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Professional News Articles : : ON PRACTICE MANAGEMENT by Janyce Hamilton : How it pays to lose: Being ethical in your practice

How it pays to lose: Being ethical in your practice

April 02, 2007

“I have found no greater satisfaction than achieving success through honest dealing and strict adherence to the view that, for you to gain, those you deal with should gain as well.”   

—Alan Greenspan, Chairman, U.S. Federal Reserve, 1987-2006

Human nature, when it comes to work, is to make and hold onto as much money as you can. If you are a doctor or other esteemed professional, you went to school for a long time and it was a huge monetary investment, so you aren't going to let the profits you reap seep through the cracks.

And, the more you earn, the more “they” take: federal government income tax, utilities, local property tax, rent, salaries, insurance, you name it.

When it comes to charity solicitations and fund-raisers (some tax-deductible but who has got it to donate in the first place?) you feel a little guilt but long ago got used to saying no.

Then when the extended family is in a pinch with a big car repair, you come through with free dentistry for the whole family to help out. Trouble is, they expect it free next time, too.

As if you weren't already having a bad day, so-and-so asks for a raise because she's completed on-the-job training for three months as of today, and her friend from school is making $6 more per hour than she does!

Who does the dentist get to ask for a raise? When do dentists get to declare themselves a “charity case” from the outrageously high, never-ending student loan debt and interest payments? What free equipment repair/replacement will the dentist get this month because money is tight from a car repair?

Nobody, never and none, respectively.

So, if dentists want to learn about being ethical in the management of their dental practices, is it a waste of time or worse, a stupid (and harmful) idea? Truly, it is counterintuitive to resist trading total honesty in case presentation to patients in exchange for profits, but hear me out.

Integrity is good for business.

Read on to take an ethics test, see how you score, and get ideas for coming across as a dentist any patient would want.

Five examples of arguments against self-evaluating your own business ethics

1. “I notice inventory mysteriously missing all the time, which means my staff isn't putting me first, so I'd be a fool to put them first. That's too trusting.”
   Agree or Disagree?
   
2. “Why should I be telling patients to wait on their treatments when they are going to need them eventually?”
   Agree or Disagree?
   
3. “If I tell or allow my hygienist to say to patients in the chair ‘Your teeth look great,” the patients don't believe me when I tell them they have some problem areas needing repair now or soon. So, I tell my staff they are not allowed to compliment the patients about their dental health.”
   Agree or Disagree?
   
4. “We used to have a policy manual when I started out years ago. It had a statement about our supposedly high clinical values and the patients' well-being as our #1 priority. I was young and idealistic. These days, I don't even know where that old policy manual is.”
   Agree or Disagree?
   
5. “My duty is to provide good dentistry. A few dollars here and there, some paid out by an insurance company, or a few treatments before they are truly needed, doesn't make me bad. I'm probably ‘middle of the road' compared with my peers.”
   Agree or Disagree?

Score

Count the number of times you felt you could agree with or relate to the above statements more so than disagreed to see how you did.

• 4 or 5 “agree”—You are tired and feel let down. Being in a defensive mood day in, day out, is draining and leaves you short on patience with those in and out of your chair, even if you keep quiet about it. You could benefit from an ethics tune-up. While difficult at first, things may run smoother afterward around the practice. With a small dose of self-reflection, and attempting a few small changes, you will feel better in no time.
• 2 or 3 “agree” — You consider yourself a decent person who tries to be honest. The temptation to regularly exaggerate isn't strong, but it does seem pragmatic financially or due to time constraints with all the paperwork. Staff gets you in a bad mood almost daily, unfortunately. Reading an ethics article or discussing the topic with your study group or in a dental meeting, even once a year as a reminder, will give you an integrity pick-me-up.
• 1 or 0 “agree” — You are generally practicing dentistry and conducting yourself around staff according to the Golden Rule, “do unto others. . . ”  As a co-worker or boss, you are fairly easy to get along with, and feel the profession is a good one. Don't change a thing!

Attitude makeover

People attend self-help groups all the time, such as Weight Watchers or Al-Anon, with no apparent change of behavior or resultant outcome occurring. Yet, somehow, making the effort to listen and learn can sink in. When you are ready to make a change - even years from now - or handle a situation differently, the groundwork you laid may be (at least partially) intact. Taking inventory of your style, thought processes and actions as a dentist toward the patients and toward your coworkers/staff may not produce a profound transformation in the quality of your life on the job overnight. But, something will be set in motion. It all registers somewhere. If nothing else, thinking about it for 15 minutes just now may give you pause next week when there's a borderline case in your chair—a case that could be $300 or $1,200—depending on your truthfulness.

Okay, so let us re-consider the ethical forks in the road in the “Five Examples of Arguments Against Self-Evaluating Business Ethics” presented earlier.

If you feel you cannot trust your staff to trot off with tubes of toothpaste, toothbrushes, bleaching kits and gold, you need to get new staff or work through your distrust issues. Sitting next to someone who you think is a common thief means you are looking, speaking and acting toward that person with contempt and disrespect, no matter how sugar-coated you try to talk or act. All this is observed by the patient,  who is smarter than you think about nonverbal cues and registers (perhaps subconsciously) the bad vibes in the office between the staff members and dentist.

If you feel like you should strongly encourage patients to get treatments when they won't likely need them for another few years, you don't feel like a crook, but you don't feel exactly right. Sure, they could leave the practice and give the business to another dentist, so why not take it while it's in your chair. . . but the person isn't an “it.” Patients feel you are protecting them and trusting their loyalty by saying, “This could wait until next year, so you should know that it is a treatment that's down the road for you, especially if you need to plan for it.” The patient then may think, “Wow, that's cool. My dentist knows I need a head's up because it's going to be a few hundred and I don't have insurance. I like that he prepares me so I can think about whether I'm going to make payments, put it on the credit card or save up. He trusts that I'll do it when I can afford to, and doesn't make me feel like I'm some broke poverty case or like I don't trust his advice. It's a relief that he's letting me wait a bit.”

Recently, a dental hygienist told me I have white teeth and that my dental health is great. More than that she added, “You will never lose your teeth and need dentures as long as you live if you keep doing exactly what you have been doing.” (I wanted to kiss her! Never before has a hygienist said such flattering, reassuring, celebrated words to me. Always it's been me self-depreciating my flossing habits or the coffee stains. In response, hygienists always say “I've seen worse” or “It's not so bad.” At best, it's been “Actually, your tooth color is pretty good.”)

Sure, my dentist came in afterward and told me, “You need two fillings on your biting surfaces replaced sometime; probably within a year would be a good idea.” But, I did trust him because it has been 15 years since they were placed. That's pretty good for a composite resin. I scheduled the restorations for six months from today. Certainly, I'll be financially and mentally prepared a half a year from now.  But here's the thing: I went home ready to whoop it up—I learned my mouth is healthy and my teeth are white.

A round of drinks on me!

When it comes to policy manuals, they are pointless if no one reads them. But, shouldn't all new hires get a copy and know the rules and code of conduct expected of them? This isn't just as a well-behaved underling, either. This means they know how to behave. For example, maybe it's a written rule to treat patients, the dentist and coworkers as they would want to be treated? Whatever it is, your policy manual doesn't have to be long or formal. A two-page document is better than none when it comes to guiding your employees in the ways that won't disappoint.

If you think you are duping people or insurance companies out of their money by just a little so what's the harm, it may not be worth the hassle in covering it up or justifying it to yourself. Think long and hard when it comes to something illegal, even if it's “only” an extra $25 in your pocket.

Speak out loud about treatment options and time frames, clearly expressing that the patient is in charge of the decision and cost. Encourage questions, and take the time to answer them thoughtfully. Not pushing or frightening the patient communicates you as a dentist who is calm and gentle, with patience and confidence. Resist giving false impressions or introducing doubts about dental health status to encourage prompt treatment. It seems ethical to approach your findings by weighing out with the patient their choices. This sends a message: I am trustworthy.

Every time a patient permits, allows and grants a dentist the privilege to restore her or his tooth or gingiva, dentists should feel as if that patient is saying, “Congratulations, doctor! I trusted you with this nonemergency. As long as you keep communicating with compassion and don't hurt me, you can treat my next dental need that arises.” The dentist needs to verbally and nonverbally communicate that, in return for this trust, he or she vows to take care of them and their wants.

Give them preventive anesthesia, keep them out of discomfort during treatment, and jump through hoops to keep them pain-free in the coming postsurgical days—as long as it is not suspect care by licensing and regulatory agencies, of course. Dental phobics or obsessive-compulsive patients can be taken advantage of, and this could be more tempting if they drive a luxury auto or live in a certain upper class neighborhood and express irrational worry over needing a full-mouth rehab or full veneers. Resist and they will entrust you their care over the years and send you all their neighbors and friends.

If you treat patients like royalty, they will continue treating you like royalty by letting you at their teeth—seemingly as instinctively guarded as any zone of the human body! When people have dental fear, it's not logical, it's a primal reaction that cannot and should not be judged by dentists. Don't try to talk the patient out of their fear, just treat them accordingly without criticism or commentary. After all, your degree is as a doctor of dentistry not psychology.

Resist stretching things or miscoding on insurance forms because alert employees will catch on even if the insurer doesn't and will lose respect for you. Then, they might think: “Why am I working here?” and morale dips.

Of course, be careful in accepting large gifts such as trips, season tickets and so forth from companies in exchange for promises to increase volume sales of their product or service, since this could affect your clinical care of patients.

It goes without saying that dating the new dental assistant—a newly graduated college student—won't go over well with staff, even if you aren't married. If you get married to him or her, the assistant may have an easier time working away from the practice so that there are fewer inequality misperceptions and rivalries.

Breaking the rules in the dental practice's mission or values statement, or a policy in the handbook, or telling others “It's okay” if they do so, is condoning unethical actions you established in writing.

Summary

Every business owner, partner, contractor or employee of the dental practice makes decisions daily that earn or cost money. These decisions on wording, how we look at one another, and act for each other's welfare (or not) may be made silently. However, they convey unspoken messages to all of those around you.

Some money is made and kept in the short-term: via treatment rendered and paid for today; saying no to a raise or to paying for a class or to a charity cause today; or by doing some creative billing paperwork today.

Some money is made and kept in the long-run: through returning loyal patients; in the ripple-effect referrals; or the modest rate of speed of completed treatment plans (sometimes over 18 months to three years) but always a prophylaxis every six months; and staff who notice they aren't getting big raises or an order for a dozen of their child's Girl Scout cookies but instead small or moderate occasional pay raises over time and an order for one box of Samoas and one box of Do-Si-Dos.

Conclusion

How it pays and how you win by losing money isn't accurate phraseology to describe ethics in the practice of dentistry. Better wording might be how being ethical and sharing a bit of your net income - even delaying reward  - can snowball and bring steady growth and profits to the dental practice over the years.

What does all of this mean on a personal level? It could mean liking your work a little more. You could just overhear a staff member defending you to another staff member. “But Dr. P. is such a nice person, so giving to everyone. So you don't make as much as Megan across town? No one complains about working here one bit, while Megan hates going to work for her boss every day!”

Janyce Hamilton is a Chicagoland freelance dental writer and editor. Send suggestions for topics to be covered, or any comments on this column, to review@cds.org.

Copyright 2007, Chicago Dental Society