Overtreatment is clearly an ethical issue in dentistry; we need leadership within the profession that is not afraid to confront the challenges which face both practitioners and the public.
In the early years of my career, before I came to Australia, I had a challenging experience working within a dental practice as a self-employed dentist in the UK. The culture of the practice was all wrong; firmly focused upon financial targets rather than good quality patient care, providing patients with care they didn’t need in order to drive the profit of the business. I didn’t stay for long, leaving after only two weeks, but the experience was formative, leading me towards many of the decisions I have made subsequently in my career.
Shortly after leaving that practice, I published an article discussing the ethics of targets in dental care, and have held an interest in the relationship between the commercial nature of dental practice and its impacts upon professional behaviour ever since, finding that there was a general dearth of prior exploration in this area.
Quantifying the issue of overtreatment is hard to do; dentistry exists within a fragmented organisational structure, where each service and provider and the data that they keep are isolated from other service providers. Third parties, such as health funds and insurers who collect data about service activity only have a record of what care has been provided, with no detail about why a certain treatment was given to a patient. It is subsequently hard to examine the issue of overtreatment in a way that helps us to understand how often it might occur in dentistry.
Despite a paucity in data, we certainly know that overtreatment does occur. The profession is haunted by cases such as that of Andrew Istephan, who admitted in front of the NSW Civil and Administrative Tribunal that his actions in providing extensive and complex dental treatment to incapacitated patients in aged care facilities was motivated by greed. Any aspiring lawyer in Australia will quickly be introduced to the case of Dean v Phung, a case which involved the unnecessary provision of root canal treatments and crowns to a patient who had suffered only minor trauma to their front two teeth. While these are extreme cases, there is a lack of discussion within the dental profession about the issue of overtreatment.
Our research looking at overtreatment as an ethical dilemma, published in the journal, Community Dentistry and Oral Epidemiology, examined the nature of overtreatment in dentistry through qualitative interviews with dentists working in Australian private dental practice. Participants shared their experiences in practice detailing how they managed the incentive to engage in overtreatment and how they had encountered other practitioners engaging in overservicing. In our work, we defined overtreatment in dentistry as: “instances where dental treatments are provided in a manner that exceeds its clinical justification, or where there is no justification for that care being provided at all.”
While the majority of the participants of the research did detail that they had encountered overtreatment in practice, one of the heartening elements of our findings was the evidence of a great amount of reflection that participants had engaged in through their practice in how to manage this phenomenon in their practise:
“Look I’d always put my professionalism first. There’s been a couple of times when I’ve recommended a crown and I sort of thought okay am I doing this because the crown is a high-end item or because I really believe it’s the best thing for the patient and I always go with what I believe is the best thing for the patient.”
Participants were critical of colleagues who ‘look’ for treatment to provide:
“I’ve always thought when people have said, ‘Oh, you need to find work when your patients come in’. You don’t need to find anything. You examine them and the work is there. It’s either there or it’s not.”
One participant spoke about how vulnerable the consumers of dental care are to being overserviced in dentistry, being mindful of the doctrine of caveat emptor (‘let the buyer beware’) being applied in dentistry:
“Well, I think the buyer beware is a very dangerous one to use in healthcare, particularly in dentistry because unfortunately the buyer doesn’t know much about what is happening in that small dark red hole, and so when the dentist says you need six fillings, they don’t have a reference point unless I go to another dentist to give an opinion on whether that’s valid or not. So I think with our professional hat on and moral and ethical hat on, we’ve got to take an approach that we can’t stop at buyer beware because the buyer can’t be aware…I think it’s an obligation on us, on our professionalism, not to take that buyer beware approach.”
In another article, born out of the same data collected during this research, we explored this idea of dentistry becoming commercialised and how this has the potential for oral healthcare to become comparable to any other non-health business enterprise, where the doctor-patient relationship becomes predominantly transactional and absent of altruistic obligation.
Again, to see our participants recall instances where they resisted commercial behaviours and pressures in practice that place the interests of the business before those of patients demonstrates the importance and prevalence of professional values in the dental profession:
“I quit my first job because they were overly commercial and I figured that out about two weeks in because there it was very much a matter of, ‘how many crowns are you doing per week? We expect our clinicians to be doing at least a crown a day’ and there was no real care factor towards, what does the patient actually need? It was very much a matter of, ‘Okay, you’re seeing a new patient, see if you can get this much revenue out of that one’.”
When we embarked on this project examining how dentists managed the nexus of dentistry as both a healing profession and a business, we did not think that overtreatment would feature so prominently in the participants’ narratives. That it did demonstrates how deeply this phenomenon may impact the practicing lives of dentists and how important it is for dental practitioners to be trained to manage instances where overtreatment is encountered in both their own practice and the practice of colleagues.
One of the elements that we have identified that contributes to overtreatment is the activity-based payment system that dentistry exists within; most dentists working in private practice get paid based on their levels of activity; the more treatment that is carried out, the more money is earned. Grytten made the observation that this way of paying people works well in the context of an orchard owner paying apple pickers but is less applicable in paying professionals such as dentists. Other payment schemes exist but are less common in dentistry. For example, a capitation model of paying dentists would pay practitioners a monthly amount based on patients being members of the practice, paying for care in isolation to receiving clinical services. Recent research from the UK demonstrated the impact of different payment schemes on how much treatment dentists provide, with the introduction of a capitation payment scheme lowering the amount of treatment provided, without diminishing the experience of patients accessing care.
When we published our research examining overtreatment, the interest and engagement from the public in this topic was clear; I was invited to write an article for The Conversation, as well as being invited to several radio interviews (one example being ABC Nightlife available here: part one and part two). The reception from the dental profession was also largely positive, with colleagues agreeing it was time for us as a collective to have a broader, more meaningful dialogue around the issues raised by the research.
However, the Federal Body of the Australian Dental Association has been less receptive to this work. I was challenged by several members of the executive committee of the Board as to why I had engaged with the media; highlighting research which they felt was unflattering to the profession. At the time this work was originally published, I held a position as a Federal Councillor and member of the Board of Directors of the Federal Association, elected by the membership of NSW. Following publication, I found the association’s leadership had, through contacting colleagues at the University of Sydney, attempted to remove me from another, unrelated research activity, suggesting a conflict of interest in a way that did not follow the association’s own by-laws. While I received an apology for the impact of this conduct, conflict of interest was raised against me again by members of the executive committee of the board, it even being suggested to me that by researching the issue of overtreatment, I had acted against the objects of the association. This allegation was made despite there being specific mention of the association’s role in promoting ethics within dentistry within the association’s constitution. Following the initial reaction to my research from the organisation, I resigned my directorship of the Federal branch of the Australian Dental Association. I should have perhaps seen the writing on the wall; for some time members of the Federal association’s board have been unimpressed with my written work, some of which has been published in Pearls and Irritations, exploring issues of a universal dental scheme, investment in oral health, the role of private health insurance in oral health and the behaviour of professional associations. One of the arguments against my work that has been put to me has been that as directors of the Federal Australian Dental Association, the board must share a common voice. I remain a director within the NSW Branch of the Australian Dental Association, with my colleagues in the leadership of that organisation being supportive of my work writing about ethics and professionalism issues in dentistry.
Overtreatment is clearly an ethical issue in dentistry; we need leadership within the profession that is not afraid to confront the challenges which face both practitioners and the public. It is my firm belief that most dentists are sincere in seeking to provide appropriate clinical care but find themselves operating within systems which drive activity and which do not value the outcomes that their treatments are supposed to provide. The issue of overtreatment is not solely attributable to dentists; it is a product of systems and the commercial framework of oral health care. The solution therefore needs to bring together key stakeholders from the profession, public and wider health system to identify opportunities to address this phenomenon. Overtreatment in dentistry might not be an easy issue to address, but it is certainly one that we owe to society to critically examine and include within discussions which lead to the development of oral health policy in Australia and beyond.
Dr Alexander C L Holden is a senior lecturer and dentally qualified ethicist at the University of Sydney School of Dentistry. He has just completed specialist training in public health dentistry.
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