! Really. I mean it. It is NOT us. It is the sick traditions of the schools. My military experience was better than dental school, and I was in a war zone. I’ve had many bad dreams about dental school. Never about my time in the Navy. Why would I EVER go back to the school. I’d sooner rejoin the military, and I’m not kidding.
Reject the system if you prefer, but don’t forget that without dental school (as flawed as it was) you would not be where you are today: practicing dentistry.
Ummm…. the point being (about dental school)???
I disagree that it is “the system.” Corporate dentistry is A “system,” but it’s not THE “system. It doesn’t affect me one way or the other, except for some benefit by driving some high-value patients to my practice. 😀
My missive was observational. The free market (as long as it remains free) will determine the long-term outcome.
Yes. My comment was referring to your sentiments in regard to dental school. Sorry I conflated the two topics.
In regard to corporate dentistry, I agree it is not ideal and yes, the free market and other larger influences will determine the outcome. Honestly, I don’t think the ADA nor the people working in the profession have as much control over the direction of the profession as we would hope to think, especially as mentioned, it’s fractured nature.
As pointed out, the free market presented an opportunity (a need) for corporate dentistry. Increasing tuition, increasing overhead costs, fewer associate opportunities has made it increasingly difficult for new graduates to obtain viable positions withini PP. The economic recession of 2008 affected retirement investments as well as care acceptance placing economic pressures on long time dentists to continue working past intended retirement.
If these guys and gals can hang on long enough and not sell out to corporations, maybe there will some hope for turnover into PP for the younger generation.
The problem with this scenario (as it pertains to PP versus corporate) jimho is that the consumer often can’t good dentistry versus poor dentistry unless it is very, very obvious.
Of course the free market in this case involves many consumers (not just the end user, I.e the patient).
I disagree.
Young docs work in corporate because no one in private practice will hire them. It’s not glamorous. It’s not like they want to do it.
Patients choose corporate because private practices don’t take their insurance. Everyone knows it’s not the best dentists in town. It is a symbiotic relationship.
The quality of work is pretty bad. This is more likely the result of lack of experience. Everyone sucks right out of school.
I’ve worked for corporate and private. I was pressured more at the private practice. Either way, how many dentists do you know are going to roll-over and misdiagnose because they are told to? Would you?
And yes, dentists leave corporate after a year or two. This is before the fees are low and patients are mostly lower class and a pain in the ass.
It’s a stepping stone.
If you don’t like the system, you either need to hire new associates yourself, or take HMOs.
Would you rather have the government step in with socialized dentistry or should we force private practice owners to hire new associates? What’s your solution?
I’m not suggesting a “solution” be enforced by anyone, and certainly not the government. I say let the EDUCATED FREE MARKET take care of it. My suggestion, if any, is that we all (private care dentists) win the battle, one patient at a time. Eventually, the public will figure it out. In the mean time, I’ll also use my writing skills to spread the truth.
Your condescending suggestion of taking HMOs or hiring an unneeded associate is both vacuous and specious. Why would I do either of those, both being detrimental to my practice?? To make a point? To “solve” a societal problem? Yeah… no. I’m not going to sacrifice myself on that altar.
But, to answer your question about dentists who would “roll over”…. Ummm, yeah. PLENTY. I’ve seen it. Would I? No. Did I (when I worked in a chain)? No. But, I also lasted only 10 months.
After nearly 7 years in the military as a dentist I worked in a corporate chain briefly, and it was not a good experience. There was so much that was below the standard of care that I was amazed the clinic was still open. Bringing up shortcomings in materials, staff, and organization were not welcomed. Patients openly complained about not seeing the same doctors and even front desk personnel. I wouldn’t work in a corporate chain again nor would I advise anyone else to do so either without realizing first you won’t be able to practice at your best in my humble opinion.
“Squiddoc” = Navy? Me, too. When and where were you stationed? I also went straight from the Navy to a corporate clinic. HUGE “culture shock” in terms of “standard of care.”
Thanks for your comment!
I have a hard time finding a good dentist for me because I do not react to the numbing medicine like most patients. It often takes much more and I metabolize it rapidly. I have only been to two dentists in my area, Albuquerque nm, that have been able to work with me. With both it was a training experience for the dentist as it does not seem to be a common issue, unfortunately for me the dentist who was covered under my insurance no longer practices, and the dentist who took over the practice was extremely aggressive about treatments that she would not offer alternate options or identify risks for the treatment or non treatment. So again I find myself without a dentist and unwilling to find another due to the difficulty of finding one who will listen and work with me on numbing before working on my teeth.
I have been to several dentists who give up numbing me and just start working on my teeth and those are experiences I do not wish to re-live.
When you find a good dentist keep them and I will not go to places where there is multiple dentists seeing any individual patient.
Hi Roger,
Sorry to hear about your challenges finding the right dentist. Don’t give up! There are lots of great dentists out there. Though, if you are limiting your choices to those on a restrictive dental plan, it’s going to be very hard. Consider finding a private care dentist who will treat you rather than your plan. Yes, you’ll have to pay out of pocket. When you find one willing to listen to you about your difficulty getting numb, you might refer him or her to my article: https://thedentalwarrior.com/2014/05/21/slam-dunk-anesthesia-for-lower-molars/
Good luck and best wishes!
Hello Dr. Mike!
Loved reading this article and I would love to hear more about how you set up your practice. I am a new owner after finishing 4 years in the Army and currently bought a practice that participates with all PPOs and want to move away from it. Would love to hear about your experience with it and see if possible to try when a practice is still not busy with schedule (in fact, still filling schedule day by day)
I started off from Day-1 with no plans. So, I don’t have any experience dropping out of them. But, from what I hear, you don’t want to do it willy-nilly.
While open spots in the schedule scare most dentists, I see them as opportunities to fill with “good” patients. They don’t always fill, of course. But, being booked out for months with no open spots can lead to MISSED opportunities.
We have a lot of “big box” dental practices in our area–both corporate and private offices styled after the corporate models. The dental insurance companies are complicit in this too. When Dr. Bramson left the ADA, as executive director and went to insurance, I noticed that the insurance company went downhill and fast. I said he went to the dark side, much like Darth Vader, hence my new nickname for him, Darth Vader. Since he left, it has improved a little bit. I dropped out of that plan, but I had some serious ethical issues with them and I could not ethically work with them any more. I have seen a lot of corporate dentistry and it sucks. Young dentists right out of school being force fed to do high level procedures, that should be referred out to specialists, create lots of failed treatment. They want to keep as much treatment in house as possible, to increase profits and I guess, to keep other dentists from seeing their below the standard of care treatment. That’s my soapbox for today!
Thanks for you comments, Lou!
Seems there’s quite a bit of “inbreeding” between the ADA and inscos. You might enjoy another article I wrote: Why Can’t the ADA More Like the NRA? 🙂
I agree with your comment.