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The Indescribable Value of Autonomy

September 9, 2015

Filed under: ARTICLES,Happiness — Tags: , , — Barry @ 9:10 AM




For old timers like me this film clip is one of Hollywood’s most iconic ever.  Go ahead and watch…and if you’re too young not to remember this scene from Nicholson’s Five Easy Pieces…enjoy.

The scene is Jack Nicholson at his best.  It illustrates why he has so many fans — he is the renegade in all of us.  He is truth, justice and the American way.

Oh if we all could just behave like that when we are being shit on.

Five Easy Pieces was made in 1970.  Yet watching this clip tells me things haven’t improved much…and maybe in the world of health professionals has gotten worse.

Most dentists go to school to be free from micromanagement.  We want to be masters of our own destiny.  But that is not happening today.

Autonomy is the word I like to use.

Another word might be discretionary, or being allowed to use one’s own judgement.  That’s probably the reason I never accepted dental insurance—it was the Jack Nicholson in me.

I always had a difficult time writing letters to “beg” for approval—the equivalence of “holding the chicken salad.”

A few years ago I was asked to be on a panel for the Huffington Post (See the blog post Dentistry Looked Bad – May 2013).  On the panel was two patients, an insurance company fraud specialist and myself.

What a joke!  The fraud inspector said it all.  Probably like the waitress in the film clip, there was such a lack of trust that it is hard to do a good job.  That’s where we have come over the last forty five years.

No one likes to be surveiled.  No one wants someone looking over their shoulder.
We want the freedom to do our jobs to the best our our abilities…that’s how we build our self-worth.  Through our work.

And I am not just writing about doctors and dentists.  We need to trust our employees enough to do the right thing.

Take a look at Jack’s reaction.  How often do we feel like that when speaking with an uncooperative service provider?  How does it feel?

What’s worse though is the stifling effect it has on the provider.  It can destroy trust in the entire system.  Whether it’s getting something as simple as two pieces of toast or getting your cable turned on in time for this week’s football game—we need people to have the freedom to use their judgement and behave with a sense of autonomy.

Dentists, as well as doctors are feeling this more and more.  The ideology of insurance companies and now corporate dentistry, is putting constraints on health professionals in order to become more efficient and more profitable…at the cost of losing autonomy.

When autonomy is gone…so is passion.  It’s just a job..and that’s not why we went to school.





  1. When the tide goes out we know who is not wearing a bathing suit.
    Insurance companies quickly and easily discovered that dentists lacked testicular fortitude and without courage, most humans are easily led.

    What has happened to dentistry is what we have done to ourselves.
    1. We accept fees from insurance companies that are below the cost of doing business which forces dentist to steal money, steal tooth structure or steal trust.
    2. Dentists have permitted the ADA to be a spineless and useless organization which leaves most dentists without any leadership at a time when we desperately need a leader
    3. Dentists permit dental schools to continue to teach the same crap that we were taught 40 years ago. The basic sciences should be a requirement to be accepted into dental school and never taught again. This would allow 4 years of intensive learning in diagnosis, treatment planning, occlusion, function , esthetics and implant training. The average recent graduate knows very little about functional dentistry which makes them easy targets of dental medicaid mills and corporate clinics.
    4. Dental School faculty should be first rate clinicians and teachers and should be paid$250,000. Private dental schools have become profit mills.
    5. Dental schools have taught students to design, build and repair carburetors in a fuel injection world and it must stop.
    We have lost control of our profession and life because many dentists lack the knowledge, skill and passion for what they do.
    I certainly do not mean to offend anyone. One learns a lot by observing changes over a 40 year career.

    Comment by Gerald Benjamin — September 9, 2015 @ 10:59 PM

  2. Great comment Gerald— I agree with everything you say. I believe that a lack of leadership at every level is the proble. At the individual level, at the practice level and at the industry-wide level.
    What’s at stake?
    The well-being of every professional.
    We get our self-worth from work—not just money. This is an ideology—a paradigm if you will. If we continue to believe that money is the ONLY reason we go to work—we will be slaves at the hands of the economists.
    It all starts with a shift in ideology about why we work—and it starts with the individual—as you say—one thing all leaders have is COURAGE….which is so sorely lacked today.

    Comment by Barry — September 10, 2015 @ 7:33 AM

  3. I was recently offered a position as part time adjunct faculty. The pay: $100 / day. I wish I was kidding. The school charges ~ $65,000 / year for tuition.

    I would have to drive a bit over an hour each way to be there.

    I turned it down. Pathetic.

    Comment by TheDentalWarrior — September 12, 2015 @ 7:15 PM

  4. Mike–Dental schools are operating from a very old paradigm. They barely teach enough for the young dentist to get by…and are just setting young people up to work for corporate dentistry.
    Somewhere on this thread –I think Gerald said it—dentists are becoming the commodity. What a shame.

    Comment by Barry — September 12, 2015 @ 8:48 PM

  5. This is the 21st century, things are different. Once us baby boomers are gone who know how it used to be, all that will be remaining are easily-controlled people who have been bombarded with crap since birth. Corporate dentistry, contract dentistry, public health, private practice- they are all the same. A dentist is just a commodity now. Do as you are told and like it, or you’re not going to last long.

    Comment by Roger — September 12, 2015 @ 11:19 AM

  6. Yes Roger…it is us who have become the commodity…how ironic.
    Yet I came across this quote the other day which is quite appropriate:

    “The ideas of economists and polititical philosophers, both when they are right and when they are wrong, are more powerful than is commonly understood. Indeed the world is ruled by little else. Practical men, who believe themselves to be quite exempt from any intellectual influences, are usually the slaves of some defunct economist.”
    John Maynard Keynes

    But of course I don’t expect the dental community to understand this logic…as shown by where we have gone. Just let it be said that these ideas are out there.

    Comment by Barry — September 12, 2015 @ 11:29 AM

  7. Hi Roger;
    You are exactly correct.
    What has happened has not happened in a vacuum. We were willing participants when insurance companies promised us 95% of our usual fees. We were willing participants when we let the dental schools teach skills that were relevant 40 years ago but our of date today. No one has done anything to us…We agreed…We consented…We rolled over…We were (are) afraid.

    We are at a tipping point at this time in dental history. Either we will make changes and forever change the course of our beloved profession forever and for the good OR we will allow corporate and clinic style dentistry to become the dominate delivery system of dentistry and we will no longer have a profession…OUR choice…No one is forcing this down our throats…

    130,000 practicing general dentists to take care of 315,000,000…The game is overwhelmingly ours if we take back the night.

    But dentists are cowards even though they think that they are ‘independent thinkers’ and can only work for themselves. For the last 15 years I have heard dentists say, “You don’t understand, everyone in my area participates and I would lose my patients and practice if I didn’t participate as well.”
    Of really…78 dentists in my small town and I don’t participate…5,200 plus hours of CE gives me the freedom to compete the way I want.

    Take back the night…Regrow testicles. Join together. Say no AND mean it.

    Comment by Gerald Benjamin — September 12, 2015 @ 12:48 PM

  8. Gerald…you say, “But dentists are cowards even though they think that they are ‘independent thinkers’ and can only work for themselves.”
    How can we change that? Cowardice, fear and self-doubt are part of the human condition. I agree with you — but finding a solution will be tough.

    This is what Keynes (an economist) meant when he said…”Practical men, who believe themselves to be quite exempt from any intellectual influences, are usually the slaves of some defunct economist.”

    Slaves are usually cowardly people—-this is one of the reasons why I have criticized dentistry for not teaching or promoting leadership–at all levels—individual, practice, community and industry. There are no leaders taking us to a better place. We are being led along by the economists (insurance companies, corporate dentistry etc.) What’s worse is that the climate is ripe for a complete takeover now that baby boomer dentists are leaving—selling to the corporates and moving on. I really thank all the sell-outs—some of the most prominent practices in the country (that’s sarcastic).

    Comment by Barry — September 12, 2015 @ 2:53 PM

  9. It’s not just dentists that are pussies these days. It’s a majority of our American culture. The “pussification of America” has permeated our politically-correct and perpetually-offended society.

    Pussies! All of them.

    BTW… when I was President of the local affiliate of the dental association, I said exactly that, in those very terms. It did not go over well, when I called the board a bunch of pussies. 🙂

    Comment by TheDentalWarrior — September 12, 2015 @ 7:18 PM

  10. Michael Barr is correct: dentists ARE pussies. They think they are in control, but are not. They will never admit that they are working harder and harder for less and less. They try to keep up appearances of the old, defunct model of the 1980s and before. Times have changed. And as long as dentists keep participating in PPO insurance schemes, they will continue to be on the treadmill, with someone else turning up the speed on them and offering less and less for it. Take Aetna, for example. They raise premiums to employers by say 10% and at the same time reduce benefits to providers by 15%. They gain an easy 25% income with barely any effort. And dentists just keep taking the slapping in the face. Yes, dentists are pussies, and they did it to themselves by taking that carrot of assignment of benefits. And no other business provides goods or services without being paid first, none other than dentists. No other business discounts what they charge for their skills and services. No other business gives things away as dental offices do. Yes, times have changed. Dentists have found themselves left behind and taken advantage of. Nothing will ever change. Dentists are not in control. They are pawns in the big plan that they are unaware of. It was a short time ago when all the journals were touting how wonderful it is to be a dentist, while the elephant was in the living room, trampling over everything, unacknowledged. Just like a lot of other situations, it has gotten really bad, too bad to correct before people started admitting there is a problem. Now one can frequently read articles and hear stories about how tough it has become to do business in the dental world. Corporate dental holding companies figured out how to use the dentists, as have insurance companies. Yes, it’s sad that dentists have become not much more than line cooks in a fast food restaurant.

    Comment by Roger — September 12, 2015 @ 8:35 PM

  11. Roger–it is truly sad to see the number of dentists who literally give away their services—from exams and x-rays to bleaching. It seems that everything is negotiable. Who could have imagined this thirty or forty years ago. Roofers and painters have more dignity than that. Lawyers are in the same boat. Amazing…really. But who will come to our aid—-I’m not sure if calling America’s dentists, pussies is the answer—that’s blaming everyone and no one at the same time. Professional services should never be considered the same as commodities in the marketplace. Economists have known that forever—but no one stepped up to protect any of the professions—now see what happened.
    And what’s at stake?
    Just the self-worth of all professionals—

    Comment by Barry — September 12, 2015 @ 8:55 PM

  12. Hi Barry;
    A group of older dentists need to step up and have a coup de state of the ADA or failing that…Start a competing organization devoted to the advancement of private practice dentistry. We need to partition Congress the way that the automotive industry did in the 1980s when the Big 3 stated that Ford, Chrysler and GM were no longer competitors and needed to cooperate to get relief from the Japanese auto industry flooding the American market. Once we get relief from prosecution under Anti-trust laws based on the fact that individual dentists are no longer competing with each other but insurance companies and corporate entities who conspire to keep fees low to drive out private practice. Then and only then do we make a move to create an organization to fight disenfranchisement by the ADA. We want the right to select the President of the ADA who must be under 50.

    Comment by Gerald Benjamin — September 12, 2015 @ 9:17 PM

  13. Waiting for or depending on the ADA is a waste of time. All dental education is geared toward new technique courses—sleep apnea, implants, botox—all developed to put more money into the pockets of the CE entrepreneurs who are no better than the dental schools—all self-interested organizations—fiddling away while Rome is burning. A new organization, as you suggest, with its only agenda—to protect dentistry from these pirate forces –could work.
    I continue to see new groups popping up–but with no agenda other than to help provide more education or to create buying groups—

    Comment by Barry — September 12, 2015 @ 9:44 PM

  14. You’re on the right track. The ADA is old, useless for supporting dentists. A new organization that will fight hard for dentists and be a dedicated advocate for the interests of dentists is needed. If that were possible, it would take years to effect any positive changes and to break the grip that insurance companies and holding companies have on dentists.

    Comment by Roger — September 21, 2015 @ 5:43 AM

  15. Roger–is trhat you agreeing? That’s a start. Yes– things are pretty shaky out there—but the first problem is to realize—that we have a problem–and then get some agreement. Blame is never good—it starts with realizing we have a problem.

    Comment by Barry — September 21, 2015 @ 8:29 AM

  16. Sometimes “calling a spade a spade” is the wake-up call that is needed. Dentists aren’t the only pussies. MOST American men have become pussies. It’s not hyperbole, it’s fact. Most men don’t even know how to change a fucking flat tire anymore. They “call someone” (AAA). Pussies. They are what they are. Prove me wrong. Real men… real people with real principles are now the minority.

    It reminds me of my favorite quote:

    “If ye love wealth better than liberty, the tranquility of servitude better than the animating contest of freedom, go home from us in peace. We ask not your counsels or arms. Crouch down and lick the hands which feed you. May your chains set lightly upon you, and may posterity forget that ye were our countrymen.”
    ― Samuel Adams

    My fellow board members at the local affiliate association repeatedly would say, “But, we have to sit at the table, or we’ll be left out.”

    I replied, “Fuck no we don’t. Without US, they have NOTHING. WE are the ones with the talent, skill, and knowledge. Without us, they don’t have dental services to offer anyone. WE are holding the cards, yet you deny it. Sit at the table? No! STAND UP! Walk away! And, if necessary, kick the table OVER.”

    Well, you can only imagine how “popular” I was. 😉

    Comment by TheDentalWarrior — September 13, 2015 @ 10:04 AM

  17. Mike…somehow I tend to agree with you…but I can’t lay blame on any individual dentists…you are sounding a bit Trumpish. Dentistry needs solutions…we can’t just discuss the source of the problem (although you are probably correct). I would also include the greedy sons of bitches who promote ridiculous forms of dental education rather than doing something about what really ails the profession. Gerald was on to something when he suggested an organization (certainly not the ADA) that’s sole purpose is the protect dentist’s right right to make a living rather than just their right to “make money.” There is a difference, you know..

    Comment by Barry — September 13, 2015 @ 10:58 AM

  18. Once we define the problem we either commit to solving the problem or we become part of that problem.
    The key to organizing to take on ‘organized dentistry’ aka the ADA, is to get exemption from prosecution under anti-trust laws. The ADA will side with insurance companies and claim that we are colluding.
    We need to entice young dentists who have everything to lose and everything to gain if our efforts are successful

    Comment by gerald — September 13, 2015 @ 10:40 PM

  19. Yes Gerald–we have become part of the problem. Aging dentists are done with the political and economic landscape. This is about the future—organizations should start in dental schools—dentists need to be trained in entrepreneurship, business, leadership, and communication—or else it’s the blind leading the blind.
    Young dentists need to take a stand—forget about anti-trust—that’s old school thinking.

    Comment by Barry — September 14, 2015 @ 10:28 AM

  20. It’s too bad there is no equivalent in dentistry as woth police and the thin blue line. It’s a shame there never will be as well. Talk about the ADA doing anything for dentists is a waste of time. What have they done up to now? All the ADA is, is a group of old pompous asses who take care of themselves. Same goes for every state dental board. They never stand behind a dentist who is in need.Get yourself an entry in the practitioner data bank and you are screwed for life- some states will not allow you to earn an income in their state if you have a data bank entry- deserved entry, or not. It does not matter. Dental schools are just trying to stay in business, and the entrenched administration and tenured professors just want to keep their income and “prestigeous” jobs. It’s all sad really. The age-old hype about dentistry being a noble profession that comes with respect and a good income is largely dead. Try taking your 20 plus years as a dentist and go apply for a job as an employed dentist in some health center or corporate holding company dental mill. You think it matters to any of them that you’ve been a dentist for decades? HA! Your application will be thrown in with the new grads who are scrambling for a job as a dentist, and your experience will not be negotiable for a higher rate of pay. And even if you did manage to land that job, see how long you will last and how much respect you will be given for all your efforts.Face it- insurance companies have figured out dentists, corporate holding companies have figured out dentists. The only ones who do not know the personality of dentists, are the dentists. And as long as one practitioner takes assignment of benefits, nothing will ever change. Dr. Barr’s contention that dentists have no balls is valid.And dentists will never sacrifice and band together in solidarity for the better good of all. Oh yeah, and even if they did manage to do that, the government has that trump card called collusion. Instead, dentists just keep on accepting what they are allowed, and keep giving away their services to try to hold on to that piece of the pie. No other profession or skilled trade discounts what they do as dentists do. Try getting an HVAC guy or plumber or electrician or even an attorney or M.D. to give you discounts. They’ll basically tell you where to go, and to come back when you can afford their fees. It’s sad for all the dentists, young and old, new and experienced, all running on the treadmill chasing the dream that just no longer is attainable, by and large, all scrambling for smaller piece of the pie, while puffing out their chests and thinking they are highly respected for being allowed to be called “doctor”.

    Comment by Roger — September 14, 2015 @ 9:12 AM

  21. I don’t know if this comment will go through, as Barry’s blog keeps remanding me to the ranks of “spammers.”

    But, Roger might enjoy my article contrasting the ADA and the NRA:

    Comment by TheDentalWarrior — September 19, 2015 @ 9:06 AM

  22. The ADA is a bad joke on dentists. The only thing they were good for was a decent-looking monthly journal, and now that has been reduced to being about as useful as a comic book. Dentists have no autonomy. It’s not the 1980s anymore. Once those dentists who were in the game in the hey day of dentistry are gone, all that will be remaining are corporate dental mills and FQHCs run by the federal government. The few remaining private practices will not be the captains of their own ship as it used to be. They will be working harder and harder for less and less and have more and more regulations and restrictions placed on them. It’s already happening. Just wait and see ten years or so from now.

    Comment by Roger — September 20, 2015 @ 3:45 PM

  23. Exactly Roger…that’s what the blog post implied.

    Comment by Barry — September 20, 2015 @ 3:51 PM

  24. Well then, pardon me. I guess I am just passionate about the subject, a passion acquired by a lot of experience and observations. It’s really sad how dentistry has evolved to less than a professional endeavor. One could feel badly for those who are graduating these days… Pardon me for the error, Barry.

    Comment by Roger — September 20, 2015 @ 4:36 PM

  25. No error Roger…it just seems that the issues are so obvious…and yet no one, or no organization, or any party is stepping up. There is so much at stake for young people, yet the train keeps rolling.

    Comment by Barry — September 20, 2015 @ 4:46 PM

  26. Roger and Barry;
    The most important thing is that the current situation is of our own making. No one ever forced anyone to participate with insurance companies. And once we graduated, no one ever put pressure on schools to improve their diagnosis, treatment planning and esthetic, functional and occlusal education. Consequently, the students and recent graduates know less and are willing to earn less when they participate with insurance companies.
    Also, some of THE BEST practices in the country have partnered with Hartland and other corporate entities to create a protocol so that very average clinicians with the help of technologies, scans, cad/cam etc will be able to produce comprehensive dentistry.

    Comment by gerald — September 20, 2015 @ 5:33 PM

  27. Gerald…the problem is bigger than any one of us. You bring up a good point about the prominent practices selling out to Heartland. Those big practices with their influence not only in their own communities, but in dental education, have shown what they really care about…their own pockets…not the state of the industry. Some of them could have done much more.

    Comment by Barry — September 20, 2015 @ 7:43 PM

  28. Barry;
    Yes the problem is bigger than any one of us. Yes it is bottom of the eighth, we are the home team and behind two runs…NOW WHAT?????
    We can do nothing like we always have done OR???????????????
    The solution will cost upwards of $1million…and dentists are sooooooo blankety blank cheap…..
    When I started planning for the world’s first esthetic center within a dental school (Buffalo, 1995) I was up against the entire full time faculty and it personally cost me $100,000 so I am not afraid of a fight or to put my money where my mouth is…It is the rest of the dental community that I have no trust in.

    Comment by gerald — September 20, 2015 @ 8:36 PM

  29. I believe it starts with education reform. That’s not too strange or futile of an idea. General education and medical education is being reformed right now. Dental education is stuck…because…well…it’s being controlled by dentists (or businessmen). Terry Cosgroveg a cardiologist is changing the Cleveland Clinic because he is a forward thinking clinician. That is why I get upset when the “powers” in dentistry sell out to corporate and to the manufacturers. There was a time when one very prominent program in Florida refused to take any money…but that was a long time ago…seems like everyone sells out these days.

    Comment by Barry — September 20, 2015 @ 8:47 PM

  30. We are end game…no hypotheticals, no what ifs….What will 130,000 general dentists agree on to preserve our profession. You and I will not be able to sell our practices in the very near future is something significant is not accomplished.

    Comment by gerald — September 20, 2015 @ 8:52 PM

  31. I have to say there will always be a market for the “elite” practices…but that will probably be controlled by the specialists. Not a good scenario for the generalist. Practice transition will get tough if we’re not there already. These are not good times. I just completed a new book…Short Guide to a Long Career, in which I offer advice to young dentists. It is being distributed for free by signing on to my mailing list. That ought to happen very shortly. I will follow that up with a survey to procure good information from the dental community on their present state of mind.
    Just what I do.

    Comment by Barry — September 20, 2015 @ 8:59 PM

  32. Sad to say Roger–there is truth in your comments—the biggest losers? The patients—but like all members of the public, are screaming for mediocrity. Until things fall apart–then they demand perfection. This happens everyday in practice—and will continue ad infinitum. Until the profession makes a stand about real standards of care.
    Train dentists— in business—in psychology—people skills, economics…their lack of training and understanding creates submission.
    Educate them!

    Comment by Barry — September 14, 2015 @ 10:36 AM

  33. In other words… we’re ****ed. 🙂

    Comment by TheDentalWarrior — September 21, 2015 @ 8:17 AM

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