Case: Grind It Out

CASE: Turn and Burn!

Jack Williamson, a fourth-year dental student, has just returned from an interview with a prospective employer, Dr. Edward Prentice. Dr. Prentice runs three dental offices and plans to open a fourth office in the summer. He has been interviewing a large number of senior students from dental schools in the state in order to hire a group of young dentists to staff his new office.

Like many dental students today, Jack Williamson will graduate with large debts, so the chances that a bank will give him an additional loan to start up his own practice are slim even if the urban market were not already flooded with dentists. But Jack's wife's job and their desire to remain near his ailing parents make a move away from the city unacceptable at present. So Jack has been looking for a job in the area. He has just returned from visiting Dr. Prentice's main office to take a look at the practice and to be interviewed.

As soon as Jack walked into the students' common room, everyone knew he had been out on an interview. "Very nice suit, Jack! Are you trying to upgrade the clinic? Too much boring white?" The speaker was Len Billings, another fourth-year student. "How did it go?" he asked.

"It was a little weird. You know where I was? Prentice's Smile Centers."

"I've seen the ads. What was it like?" .

"Very cushy. The new place is going to look like the Taj Mahal. All the latest equipment is going in there, too. That part was pretty interesting."

"What wasn't so interesting?" asked Becky Lissen, another of Jack's classmates.

"The part about taking care of patients," said Jack. "I spent about an hour and a half at the place on Oakville Boulevard. That was Prentice's second office, and it's where he has his own executive office. There were a huge number of patients being taken care of and waiting for treatment-a huge number-and it looked to me like 'Grind it out' was the motto."

"What do you mean?" said Robert Teng, another fourth-year student.

"The dentists-four men and two women, pretty much like us, all just out of school were working as fast as they could. They had the latest technology and lots of assistants, but all in the interest of speed and volume. They might as well have had 'Grind it out' tattooed on their foreheads."

"You mean Prentice pushes them hard?" asked Len. "What do you expect? If we can't afford our own practices, then we have to take what we can get. But you could handle that, Jack. Any of us in our group could. We all know how to work hard, and we're pretty fast, too .... I mean, unless Prentice is some sort of jerk. That would be a problem."

"He doesn't strike me as a jerk, Len, and hard work doesn't bother me either," said Jack. "I've worked for plenty of bosses who pushed you on the job, not to mention the pressure on students in this place. No, it's the quotas that got me, Len. They have target numbers, a certain amount of billable work per patient, per hour, per day, and so on, that they are judged by. Prentice is apparently very clear about it-that is simply what is expected. One time, while Prentice was on the phone, I saw that one of the guys wasbetween patients, so I went into his operatory and asked him if there was a lot of pressureto get patients in and out, or to pressure them to buy a lot of care. He looked firstto see who could hear him and then said, 'Grind it out or get your butt out of herethat'sthe story.'"

"So I said to him, 'Prentice doesn't seem like a bad guy,' and the guy said, 'He's notnasty about it. He's a very friendly sort of guy, in fact, but that doesn't change the expectations.He doesn't have to be nasty; he's in charge. He hires and he fires. If someonedoesn't perform, they get the boot.'''

"Does he force them to do unnecessary care?" asked Becky. "Are his dentists supposedto trick patients into thinking they need something when they don't? They can'tdo treatments without getting the patients' consent, can they?"

"I asked Prentice about it later," Jack answered, "about whether the high volume oftreatment that I observed involved pressuring the patients or putting extra pressure onthe dentists."

"What did he say?"

"'First of all,' he said, 'clear expectations make for good relationships with youremployees. Suppose you came to work for me,' he said, 'and you wanted to know whereyou stood. You could figure it out yourself just by comparing your work to the targetnumbers. That makes things very clear between us. As for the patients, Jack, of coursethey have to give consent before they are treated. That's the law, and I certainly don'twant my employees violating the law. I tell them that very clearly.'''

"What about pressuring the patients?" asked Becky.

"He said, 'Patients know very little about dentistry. They depend on the dentist totell them what they need, and that's how we create our volume of work. A dentistshouldn't tell patients they need things that would harm healthy teeth-that's a given.But that still leaves us a lot of leeway. If an amalgam is showing signs of wear, we recommendthat it be replaced. We don't recommend restoring a tooth with a second orthird amalgam, or even a large first amalgam, when a crown will certainly last longer,and so on. Discoloration, other aesthetic things, many things can be proposed as needingwork without lying to a patient, much less violating their right to accept or rejectour recommendations.'''

"What about patient education?" asked Robert. "If they were really educating thepatients, the patients would be told that some of these things are not serious reasons fortreatment, at least for most people, and there are often less expensive options than acrown, too."

"I asked if patient education was a priority," said Jack. "What Prentice said was,'Patient education is important. But it takes a lot of time, and most patients won't sitstill for it when they know the meter is running. They come here to get their teethfixed, and we fix them; that is what they are interested in and that is what we are interestedin. One of the reasons they like us so much is thatthey can come in, get the workdone, and get out. Like our ad says, "Quick appointments when you need care; shortwaits when you get there.'''''

"Then these patients don't really know what they are consenting to," said Becky.

"What Prentice said," said Jack, "was that if a patient asks for education, his dentistsgladly provide it, but with the meter running. 'We have to be realistic here, Jack,''' saidJack, imitating Prentice's slightly pompous manner. '''The rule of the marketplace iscaveat emptor: Let the buyer beware. We never lie to patients; we only make recommendations.But if the recommendations are well made, carefully made, they can work veryeffectively to sell treatments that will keep our numbers high. That's what we expect ofeveryone in my offices, myself included. If we all follow through on that, we all make agood living out of it. Anyone who isn't interested should work someplace else.'''

"I couldn't work in a place like that," said Becky.

"It bothers me, too," said Jack. "But a dentist has to make a living, like anybody else."

"Lots of dentists make a good living without doing it that way," said Robert. "Didanyone there even mention doing what is best for the patient? That's what we've beentaught, that the patient comes first. But it doesn't sound like the patients come firstthere; it's their wallets that come first."

"Did you ask Prentice about that?" asked Becky, "I mean that it seems unethical topractice that way?"

"Not exactly, but he could tell I was having a problem. Before I left he said, 'It looksto me like you've still got that idealism about dentistry that so many students havebeforethey have to practice in the real world. I understand it; I was idealistic, too, whenI was in school. But remember, when the patients in your school's clinic don't pay, itdoesn't come out of your pocket. When it's your pocket that's involved, you find outthat things don't look the way they did in school. No one is out there saying, 'Dentistsaregood people and do a lot of good, so let's make sure they get their fair share and earna good living.' Instead, you find out very quickly that you have to make your own way.Weall do. I've found a way to do that and to practice technically good dentistry at thesame time. I don't hire bad dentists; I don't even interview bad dentists, Jack, only dentistsin the top half of their class, because bad dentistry is bad business. But if you don'tsee that dentistry is a business, if you keep that idealism, Jack, then you're going to beliving in a dream world. You're welcome to try it if you want, but I think you'll find outvery quickly that it won't hold up.'''

"That's sure a long way from what I've been taught," said Becky, "and from the dentistsI've really admired. I think it's unethical to practice like that."

"Maybe it isn't ideal," said Len, "but maybe it's realistic. It's a different world outthere from what it was fifteen or twenty years ago, when the dentists that we admired askids were starting up. They could graduate without huge debts, get a loan from a bank,and set up a lucrative practice. But that's not true any more, not for most of us anyway.They could afford to be idealistic and still make it. And maybe some of us will be luckyenough to end up in practices that are still like that. But you sure can't count on it."

"I'm not competing with Jack for a job," Len continued. ''I'm going back to Minnesota.So I can hope Jack gets lots of offers so he can stay here in town. But suppose that Prenticelikes Jack and makes him an offer, and suppose Jack doesn't get any other offers tochoose from. He's a good dentist and a good guy and all that; he just doesn't get any otheroffers. Are you saying, Becky, that Jack shouldn't take Prentice's job? Maybe Prentice is a littleextreme with the ads and the marketing and everything. But he doesn't practicebad dentistry; he doesn't harm people, and they still have to consent to every treatmenthe does for them. Are you saying that it would be unethical for Jack, or any of us, towork for a guy like Prentice if the alternative is worse, like maybe not practicing dentistryat all?"

"It may mean some hard choices," said Robert, "but if you stand for something, thenyou have to draw the line somewhere."

"Yes," said Jack, "you do have to draw the line somewhere. But where?"

Analyze this case in terms of the professionalism discussion in class. What do you think of this? Is this clinic operating in a professional manner, or is it more in line with the commercial model? Is this important?