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Who is Your Doctor?

February 11, 2015

Filed under: Uncategorized — Tags: — Barry @ 1:28 PM



Guest Post by Dr. Alan Stern:


Health care has hit rock bottom. And, we’re still digging.
I spend several weekends a year treating National Guard soldiers. Not having served in the military (and feeling just a bit guilty over it), I have developed a profound respect for people who volunteer their time and risk their own well being so that the rest of us can live our lives in peace.

I jump at the chance to help these great people, and I work with the same enthusiasm and energy as I do in my office and in other aspects of my life. The work is markedly different than what I do in my office, but the National Guard’s dental mission is true to its values and the work is profoundly appreciated by the soldiers and their commanding officers.

I really enjoy the time I spend and the work I do with our heroes!
One of the standard questions on a soldier’s health history form is familiar. “Have you been under a health care provider’s care in the last two years?”

This is , of course, a very appropriate question, but when a  few soldiers checked off “yes” this past weekend  and wrote down the name of an insurance carrier as the explanation to the affirmative answer, I wanted to scream, cry, bang my head against a wall, and chug a bottle of scotch all at once. As an alternative to all the above, I started writing!

The soldiers I encounter are ordinary people doing extraordinary things. If their mindset towards health care is reflective of our nation’s thinking, then we are in BIG trouble.

The medical community has utterly failed to teach the public that an insurance company and the U.S government are not physicians. They have, in many senses, surrendered their role as care givers and have been relegated to technicians and trades people.  It can be argued that the role of today’s physician is to do as he/she is told, fix what the government or the insurance company orders them to fix at whatever rate of reimbursement the third party chooses, fill out the paperwork with appropriate codes or face criminal charges for failure to do so properly…. and move on to the next patient.

The patient, on the other hand, is expecting first class care while their benefactor, the third party payer, is paying third class reimbursement to the repair person whose title remains doctor. The patient is expecting Marcus Welby, MD to watch over their well being while the doctor is legitimately worried about coding, paperwork, productivity (that is, generating enough money to pay a burgeoning overhead and take a  much reduced salary or justifying his or her pay to the corporation to which they have sold their practices and/or with whom they have entered into employment agreements).

The third party payer is worried about earning more than they are spending (just like all of us, by the way), making sure that their premium dollars reflect a perceived value to the customer, and that their policies fall under government guidelines. Yes, they provide some assistance to their members in obtaining their care from their “providers.” (I despise this word.) And, my own encounters with some customer service representatives have been helpful. But, who is my health care (ugh) provider? Is it the insurance company? Is it the physician? Is it an appointment secretary? Is it a nurse practitioner or a physician’s assistant? And, who is accountable to whom, and for what are they accountable?

A few years ago, I had a discussion with a college professor on this very subject. She made the point that health care is the one area in which the entity that is paying for the service has no vested interest in the outcome, the recipient of the service has no financial accountability to the provider of the service, and the provider (God, do I despise that word) of the service has an obligation to someone other than the recipient of the service. This is, in my young adult kid’s vocabulary: “a train wreck if ever there was one!”

In dentistry we are beginning to see the train wreck approaching. Decades ago, people like Avrom King, L.D. Pankey, and others saw this coming. The dental marketplace would be tiered, they said, dividing it into what was then called welfare care (e.g., Medicaid and other government-provided treatment), insurance care subject to the market forces described above, and private care. Well, that day is here, and no dentist and no patient will be exempt from the struggle.

All patients will need to decide what type of care they want and what price they are willing to pay to do so. And, we dentists will need to decide what type of care we want to provide and what price we are willing to pay to do so. More importantly, for those who choose to pursue the private care model, the need to distance ourselves from the typical medical model AND to provide a service that is worth money, both in perception and in reality, is more critical today than ever.

So, the question I have asked myself and now pose to you is “What will YOU do to provide real care, skill, judgment, and service to those who choose you as their health care PRACTITIONER? Do you wish to play the insurance game? (That’s OK, if you’re OK with it.) Do you wish to provide care to the under-served? (That’s OK, too!) Or, do you wish to go the route less traveled?

The one less traveled is a very risky road with no guarantee of outcome. For some of us, though, it’s the only way, because for some of us, climbing is a better route than digging!


  1. This is incredibly brilliant! Why is it that so many of our colleagues in medicine and dentistry can not grasp the concepts expressed here?

    Comment by James Craig — February 11, 2015 @ 2:26 PM

  2. James, it’s something that practitioners of ALL specialties need to think about. More importantly, it’s something that patients need to ponder, as well. A frank discussion without judgment of whether third party intervention is right or wrong is needed. Each one of us, both as givers AND as receivers of care need to see it all for what it truly is and decide what is right for ourselves!

    Comment by Alan Stern — February 11, 2015 @ 2:50 PM

  3. I agree Jim. There has been a real paradigm shift in health care.

    Comment by Barry Polansky — February 11, 2015 @ 2:39 PM

  4. Paradigm Shift. That’s an understatement.

    Comment by Roger — February 11, 2015 @ 8:27 PM

  5. Bary, Barry- Where have you been for the last decade and a half. You are just finding out about all this now? It has been FUBAR for a good while now, and no t gonna get any better, sorry to tell ya.

    Comment by Roger — February 11, 2015 @ 8:12 PM

  6. The reason medicine rolled over to the insurance model in the early 1980s was that there was a promise of thousands of patients with a ~92% reimbursement of the usual and customary fees. Dentists participated because reimbursement was again high and many people that had never visited a dentist on a regular basis started to do so increasing spending on their dental health. That said, a dental school education was relatively inexpensive and dentists enjoyed a comfortable lifestyle.

    Fast forward 35 years, dental school costs the same as a Ferrari and reimbursement is 35% of usual fees.

    Dentists that participate with insurance companies are struggling and have become burned out.
    1. Dental Schools teach the same material as 40 years ago in an era of digital impressions and complete digital implant planning and execution.
    2. The leadership of organized dentistry is in their late 60s while the average dentist is in their 40s. If organized dentistry was useless 40 years ago, it is irrelevant today in the lives of our young colleagues.

    There is absolutely no reason for any dentist to participate with an insurance company. Why?
    There are only 130,000 general dentists to provide care for 310,000,000. Who will provide care if dentists won’t participate?

    Is dentistry in trouble because the country has no money? Absolutely not…Every luxury car maker in the world had record sales last year EXCEPT Ferrari. Ferrari decided to cherish its exclusivity by intentionally limiting production….So the money is there.

    I have been insurance independent for almost my entire 38 year career but I have invested heavily in my dental education with over 5,000 hours of CE.

    Unfortunately, the ‘average’ dentist brings nothing special to the table which
    forces them to participate with insurance companies.
    What can be done?
    1. Force dental schools to change the curriculum so that they teach relevant dentistry
    2. Have young dentists to decide on any given day to stop participation unless and until reimbursement is acceptable.
    3. Have direct elections for ADA leadership so that an activist leadership is receptive to the needs of young dentists.

    Comment by Gerald — February 11, 2015 @ 8:57 PM

  7. wow…the road seems very long to earn your kind of success…I admire and applaud your proactive education and envy that you have patients that care enough about their health enough to pay more for excellent workmanship. While I try to discuss a patient’s health as equivalent to their “life,” when tx options are discussed (because I am so terrified that if I do not tell them about all of their different options they will come back and sue me for negligence in not at least offering a certain treatment), at the end of our discussion, once they’ve looked closely at their teeth in our patient mirror, criticized their own dental photographs zoomed in on our computer screen, and openly recognized their personal hygiene lapses…99% of the patients will ask me (unprompted by any financial reference)…”which is covered more by insurance?” And although I can predict that this will happen, every time seems like a new crushing blow…terribly disheartened, knowing with 99% certainty that they will not choose my clear recommendation for their long-term oral health, I turn them over to our financial manager.

    Comment by kelly — February 11, 2015 @ 10:20 PM

  8. Hi Kelly;
    I understand your frustrations. What Alan, Barry and I will tell you is that this battle is never over no matter what level we practice at. In the old days, the best dentists had an oversupply of patients but today, that is not the case. Top clinicians find it very challenging to maintain a full schedule.

    Comment by Gerald — February 11, 2015 @ 10:31 PM

  9. Gerald…I agree…you give a good history of how we got here. On the ADA…they have always been a paper tiger…and that’s a shame because they have the opportunity to really stand up and lead. They never have. Interesting to note though that back in the fifties and sixties they partnered up with some real leaders…Proctor and Gamble, Colgate and other corporate Giants who had something sell. In selling there products they also taught Americans how important dental health was (remember Bob Barkley and The Academy of Preventive Dentistry?). Today…the message is mostly about whitening, and cosmetics…important? Yes…but not the message America needs to hear about health care. This lack of messaging, I feel, has hurt our overall “health” message. Since the FTC has allowed advertising for professionals all I see is dentists telling patients how their ___is better than___. Not great messaging. So how did we get here? Very complex.

    Comment by Barry Polansky — February 12, 2015 @ 9:39 AM

  10. thank you for your reply…I think even more frustrating is that the very least expensive treatment is often the most difficult to complete technically. I will not allow myself to complete work that I would not accept in my own mouth. So when I’ve spent an hour working on a very difficult wrap around cavity, killing myself to keep as much natural structure as possible, not hit the pulp, and get excellent contoured contacts and the patient then actually complains that I’ve been working too long on them, I feel like crying. Does the patient not realize that I am certainly not spending my time on them for the money, nor for my own health, but for theirs?….so that their tooth does break off the next day?…so that they don’t say it is my fault that their tooth broke and they want a refund?…so that they don’t take me to court for heaven knows what reason?…I don’t think I’ll make it through 40 more years like this.

    Comment by kelly — February 11, 2015 @ 10:49 PM

  11. “so that their tooth does *NOT* break off the next day”…oops

    Comment by kelly — February 11, 2015 @ 11:07 PM

  12. Kelly,
    Your words make me feel so sad. I have loved being a dentist my entire career and am fortunate to be able to say that I have not suffered like you are now. Feel free to contact me at http://www.benjaminsmile.com. I would be happy to help you in any way that I can.

    Comment by Gerald — February 11, 2015 @ 11:23 PM

  13. Kelly…I love you. You have expressed what so many young dentists are going through. I feel your pain…the frustration, the anger, and the fear. It’s a shame because truly….You Are The Future of Dentistry. That was the title of a speech that LD Pankey gave back in the eighties to the Florida Academy of General Dentistry. It rang so true back then…I wonder how it would be received today.
    Kelly…dentistry is and always will be about people and relationships. Who you are…and who they are. They never teach you that in dentistry…they teach you teeth. And now you are blessed with the Curse of Knowledge about teeth. To the lay public…dentistry is teeth. But it’s not. It’s not about teeth…and most dentists are technically arrogant about that. Others, outside of dentistry…who understand people’s behavior better, have taken over.
    I could go on…but it’s you who must change dentistry…Big Job.

    Comment by Barry Polansky — February 12, 2015 @ 9:47 AM

  14. Alan—Irony of ironies—right now I am going to extract a tooth—totally hopeless tooth, on a 33 year male—he works in human resources. He advises people on their medical and dental health benefits.
    I ask him…so what do you tell them–
    he says he educates them.
    I look at him and he smiles. We both get it.
    Everyone gets it—we need more than education—we need responsibility and maturity.

    Comment by Barry Polansky — February 12, 2015 @ 11:34 AM

  15. Barry, you’re totally right. We are all responsible for our own health. IF we eat to obesity, smoke, and drink incessantly, no doctor- or insurance policy- will bring us to health. Primary care is what you do for yourself!! Those who do not practice good health habits are in for a very rude awakening

    Comment by Alan Stern — February 12, 2015 @ 7:27 PM

  16. Amen.

    Comment by Barry Polansky — February 12, 2015 @ 8:33 PM

  17. Hello Barry..i stumbled upon your blog while i was searching online for practice improvement tips..i get more frustrated as i read through your blog starting 2010 because here where i live 97% of population can not afford the type of dentistry you are teaching us..so our practices are crammed with insurance patients for which the most generous company pays 3$ (per head) for the most sophisticated procedure..i have to examin 20 patients daily in order to be able to survive and keep practicing..i hope by finishing reading your inspiring book that i will find a way to create a balance applying your art while serviving this tough environment.

    Comment by African Dentist — February 15, 2015 @ 12:48 AM

  18. Dear African Dentist…I read over your question many times before answering. It is a wonderful question because it strikes right to the essence of why I write…and why I have become so interested in this topic (it is not practice management…as so many in the field have tried to pigeon-hole me into). At its core my writings, books, articles and blog are about the well-being of the dentist. This is so important to me because without a “happy” provider (I know Alan hates that term), there can not be “happy” patients. That is a generalization but day in and day out for thirty to forty years, I think it’s valid. So to your point about money.
    The positive psychology researchers have answered the question about money and happiness…it’s necessary…just a question about how much. Your numbers would qualify as not enough. So the psychologists then tell us the role that politics, government and economics play in our general well being, and they tell us that it matters. There are different levels of happiness that are determined by geography. When we (the dentist as well as the patient) does not have freedom of choice…there is a marked decrease in well-being. This strikes right to the heart of Viktor Frankl’s work about the gap between stimulus and response where our freedom to choose lives. It also is an example of Maslow’s Hierarchy of Needs…it is impossible to rise to fulfill our higher needs when we are stuck in survival. This is a reason why so many people want to come to America in spite of so much “bad press” these days.
    Of course there are people who would wander the streets of Calcutta without a thought of any material reward at all…but they are few and far between…angelic if you will. Right here in America because of reasons of economics, competition and corporate interference…sometimes it’s better for a dentist to change local environments…the same principles apply…but at least here in America there is more control…more freedom of choice.
    I hope this helps…great question.
    BTW…what is your name and what country are you from?

    Comment by Barry Polansky — February 15, 2015 @ 10:37 AM

  19. Hi Barry;
    Because we have the same kind of patient oriented practice and perform the same kind of treatment, I almost always agree with your thought process and conclusions.

    What I will somewhat disagree with is that a change in local environment i.e. move your office is not as significant as it used to be. Having built in new office in a moderately upscale location and having moved from a country practice, things have not changed that much because as you might say; “people are people.” Wealthier patients certainly have the ability to pay for complex dental care but an insurance dependent mentality combined with a lack of value for fine restorative dentistry makes them comparable to financially less fortunate individuals.

    Comment by Gerald — February 15, 2015 @ 11:33 AM

  20. Thanks for clarifying Gerald…I was more referring to a macro change…like out of Africa…but even here in the U.S…..moving from the east or west coast where there is a high concentration of dentists to the middle of the country where the economy wasn’t hit as hard could be a solution for some. Then again those things can be tough compromises.

    Comment by Barry Polansky — February 15, 2015 @ 11:55 AM

  21. Thank you Barry for your great response,me and my colleagues here in Sudan feel closer to solve our dilemma as we read through your blog daily,and we also feel more capable of achieving our “well-being” as we discuss your ideas..keep inspiring us Barry.

    Comment by Muhanad (African Dentist) — February 16, 2015 @ 11:51 AM

  22. Thank YOU Muhanad—As someone who writes —books, articles and my blog—I never know how far and wide my words reach. Sometimes I feel as if I ma a voice in the wilderness– even moreso here in America. I love this profession—and have so much feeling for dentists who have sacrificed so much–yet never reach any level of happiness. There is so much complaining here in the US as well—for much less reason than you wrote about. Your comment tells me that people are listening—and that’s where I get the meaning from—
    Thank You my friend.

    Comment by Barry Polansky — February 16, 2015 @ 12:04 PM

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