Practice Ethics Assessment and Development

Welcome to the Practice Ethics Assessment and Development (PEAD) program! Immediately, if you have an interest in PEAD, we know something about you and your office team: you are very likely more attuned to ethical issues and probably more effective as a practice than most dental offices in America. Research on businesses generally confirms that those who are ahead of the curve are interested in staying there.

Why Are Ethics Important?

Ethics raises the overall level of the profession. Business research has shown that organizations that strive for high ethics enjoy greater productivity, innovation, employee loyalty, customer satisfaction, and profitability.

What Is PEAD?

PEAD is a comprehensive, voluntary, no-fee program for practicing dentists to self-assess the ethical climate and foundation of their practices through guided self-evaluation exercises and activities. The entire office staff is involved. Suggested resources and improvement activities are also included.

Why Participate in PEAD?

Practices will want to participate in this project because the office environment is a powerful context that influences how patients are treated, for both the good and otherwise, over and above the dentist’s ethical intentions.  The ethical climate in a practice can be improved through reflection on what changes would be beneficial and engaging in individual and group activities to build better ethical office routine.

There has been an awakening interest in ethics in the profession. All dental students who have graduated since 1987 have had an ethics course: it is required for accreditation. Several journals regularly published columns presenting discussions of clinical cases involving ethics. The focus during this period has been on professionalism (what dentists can expect from each other) and reflecting on the ethical dimensions of clinical care.

PEAD Is Unique

PEAD is different. The unit of concern is the entire dental practice, from the dentist to the office team. All members of the practice build an ethical context in which the particulars of ethical procedures can flourish. The exercises in this program are meant to carry the office far beyond thinking about hypothetical considerations. It is about creating a more ethical office. Among the assumptions upon which this program is based are the following:

  • All dental practices are not the same—there is no one size that fits all and prescriptive standards tend to be vague and weak.
  • Dentists are best motivated by high aspirations, and “imposed” approaches to ethics in dental practice will be resisted and are often ineffective.
  • All practices can improve; all improvements are welcome—there is no baseline that divides practices into those that are labeled ethical and those that are not.
  • External auditing, by visitors or of records, would create defensiveness.
  • Dentists are in the best position to know when it is time to improve their practices, to recognize opportunities for improvement, and to bring about change.

This program is modeled after the Malcolm Baldrige National Quality Awards. Based on research regarding how small businesses operate and how they incorporate ethics and organizational culture into their daily operations, a model was created for the ethics components of dental practice. The model is shown below.

Model for Ethical Practice: Five Blocks

  • Components

  • Core Concept

  • Activities

  • Reflection

  • Closing the Gap

  • Resources

Each exercise is introduced with a brief explanation of a Core Concept, including a description of why it matters in a dental office. Then the office is invited to participate in an Activity, or exercise, designed to measure the current ethical climate of the office. These exercises include inventories, chart audits, reviews of existing practice documents, patient satisfaction surveys, group activities, and hypothetical cases. A guided Reflection is included so that dentists and their office teams can decide whether they are satisfied with their practice or whether they see opportunities for improvement. This reflective phase is critical since all offices are not the same, and it would be impossible for an outsider to prescribe what all practices need to do to improve. Once the meaningful differences between what the office wants to do and what it typically does have been identified, there are some tasks the office can engage in to Close the Gap. Finally, there are some Resources that can be used, both in the exercises and as follow up.

When you have completed the following exercises please complete and submit the PEAD Reflection form.

The ethical character of a dental office can never be greater than the ethics of the dentist and the dental team. The natural place to start is with the people who are the practice.

Sometimes one hears about a debate whether ethics can be learned after the formative years of youth. That is framing the question in a strange way. It is better to ask whether adults can improve the way they function ethically. The answer, of course, is yes. But looking at the matter this way highlights two important points: (a) we must start where we are and (b) improvement is a matter of change, not adding on a few new skills.

The exercises in Block A are designed so the dentist and the office team can reflect on the way they naturally approach the ethical dimension of practice. There are three self-scoring self-assessment inventories to help you locate yourself in the range of orientations toward ethics. There is also a survey of your professional values, as you understand them. Finally, there is a little exercise that encourages reflection on the image the office projects to patients.

The structure of activities in Block A, and the other Blocks as well, invites you to reflect on what you learn from a safe self-assessment of where you are now. Often you will be satisfied with some or all of what you learn. You may also see opportunities for improvements you want to make. That is why each exercise contains a section title “Closing the Gap.” You, individually, or as an office team, will be invited to engage in skill building for every exercise in this program. You can take this as far as you want to go. There are even references to promote further follow-up.

Three Inventories

The only test that determines whether you are moral is how you live your life. There are no paper and pencil tests for this. Isn’t there something passing strange in the idea that you would answer some questions to find out whether you are ethical if you don’t already have a pretty good idea on the subject? What would it mean to get a “low score?”

There are some “honesty” tests used when hiring employees at Big Box stores and the like where the rate of employees theft averages over 30% of what is paid in salaries and benefits. But these should be more accurately termed “Tests of Stupidity.” Typical questions include, “If I can get a little extra from people who will not miss it, then it is okay as long as I don’t get caught.” Employees who answer “yes” to such questions are more likely to steal. And they and those who hire them are not very bright.

There are, however, interesting differences among dental professionals over what they take to be ethical issues (compared to purely technical ones), their habits of thinking abut ethical problems, and the role that ethics plays in their lives.

The first three exercises in this section can be used by dental professionals to stimulate reflection on ethical orientation or “style.” In these short surveys there are no right or wrong answers. The goal is to get to know yourself better and to call your attention to certain habits of moral outlook that you think characterize yourself. There are some norms about how others see themselves on these dimensions and some discussion about what various outcomes might mean. In the end, you will have to decide whether you feel comfortable with what you see. To that end, there are some reflection questions, suggested exercises, and resources and other activities that you may want to consider.

Exercises A1 through A3 are offered in both paper-and-pencil and computerized format. The computerized version is available through this site, www.dentalethics.org. The computer version provides automatic scoring, and it is completely anonymous.

To get the most out of these exercises, the inventories should be completed and scored before looking at the discussion of the general concepts and self-study work. It is suggested that you do these first three surveys now.

Seeing Ethical Issues in Dentistry

Core Concept

Ethical problems often come mixed with other kinds of issues. It is only in school or at CE courses on the topic that someone announces “Now we are going to focus on ethics.” In some treatment planning situations and for some dentists generally, the technical aspects of the case predominate. Other times, ethical insight regarding what is really best for patients move into view. On other occasions, the shadow of legal issues play a role, and financial considerations are seldom far from being part of the mix.

Dentists and their teams must be adept at managing all of these dimensions of oral health care because they come jumbled together in daily practice.

But there are natural differences in the perspectives we take on what should apply in practice. One dentist will put a little more weight on the technical side of treatment and another will pay more attention to the ethical or other dimensions of the situation.

Activity

Activity A1 will show you whether there are any patterns in the way dentistry is perceived. Be sure to score the activity as per the directions at the bottom of the page if you take the manual version. If you take this survey online, your score will be automatically calculated.

Seeing Ethical Issues in Dentistry Activity

Reflection

A perfectly balanced view of practice would be reflected in scores near 25 in each of the four dimensions of legal, technical, ethical, and economic types of issues. This pattern is predictive of a practice that will experience a small number of surprises and will be able to respond to challenges, since all practices experience all four types of issues. Among dentists and their teams who have participated in the pilot testing of this exercise, it is more typical to see scores around 40 for the technical dimension, followed by economic, ethical, and legal, in that order.

A score above 45 or 50 signals a strong, single-minded view of practice. At certain times in the career of a practice, this might be appropriate—as in the start-up years. Perhaps there are situational circumstances that heavily influence the results at the moment—as would be the case if one is defending against an ugly malpractice suit. But, in general, a high score is a warning of a preoccupation with one side of the practice. This does not mean that the dentist is especially effective in this area; the preoccupation may be a result of poor ability. The danger in a preoccupation is that one set of tools might be employed to solve all problems instead of using the different tools that best match the issue.

Bottom line: there are ethical issues in every practice that cannot be solved by legal, technical, or economic means. If your score shows a preoccupation in the ethical area, you may want to volunteer for your peer review committee or as a faculty member in a local dental or dental hygiene program.

A score below 10 or 15 in any category signals a potential blind spot. Although you can count on issues coming from this direction causing hassles in your practice, you might not recognize the true source of the trouble. After all, you are not paying attention to the issues with low scores, so you are likely to misdiagnose the nature of the problem by noting only its symptoms and not its causes.

Closing the Gap

The scores on this exercise may be very much in line with what you expected. You might even confirm this in a staff meeting by having everyone write down their subjective estimate of the “office average” (anonymously of course) after they have taken the survey for themselves. The scores you observe, especially the composite score for your practice, may be exactly what you were hoping for.

On the other hand, there may be a few surprises. You may find yourself agreeing with the statement, “Now I can see why these annoying situations pop up in technique, or finances, or ethics, or even legal: it is because I am not really focusing my attention in that direction.” If that is the case, there are a few things you can do to close the gap:

  1. For any score that indicates a preoccupation or a blind spot make a short list of specific, concrete examples in your practice that illustrate these unusual scores. This is an exercise that forces you to think back about what you are not looking at. If you can recall a blind spot, it is not really blind, except in the sense that it is generally hard to handle the situation, so you pretend not to see it.
  2. Start a conversation with a colleague (probably not a staff member or spouse—they already know your profile and have invested years of work in accommodating to it). A good opening line might be, “I was reading that some practices get out of balance by focusing too much on the legal or the economic dimensions. What do you think about that?” You may want to have a personal or hypothetical example handy. Generally, this is all that is needed to get a good conversation going and to allow you to get some useful feedback
  3. Write a one-sentence prescription for yourself across the bottom of the self-scored test. What could you do to make your practice better by balancing the way you look at it?

 Resources 

  1. Ethics Resource Center, at www.ethics.org, is an organization devoted to helping industry and non-profits find ethical dimensions in the workplace, especially among employees.
  2. CODE Course  Introduction to Ethics, Professionalism, and Ethical Decision Making.

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Ethical Approaches

Core Concept

There are many ways to address most ethical issues. Especially among professional ethicists, there is a wide range of theories. The goal in this program is to strengthen the ethical foundations of each practice and not to teach one or another theory. You will be helped in recognizing the approach to thinking about ethics that is most comfortable for you. With that information, you will know where to look to learn more about ethics in terms that you find congenial. You may also become curious about what you may be missing in other approaches.

You should already have completed the self-scoring test called Ethical Approaches. If you have not done this yet, you should do so before proceeding since the information below has some potential for biasing your responses on the self-scoring test.

Activity

Activity A2 will show you how you are most comfortable thinking about ethical issues. Be sure to score the activity as per the directions at the bottom of the page if you take the manual version. If you take this survey online, your score will be automatically calculated.

Ethical Approaches Activity

Reflection

  1. The Principles or Rules Approach is the most common orientation toward ethics current in American dentistry. The ADA Code of Ethics is based on the five principles of beneficence (do good), non-malfeasance (avoid harm), autonomy (do not coerce), justice (give everyone his or her fair share), and veracity (be honest). This approach is also taught in most dental schools, where cases about hypothetical situations (called dilemmas) are used to learn how to pick out the relevant principles. The principles approach is an excellent introduction to ethics because it is concrete and because it is a convenient way to introduce many of the problems dentists are likely to face.

There are two difficulties that are sometimes encountered: (a) often more than one principle, even contradictory ones, applies and (b) ambiguity about what happens to people who do not follow the principles. The rules or principles approach is standard in bioethics, but relatively little understood or practiced in the field of ethic generally.

  1. Consequentialism (also called Utilitarianism) is another common approach to ethics. The concern is with the results of actions. Rule consequentialism is probably the most familiar and basic form of ethics in the Western World. It includes the Golden Rule and generally asks the question “What should I do to make things better all around?” The admonition to “put the patients’ interests first” is an example of rule consequentialism. Consequentialists are in the habit of looking to see what the effects of their behavior are and of choosing the course of action that maximizes overall benefits.

There are two commonly voiced criticism of consequentialism. First, theorists have been very successful in thinking up peculiar inconsistencies in its application. It only works in most situations, but not always. Second, consequentialism can run toward paternalism, where we decide what is best for other people without even asking them what they want. The first concern is academic, the second one is important in the professions.

  1. Character Ethics or Virtue Ethics was fashionable in ancient Greece and Rome, and is now making a reappearance in various forms. This position is related to the influential views of Immanuel Kant who held that one’s motives matter a lot, even more than the consequences of one’s actions. The essence of virtue or character ethics (also called deontological ethics) is that good people can be counted on to do good things and that an important task in one’s life is to build habits of virtue so that ethical decisions come naturally. Virtue ethics has a natural fit with professionalism.

Some of its drawbacks are a tendency to be strongly conservative and to run in circles—people become virtuous by doing virtuous things, and they do virtuous things because they are virtuous.

  1. Ethics as Agreement (sometimes called discussive ethics) is associated with building moral community. The fundamental concept is that no one can be ethical in isolation; it is always a relationship. Those who hold this position look for equilibrium points, understandings that all parties agree are fair and no one would choose to change. Such agreements are self-policing and quite stable—two very desirable features of ethics and two features that can actually be found in most human relationships.

Closing the Gap

  1. Unlike the case with balancing the types of issues seen in practice (Activity A1), there is no score that is too high or too low when interpreting the approach to ethical thinking that suites your style. Now that you have a very large and rough map of the territory of ethics, you may choose to read a little deeper in an approach that already appeals to you—or even poke around in something new. Among the references are some basic starter articles and books.
  2. Read some “Ethical Moments” columns in JADA or cases in the Journal of the American College of Dentists or the AGD Impact and see whether you can guess the ethical orientation of the author or commentator. Most of the time, you will find a rules/principles approach, but not always.
  3. Start an ethics study club. Gather three or four colleagues together every few months for breakfast and conversation about an ethics dilemma. There are many in the literature and online on this site, www.dentalethics.org. Have each participant prepare to give a five minute analysis of the case. Listen to see whether you are able to diagnose the “ethical point of view” that is a hidden assumption. This can also be done as a staff meeting in the office.
  4. Sometimes people pick an outcome or resolution they “feel” is fair and then work the theory around to lay a good foundation for what they wanted to do in the first place. Academics are especially gifted in this art. But anybody can do it with enough practice and a realization that a problem can have multiple faces depending on what approach is being taken. The technical term for this is “rationalization.”
  5. Write an editorial. You can do it. Here is the structure: Something important doesn’t seem right. From a certain point of view, the best resolution would be X, but we should not lose sight of Y. All things considered…
  6. Listen carefully when some colleagues are taking sides on an issue. Often you will be able to hear that they are coming from different approaches to ethical analysis. They may agree on the best course of action but disagree on how to justify it.
  7. Write a one-sentence prescription for yourself across the bottom of the survey form. What could you do to make your practice better by building on your preferred approaches to ethical matters?

 Resources 

  1. A good introduction to principles, consequentialism, and character ethics can be found in Chambers, D. W. A primer on dental ethics: Part I—knowing about ethics [leadership column]. Journal of the American College of Dentists, 2006, 73 (4), 38-47.
  2. Ethics as moral communities is considered in Chambers, D. W. Faux ethics and the ethical community. Journal of the American College of Dentists, 1999, 66 (2), 36-42.
  3. Alternative approaches to ethics are also covered briefly in the Rule and the Ozar texts (Rule, J.T., & Veatch, R. M. (2004) Ethical Questions in Dentistry ISBN: 0-86715-443-8 and Ozar, D. T., & Sokol, D. J. (1994) Dental Ethics at Chairside: Professional Principles and Practical Applications. ISBN: 0-87840-759-6).
  4. Beauchamp, T. L., & Childress, J. F. (2009) Principles of Biomedical Ethics ISBN 978-0-19-533570-5. This is the classic text in bioethics.

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Moral Skills Inventory

Core Concept

This self-scoring test is built on the ethical theory of James Rest. He argued that there is more to moral behavior than thinking through issues the right way. Ethical reasoning is not the same thing as philosophical thinking, and moral behavior is more than an intellectual exercise, although that can be helpful.

Specifically, Rest’s theory includes four ethical skills: (a) being sensitive to ethical issues, (b) moral reasoning, (c) character or a life of integrity, and (d) the moral courage to take action when necessary. A moment’s reflection will show how an individual might be strong in one or two of these skills and yet appear to be morally stunted.

Activity

Activity A3 will show how you are most comfortable acting morally. Be sure to score the activity as per the directions at the bottom of the page if you take the manual version. The scoring here is a bit more complicated than for the first two activities, so go slow. If you take this survey online, your score will be automatically calculated.

Moral Skills Inventory Activity

Reflection

The maximum score in each of the four moral skills is 8 and the minimum is 0. This instrument has been extensively tested and constructed so that a score of 5.5 is typical for dentists on each of the four dimensions. That is the norm or base score you should use for comparisons.

Rest’s theory differs from most approaches to ethics because it emphasizes moral behavior rather than theoretical knowledge. The scores you gave yourself are for skills not theories. The areas in which you are skilled will be the aspects of ethical practice where you are effective; skills with low scores signal areas where you struggle or perhaps where you have withdrawn from direct effort to make things better. It is unusual for anyone to score high on all skills.

  1. Ethical Sensitivity involves awareness of situations in which ethical issues are at stake. There are few really bad individuals, but many who are ethically blind. Some people can be in the midst of ethically charged circumstances and be so deeply focused on what they are doing that they fail to see how others around them are being affected. Sometimes whole organizations, segments of society, or even countries can be blind to ethical issues. Insensitivity can become a defense against formerly painful situations about which little was done that eventually become walled off from consciousness. But there is no way to successfully address ethical issues that one does not recognize.
  2. Ethical Reasoning is a matter of the level of ethical thinking one reaches as one grows. There is good evidence that children think of good and bad in terms of what is punished and what one can do without being punished. As we grow, most of us reach a stage where good and bad converts to what is approved by our circle of influential people and what is disapproved by them. We internalize the standards of our peers. This is what is supposed to happen in dental school and the early years of practice. There is a third and higher level of ethical reasoning that some people reach and some do not. This is the level of higher ethical reasoning. The ethical is conformance with higher ideals that transcend individual circumstances. Some religious and philosophical systems qualify at this level, but not all of them.
  3. Professional Integrity or Character is the third part of Rest’s theory, and it involves weaving ethics into the very fabric of one’s practice and one’s life. Ethics is not a collection of individual behaviors, any more than dentistry is a set of isolated procedures. Those who score high on this skill see themselves as part of a profession what expects much of them and they expect much of their colleagues. The colleagues of a dentist who scores high on integrity are seen as allies for better practice. Those with this ethical tool can see patterns and anticipate ethical issues and place them in a professional context. They have the habit of doing the right thing—even if that requires going out of the way or making sacrifices.
  4. Moral Courage is the capacity to act constructively based on combining sensitivity, reasoning, and integrity. The question may be asked, “If you were accused of being ethical, would there be enough evidence to get a conviction?” Exercising moral courage seems to come easier to those who have good communication skills, deep knowledge of dentistry as a profession, and a strong sense of who they are. Those with this skill confront irregularities in a positive fashion. They are strong enough in their own convictions to open them for examination and discussion by others. Moral courage means being willing to take risks. It does not mean gossiping behind somebody’s back.

Closing the Gap

It is worth spending some time sharpening your moral skill tool set.

What is your area of greatest strength? What examples can you think of where this strength has played a prominent role? Where do you have a potential weakness? Can you see how your weakness prevents you from taking advantage of the moral strengths you have? Write a one-sentence prescription for yourself across the bottom of the survey form. What could you do to build your ethics skill set?

Consider these exercises:

  1. Sensitivity is the trickiest of the ethical skills to improve. It is not likely to help much to “look harder”; we need to find ways to see things differently. These activities might prove useful:
  1. Keep a log of what is happening at exactly 9:09, 10:10, 11:11, 1:01, 2:02, etc. for about five days in a row. The absolutely arbitrary nature of this sampling is critical because it will force you to see things that are usually screened from consciousness by habits that have been developed over time. When the log is complete, write next to each entry the answer to these three questions: (a) Why was I doing that? (b) How does this affect the interests of any who are affected by my behavior? (c) Could I give a public justification for these activities? Obviously, many of the activities will look boringly routine, they are small parts of habit patterns that have been put in place years ago. Track these little tasks back to the driving decisions, if this can be done. Remember: improving morality is about changing habits.
  2. Talk with colleagues about the reasons behind activities in your own practice or that you have heard about that cause you some concern. It is quite appropriate to make these discussions “hypothetical.” In fact, that can help a lot in getting an honest view of the matter.
  3. Find out everything you can about alternative ways of practicing dentistry—both good and bad. The question you are asking yourself when you look at these different ways of practice is not whether they are good or bad (that is the work of the reasoning ethical skill) but rather how did they come about? What are the context and circumstances that make them possible? What are the effects? This is a purely descriptive exercise rather than an evaluative one. Recall that our value structure, what we want to see, is one of the most powerful distorting influences of what we are actually capable of seeing.
  1. Most dentists tend to fall at the high end of the middle style of ethical Reasoning (conventional moral reasoning—borrowing the standards of one’s colleagues), with some at the pre-conventional (reward and punishment) and others at the post-conventional (principled) levels. Research has shown that these are stable personality characteristics, changing only over periods of years but open to change well into one’s thirties. Reading and participating in courses (a lot) can move one to a higher level of reasoning.
  2. Very likely, the best way to build moral Integrity is through active involvement in organized dentistry.
  3. The great books are a rich source of examples of Moral Courage. Just a few examples include Joseph Addison’s play Cato (from which Nathan Hale stole the line about one life to give for his country), Theodore Roosevelt’s biography of George Washington, or Elie Wiesel’s Night. But likely the most effective way to strengthen this skill is to work on removing barriers to speaking out—assertiveness training.

 Resources 

  1. The story about developing the Moral Skills Inventory, its testing on various groups of dental professionals, its psychometric characteristics, and the full version of the inventory are contained in Chambers, D. W. Developing a self-scoring comprehensive instrument to measure Rest’s four-component model of moral behavior: The Moral Skills Inventory. Journal of Dental Education, 2011, 75 (1), 23-35.
  2. Dentists Who Care: Inspiring Stories of Professional Commitment by Rule, J. T., & Bebeau, M. J (2005) ISBN 0-86715-451-9 is an uplifting collection of the personal stories of dentists who made a difference.
  3. A useful instruction manual on becoming more assertive is found in Chambers, D. W. Assertiveness [leadership essay]. Journal of the American College of Dentists, 2009, 76 (2), 51-59. JACD, vol. 76, no. 2

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Practice Values

Core Concept

Both people and practices reflect their values through the patterns in their behavior. A value is a preference for action in certain directions. Patients differ in the degree to which they value function, esthetics, or cost. Because our interest in knowing what people value is in being able to anticipate what they will do, we learn to watch them rather than listen to what they say. Just as you watch patients to see what they value, patients and your staff are watching for patterns in your behavior in order to see what really matters to you.

Activity

Exercise A4 is a form for recording personal values.

The Practice Values Inventory provides an opportunity for you to prioritize some values that are important in the profession. There are no right or wrong answers, but you can cheat on this one. If you “shade” your responses toward what you think might be “socially desirable” responses you will distort the usefulness of this exercise. In order to help clarify your values, you are asked to provide at least one concrete illustration of how you make each value a reality. If no examples spring to mind, this is a sign that the value has a relatively low priority.

It can be very helpful to get input from the entire office team. Because there is a potential for an awkward moment if there are noticeable discrepancies between the dentist’s and some or all of the staff’s views about what matters, some care will be needed. One low-risk approach would be to allow all staff members to complete the inventory anonymously and to give their unsigned inventories to the office manager who will transcribe the ratings and comments onto a master sheet. The master sheet would be the only item available to the whole office for review. The higher trust version of this approach is to list each rating (say all five of them if there are four staff members besides the dentist in the office). The low risk version is for the office manager to calculate and report an “average.” The ultra-safe version of the activity is to distribute the inventories and allow staff members to complete them without giving them to anyone.

Practice Values Survey

Reflection

  1. Begin by looking at the results, comparing your responses with those of the entire office. Is there consistency? Does the staff share your values? Are the top-rated values in practice the same as the way you would describe your practice?
  2. Looking at the norms:
  1. Compare your value priorities with the values expressed by graduating seniors from American dental schools. The national average scores from the American Dental Education Association Survey of Seniors are shown below. They are in rank order, beginning with the most important value. The percentage score associated with each value is the proportion of students rating each value as “important” or “highly important.” [Currently there are no national norms for practitioners.]

    1. (85%) Autonomy of the dentist
    2. (84%) Service to patients
    3. (81%) Income
    4. (75%) Performing quality dental procedures
    5. (54%) Status and reputation
    6. (51%) Helping the disadvantaged, mission

  2. It may also be of interest to compare your ratings with the Code of Ethics of the Canadian Dental Association’s ranking of six central values, shown from highest to lowest priority:

    1. Life and health
    2. Appropriate and pain-free oral function
    3. Patient autonomy
    4. Practice preferences
    5. Aesthetic values
    6. Cost

  3. If there are notable differences between your priority values and those of these norm groups, do you believe they are due to youthful idealism of those beginning their professional careers, geographic or other special characteristics of your practice, personality types, or other factors?
  4. What are some of the likely consequences of having a profile of practice values that differ from the norm?

Closing the Gap

Let’s be honest, changing personal values is not easy, and certainly no little ethics exercise is going to accomplish the task. The fundamental first step is to know who you are.

  1. There is an old saying that it is foolish to try to teach a pig to sing. It probably won’t work and it will annoy the pig. But all fooling aside, there is a very serious ethical matter involved here. It is flat out dishonest to misrepresent your values—to others or to yourself. Reflect back over the past week, did you say anything about yourself that really was not quite true just because it sounded good or because it was to your advantage to do so? A fertile place to look for these little deceptions is the treatment plan presentation. Every time you tell a patient what you think is in their best interests, make sure that it really is their best interests that are driving your behavior.
  2. Call a staff meeting to discuss the values.
  1. It is probably a good idea to avoid disclosing your own values and asking others whether they agree. A more productive strategy would be to announce your intention to create a consensus profile of the values of the practice, allowing a reasonable latitude or wiggle room for personal expression. This will be a big test for you and the office. One of the values that is often expressed in American businesses and professional organizations is “openness.” Your staff will be watching you and you will be watching your staff as you do this activity to see whether openness is a professed or actual value.
  2. Repeat the three questions from Analysis 1 above as a group exercise.
  3. It may very well happen that the office team “ducks” the challenge in this activity by agreeing that almost everything is a very high value and that under the right circumstances everything is important—end of discussion. You can help make the team uncover their true priorities and make the activity more concrete by posing “dilemma” questions. For example, “Can anyone identify a concrete situation where there is a potential conflict between two or more high-rated values? What should be done then?” You may want to identify in advance some actual dilemmas to have ready for this discussion.
  4. Engage the staff in thinking about what might be worth giving more emphasis to in the values profile of the practice. This will be an on-going exercise that will receive more attention in Block C (Practice Culture) and you may wish to return to this inventory of values every six months.

 Resources 

  1. Okwuje, I, Anderson, E., & Valachovic, R. W. Annual ADEA Survey of Dental School Seniors, 2009 graduating class. Journal of Dental Education 2010; 74 (9):1024-1045.A new version of the survey appears each year in the September issue of the Journal of Dental Education.
  2. Ozar, D. T., & Sokol, D. J. Dental Ethics at Chairside: Professional Principles and Practical Applications. Washington, DC: Georgetown University Press, 1994. See especially Chapter 5: The Central Values of Dental Practices.

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The Welcome Letter

Core Concept

In ethics, actions speak loader than words. There is hardly anything done in a practice that is not open for interpretation as to what it signals about the integrity of the practice. Some practitioners are careless or preoccupied and let inadvertent slips detract from their overall high intentions. Others know they are engaging in questionable practices and actively try to hide what they do from others. There is a price to pay when the practices that are covered up come into the open, and the work of “covering up” can be a brutal burden of life. The hard fact is that we don’t get to control what others pay attention to.

Activity

Exercise A5 is a hypothetical letter from the practice welcoming a new patient. Typically, analysis and discussion of such cases are more fun than the first four exercises because they are less personal. We tend to have great clarity about the faults of others.

  1. Give this case to each staff member several days before a staff meeting where you can devote about an hour to analyzing the letter.
  2. Prior to the meeting, analyze the case yourself and make two lists:
  • What assumptions does the dentist or the office seem to be making about the patient? Are you making this kind of assumption about your patients?
  • What assumptions can the patient legitimately make about the office? Do you want your patients making this kind of assumptions about you?

The Welcome Letter Example

Reflection

  1. In the meeting, ask each staff member to give his or her impression of the office based on the letter. You are asking the staff to do exactly what patients will be doing when they read the letter for the first time—projecting an image of what values are important in the practice.
  2. Make a list of the values as they emerge.
  3. Discuss whether the values this letter projects are ones that you would cherish in your practice.

Closing the Gap

  1. Assign a staff member the task of rewriting the letter to reflection the values in your office.
  2. Repeat this exercise for a practice Web page—either sampling several from practices in the community or from your own.
  3. Discuss the new letter or Web page at a future staff meeting.

 Resources 

  1. Chambers, D. W., & Abrams, R. G. (1992) Dental Communication. ISBN: 0-9632599-0-3. See especially Chapter 14: Office Environment and Written Communication.
  2. Chambers, D. W. Dentistry from the perspective of the San Francisco phone book. CDA Journal, 2010, 38 (11), 801-808.
  1. Can you make a partial ranking of the values important to this practice, using the value categories in Activity A4?

Return to Ethical Orientation

Research in fields such as business suggests that there is consistency between how leaders express their ethical values in their personal lives and their communities and how these are expressed in the work environment. It should be possible to predict some of the features of the way patients are treated by knowing how the dentist and the members of the office team manage their volunteer and social commitments.

Good practices are good fits between the office and its people and the community. A successful practice in a small, rural community with traditional family values would likely struggle if transported to a downtown urban location or even the suburbs. A practice that is isolated from the trends in the profession will soon be offering outdated care. A practice whose full staff are not part of the community and do not participate in the (non-dental) life of the community may eventually be regarded much like the gas station that offers the lowest prices.

Community Engagement Profile

Core Concept

America is one of the most giving nations in the world, ever—but a little less so in the past fifty years. And dentists are among the most generous of Americans. It is estimated that reduced-fee care, screenings and community clinics, and mission work can be valued at 5% of the total cost of all oral health care.

Ethical practices think of themselves as more than doing high quality technical dental work. They see themselves as net contributors to the communities where they are located. Unlike national firms or businesses that offer standardized franchise services, dental practices are inherently local. And their reputations are greatly influenced by the character of the dentists and the office team—as judged outside the office. One of the obligations of professionalism is citizenship.

Activity

Complete the attached Community Service Report From. Have each member of the office team complete the form as well. This can be done in paper-and-pencil format or online.

Because some may regard this as personal information, you should discuss this with your team before you start. Some offices will find it eases discomfort if staff members are allowed to complete the form anonymously. The unsigned forms can then be averaged (with highs and lows if it is a large office) by a designated tam member and the summary results distributed and discussed.

Community Service Report Form

Reflection

Now let’s compare the profile in your office with the national norms. The base figures were taken from the research of Dr. Robert Putnam and they represent averages across all sections of the United States, urban and rural communities, various age groups, sexes, and ethnic groups.

2%Participate in community improvement project, civic involvement
2 hoursWorked on community or civic project per year
8%Local officer/committee member in state or national organization
35%Weekly participation in worship service
9%Volunteer service (participation in activity set up by others)
20 hoursWorked as a volunteer/year
$1.50Average charitable contributions per $1,000 of income
5%Percent of dental services provided free or at reduced fees

Compare the national norms with the figures for your office, realizing that each team member will be making his or her own personal comparisons. Compile a general list of reasons why there might be differences between the national and your practice data. For example, several members of the office staff might have young children.

Closing the Gap

It is not the purpose of this exercise to embarrass anyone into taking a higher profile in the community than they feel comfortable with. There are three levels of response that seem to make sense.

  1. Accept that the office is largely invisible in the community other than the technical quality of the dental care for which they pay (a net neutral). Some dentists feel uncomfortable with a conception of the profession that extends beyond just doing procedures and going home at the end of the day. If this minimum standard is not met, the office will soon enough go out of business for economic reasons.
  2. A “dentist only” approach extends this notion in the direction of the dentist being seen as an important person in the community. There will be some attention to convenience of office hours, the staff will be professionally courteous, and there will be some charity work. If this is the approach that makes most sense, the dentist will probably not want to involve the office team in this exercise. But the dentist will pay careful attention to recruiting individuals who are established in the community to the team.
  3. The third approach is to involve the whole office team in community engagement. The intent is to make the “office” a good citizen. The activities, reflections, and closing the gap projects in B2 and B3 are designed to build on this approach.
  4. These three alternatives would appear differently if written up in the local paper. On the first approach, there just would never be any mention of Dr. Smile, the staff there, or the office. In the second approach, the paper would say the Dr. Smile just returned from a mission dental trip in Fiji. The story for full engagement would read, Dr. Smile’s office team has adopted the Sunshine charter School.

 Resources 

  1. Putnam, R. D. (2000). Bowling Alone: The Collapse and Revival of American Community. ISBN 0-7432-0304-6
  2. Callahan, D. (2004) The Cheating Culture: Why More Americans Are Doing Wrong to Get Ahead. ISBN 978-0-15-603005-2 is a convincing tale of the way American society is set up to encourage unethical behavior.

Return to Professional and Community Involvement

The Practice and the Community

Core Concept

Dental practices do not function in isolation. They do not get to write their own rule book for what is ethical and what is not. (The profession as a whole and individual dentists can agree on what is appropriate practice behavior, but that is professionalism which is only a part of what it means to be ethical.)

Study the figure below for a few minutes. It is a vastly simplified schematic, but it helps bring into focus the major groups of influence on a practice. The solid circle in the center represents the patients in the practice. They are a subset of the community at large, the bigger group including those individuals who attend other dentists or neglect their care. The professional circle represents the profession at large. Although the circle as shown bears little resemblance to the number of dentists and support personnel in the country, it is suggested by the diagram that there is a part of the profession that is unknown or has no influence on a particular practice. There are parts of the profession that affect dentists but not practices (such as member benefits), and even some cases where the profession affects members in the community who are not patients (as in institutional advertising and fluoridation campaigns). The personal factors of the dentist and the office team are meant to be a large and general category. They would include almost everything in the office, but also serving on the school board and helping at a health fair. This is also where values such as financial goals, autonomy, prestige, one’s family, self-fulfillment, and business practices belong. These values arise in the personal domain, but they spill into and interact with the professional and patient and non-patient community domains.

The effective definition of a “practice” is the area of overlap among all four domains.

The Dental Practice in Context

Activity

The dentist should complete Form B2: The Reputation Survey. It is also useful to have the office team complete the form individually. Close friends and family can also participate in this exercise because they will certainly know the “personal” circle very well.

Reputation Survey

Reflection

The analysis of this exercise can be done individually or in a group setting if others who completed the survey are willing to take part in an office-wide discussion. There are three questions to consider when looking at the results of the Reputation Survey.

  1. First, how easy was it to complete this exercise? If the responses came quickly to mind, and especially if there is overlap among the responses when shared in a group, the practice has a defined role in the community, the profession, and the personal lives of those on the office team. If not, the office is predominantly a professional service organization. Regardless of the quality of work done, it could be moved anywhere that is economically feasible. The practice is not taking advantage of and is not maximally contributing to the community.
  2. Second, what is the quality of the relationships with the various communities? Do many others know about the practice? Do others have an accurate image of the practice?
  3. Third, is there balance in responsiveness to various communities? There is usually a tension between satisfying personal values—such as economic security or a personal sense of accomplishment—with responding to the community’s needs or even with full incorporation of professionalism. How does your office manage this balance?

Closing the Gap

Look carefully at the sets of words you and your team feel patients in the practice would use to characterize their experience. You may want to build this list out a bit in a meeting so that you get a good picture of the office from the patients’ perspective. What you want to see is consistency between this list and the descriptions in the other three domains. Your goal should be value alignment in the practice. Unless you can achieve this, there will be structural tensions that break out in ethical problems. A full ethical tool kit or good theory and analytical techniques is never so valuable as not needing to use these techniques because the practice is balanced in such a way as to minimize problems arising in the first place.

If you are in good alignment, move to the second level: increase accurate awareness through participation. Avoid the mistake of beginning with promoting awareness. Alignment is first, and problems can be bought at bargain prices by promoting a misaligned practice. Values that are not authentic are readily seen as such and will erode the moral tone of the office.

The best outcome from this exercise is to discover and put words to a balanced and consistent set of values that place the practice in a supportive context of the local community, the profession, and the personal values of the dentist and the office team. The offices that are most likely to want to pursue enhancements in this area are those that are already pretty well along on this journey. Often it happens that an individual will become excited about the role of the practice in its various communities and will want to probe the idea farther. Deputize him or her to do so, but remember that it is always a whole office enterprise. The project in B3 can be helpful here.

 Resources 

  1. The “Surgeon General’s Report”: U.S. Department of Health and Human Services. (2000). Oral Health in America: A report of the Surgeon general. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health.
  2. Ozar, D. T., & Sokol, D. J. Dental; Ethics at Chairside: Professional Principles and Practical Application. (1994) ISBN: 0-87840-759-6
    • Chapter 13: Social Justice and Access to Dental Care
    • Chapter 15: The Dental Profession and the Community

Return to Professional and Community Involvement

What kind of practice would be needed here?

Core Concept

It is easy for practices, especially those that are doing well, to seek to conform the community to their practice style. Usually, this takes the form of selectively recruiting patients who best fit the values of the practice. That is one way of achieving an ethical match. Another approach is to move the practice more in line with the values that prevail in the community as a whole.

A prerequisite for ethical practice in the full sense is to know the oral health needs and care-seeking life patterns of those who live nearby. This project is a little larger than characterizing the stable core of the patient base in a successful practice.

Many factors are considered when a dentist selects a practice location. Chief among these are characteristics of the community. But the pattern of these factors can drift over the decades a dentists builds the practice, and the values of a dentists can shift as well during that time. It is useful for mature practices to ask whether this is the community that would be chosen again and whether the community is expecting something different from its health professionals than it did in the past.

Activity

Delegate one member of the office staff to prepare a “Consulting Report.” The report should be about 400 words in length in bullet format. The first 200 words should describe the characteristics of an ideal practice for such a community; the last 200 words should describe characteristics of a practice that would not be well suited to the community. The description should also include comments about the personality and community involvement of the staff. Consider the economic base, age and family, mobility, community values, how connected people are to each other, how well the office staff is known in the community, etc.

A variation on this project would be to collaborate with a colleague in a nearby community. You or your office does the colleague’s community assessment and vice versa.

Reflection

In a staff meeting, discuss the “Consulting Report.” The group should, by consensus, add items or make amendments.

Closing the Gap

In a full staff meeting, discuss how well the office fits into the community. Be certain to save plenty of time for this meeting—at least an hour. Use the results of the Community Service Report form and the community analysis expressed in terms of the best and worst types of practices. Your goal is to identify ten ways the practice or the community behavior of the dentist and office team could be changed to promote better fit between the office and the community. From that list, agree on the top three. It is important not to cheat and pick two or four. (This is an ethics exercise.) The reason for forcing exactly three is to encourage debate in order to bring out the underlying reasoning.

 Resources 

  1. Information about your community: Chamber of Commerce and Country Economic Development Board have websites
  2. Information about practices: American Dental Association website for practice resources
  3. Some Volunteer opportunities:

Return to Professional and Community Involvement

Practice Profile

Core Concept

Dentistry is a service to the community where one practices. This exercise is designed to provide a profile of that service. Some of what dentists do is intended to meet the needs of a special class of individuals—patients of record. Not all dentists provide the same services to this class. The community where one lives or practices also contains another class of individuals (for which we have no convenient name)—individuals who are not patients of record in dental practices. Dentists also customize their practice profiles to respond to their professional strengths and interests.

Occasionally, practice management consultants will work with dentists to adjust their practice profiles to match some targets. Dentists should take an active role in shaping their practice profiles, and this should be done against a full range of the dentist’s values.

Activity

Characterize the practice profile:

  1. The dentist and the office manager should independently complete the Practice Profile, From B4.
  2. The office manager should reconcile any discrepancies, in consultation with the dentist.

Practice Profile Form

Reflection

Reflection on dentistry as a public trust:

  1. This is an exercise for the dentist alone, or possible for the dentist and some close friends
  2. There are three standards that can be used to judge the appropriateness of the current practice profile:
  • Your practice and similar practices in the community
  • Your practice and the needs of the community
  • Your practice as it exists now and the practice you feel is ideal
  1. For each of the three possible comparisons, identify discrepancies that you feel are significant (a few percentage points one way or the other are probably not worth worrying about). Note one or two reasons for each discrepancies
  2. For each discrepancy you have noted, list one or two consequences. These can be consequences to you, to the profession as a whole, or to the community

Closing the Gap

Plan to address the discrepancies:

  1. If there are discrepancies between your current and your ideal practice profile:
  • Sketch a new profile to reflect the target you are aiming to achieve in three years.
  • List three things you will do within a week to start on your three-year journey.
  1. If there are discrepancies between your current profile and the oral healthcare needs of your community:
  • Identify changes you should make in your own practice.
  • List three things you will do within a week to start on your three-year journey.

 Resources 

Various American Dental Association reports on practice characteristics

Return to Professional and Community Involvement

The focus of this unit is the ethical climate of the practice itself. As leaders of their dental teams, dentists have the opportunity to create environments and work routines that embody and support best ethical practices. Once these characteristics of practice acquire the routine of habit, they become silent, powerful foundations for affecting every aspect of the way patients are treated. From time to time it is useful to review what one’s practice says about one’s ethical stance.

It is possible for the dentist to complete the unit individually, but some of the activities will be more effective if the staff is fully involved. Some dentists will also what to involve a trusted professional colleague who is also participating in this program by sharing insights and feedback.

Statement of Practice Philosophy

Core Concept

Well-run organizations are guided by a mission statement or statement of philosophy. Typically, these are no more than twenty words long. They state what is most important to the practice. They answer the questions “Why does the practice exist?” “What makes the practice unique and highly valued?” “How could I quickly recognize that the practice is putting too much emphasis on unessential matters or not being true to itself?”

Two examples of statements of practice philosophy are:

  • Dr. Smith’s office serves the comprehensive oral health needs of every member of the community of Fulbright, Montana.
  • Image Dental Center is committed to helping you express your inner beauty through the most advanced technologies consistent with sound oral health fundamentals.

It is not easy to create a good statement of philosophy. It should be short enough that every member of the office team can memorize it and can even work it into their conversations. When given several such statements, colleagues and even patients should be able to pick out your statement as truly representing your office.

Some offices will want to add “core values,” words or phrases that identify how the philosophy is realized. This can be a useful activity, but the core values should be kept separate from the statement of philosophy.

Activity

Spend a few minutes on line. Look up dental organizations such as the American College of Dentists and the American Dental Association and you will see their mission statements prominently displayed. Try this with a few major American corporations.

Reflection

What do you like and what seems out of kilter in these mission statements? Do the missions match the way you think of these organizations?

Closing the Gap

  1. If you have a statement of practice philosophy, give it a check up
  1. Is it worded to your liking? Is it still current? Is it consistent with the values you identified in the unit on your personal ethical orientation?
  2. Ask your office team, in a meeting, to write the statement (or their best approximation of it) from memory and to give some examples of it.
  3. With the help of your staff, make a list of the ethical implications of the statement; which practice routines are essential to the ethical tone of the statement; which practice routines would be violations of the statement?
  1. If you do not have a statement of practice philosophy, it is time to create one
  1. Begin by asking friends, colleagues, staff, and perhaps even some patients: “What comes to you mind as a word or phrase that is an essential characteristic of this office?”
  2. In a two-hour staff meeting, create a draft statement of philosophy.
  3. Live with it for about a month and then go through the steps above beginning with (1.a).

 Resources 

Surf the Web for large corporations such as Ritz or McDonalds. You will find mission statements on most of the home pages.

Return to Practice Culture

Office Ethics Code

Core Concept

As guidance for specific ethical situations that arise in the professional lives of dentists, the American Dental Association has a Code of Professional Conduct; the American College of Dentists has an Aspirational Code of Conduct. Your practice should fully endorse such codes and may even want a similar document customized to your office.

This is not a rule book or a restatement of the office manual. It is a statement of commitment to how everyone in the office has agreed to approach the most common and representative ethical choices that arise. In some offices, there are standing orders for taking radiographs before the dentist has examined the patient to see whether they are indicated. In some offices, treatment options are presented in order from those with the greatest profit margins, in others the goal is to establish a continuous and comprehensive relationship with patients.

In most cases, it is sufficient for the entire office to occasionally review and discuss the ADA and other appropriate ethics codes. But you may want to go further. There may be aspects of your practice that set it apart from other practices. You may want to emphasize ethical practices that are especially important. One convenient way to customize the ethical stance of a practice is to create a Patient Rights and Responsibilities Statement. That can be a benefit to introducing new patients to the practice, establishing useful expectations, and giving permission to talk about topics that some people may find uncomfortable.

Activities

  1. Review available ethics codes:
  1. Download applicable ethics statements from the list provide below.
  2. Discuss these codes in staff meeting of sufficient length.
  3. The codes should be distributed to all staff members in advance and the discussion should focus on whether there are opportunities for the practice to strengthen the way it implements the codes.

Reflection

These reflections can be done individually or as group exercises.

What strikes you as effective in these sample codes of ethics? Can you see how they would guide behavior in difficult times? Even if they are not perfect, are they a workable compass to steer by?

Now reflect on your own practice. Do the codes you have looked at cover your practice? Although most dental codes are strong in the areas of dentist-patient relationships and dentist-dentist relationships, there is more to practice than that. Do these commonly used codes speak to you personally about what you owe to yourself and your family, about the community, about staff relationships?

Closing the Gap

There are two levels of participation in this exercise.

  1. The direct method would be to adopt one of the major codes for dentists and develop your own appendix that addresses what is special about your practice and speaks to some of the relationships that are important in your practice but not covered in the general codes. This can turn out to be a great team-building exercise.
  2. Another approach is to develop a Statement of Patient Rights and Responsibilities. In this exercise, the goal is to form a deeper understanding of the relationship you expect to exist between the office and patients.
  1. Begin with two lists: What can patients expect from this office? and What can the office expect from patients?
  2. These lists can be worked into a one-page document (anything much longer tends to turn into a list of rules rather than mutual ethical expectations)
  3. Add an introductory paragraph of no more than two sentences (one of which might be the statement of practice philosophy)
  4. Pilot test the Statement of Rights and Responsibilities for several months before having it printed in bulk
  1. The test of a Statement of Patient Rights and Responsibilities is in its implementation. An effective statement will anticipate and give guidance to the important ethical dimensions of the relationships between patients and practices. It should help by “pre-thinking” appropriate behavior on both sides. If you have such a statement and an ethical problem comes up, go back and visit your statement of Patient Rights and Responsibilities. You may find that you can make progress by amending it.

 Resources 

Code of Ethics, Canadian Dental Association
ACD Core Values and Aspirational Code of Ethics
ADA Principles of Ethics and Code of Professional Conduct
Montefiore Code of Ethics
National Center for Ethics in Health Care (VA)
ASDA Ethics Code
AMA Code of Medical Ethics

Return to Practice Culture

Creating a Culture of Quality

Core Concept

The ethical standards of an office are better read from the pattern of practices than from printed material. Occasionally there are slips between what is intended and what is implemented. Sometimes a desirable system that was put in place years ago has been “overtaken” by changing circumstances and improvements made to other parts of the practice. An audit accomplishes two goals:

  • It reminds everyone of what characterizes the practice at its best
  • It brings to attention areas that need more work.

The “acid test” of ethical commitment is what happens when a gap is detected between what we say and what we do. Do we have habits of not seeing problems; is there a tendency to blame; is there a pattern of talking about issues until something else comes up’ do we jump from crisis to crisis because some people are good crisis managers?

In the hierarchical model of organizations, each person gets a job, a description of how to do it, and some training. The organization purrs as long as nothing unusual happens, the world of dentistry doesn’t change, and everyone does his or her job. A false advantage of this system is that it is easy to see who to blame when there is a problem. People with power like this arrangement because their goofs are often not commented on and they can change the rules to allow exceptions. People without power hide their slips.

Current high performing organizations more often create a culture of quality. The entire office is responsible for continuous improvement. There is no role for blame in this system. Finding opportunities to make things better is everyone’s job. It is assumed that wisdom about how things really work is widely distributed throughout the office. It is also assumed that most slips are a result of poorly designed systems rather than individual negligence or incompetence. The office works together to find potential problems before they occur and to design office-wide improvements.

It is unethical to blame an individual for a problem that is caused by the way the office work flow is designed.

Activities

This exercise must be done by the entire office as a team. It won’t work for the dentist to do a top-down analysis on behalf of the office. It is a high-trust exercise.

  1. Each person in the office gets a piece of paper to make notes for a week on desirable changes. The heading at the top of the page says: “It would be better for patients if they could….” Focus on the patient.
  2. Make notes for a week. It works best if short sentences or phrases are created at the end of the day rather than while working.
  • Attention is not fixed on any team member; that is not where it belongs.
  • Notice that solutions or changes to the system are not expected; this is about identifying glitches in the patients’ experiences.

Reflection

  1. In an hour-long staff meeting, share the observations. Avoid the temptation to judge the perception of what problems patients are experiencing. It is fine to add, “Yea, I saw something like that too.” But it is going beyond the rules of this exercise to say something like “I think you are exaggerating” or “That was a rare event” or “Some patients just don’t get it.” It is also strictly prohibited at this point to begin exploring solutions.
  2. Spend another week gathering observations.
  3. Have another debriefing session. (Hint: continuous quality improvement cannot be accomplished in a one-off session.)

Activities

  1. As a team, pick one problem to work on (or two if you must and it is a large office). Avoid beginning with the obvious fix, that will take care of itself very quickly once there is a culture of quality in place.
  2. Select exactly two team members to work on this problem. This work group already has team-wide input on the problem, and they will quickly realize that any effective solution will require getting more information.
  3. The team presents its suggestions for improving the system at a subsequent team meeting. Discuss, adjustment, trial, and further adjustment flow.
  4. Repeat.

Closing the Gap

The exercise of creating a continuous improvement cycle for office-wide enhancement of patient experiences will go a long way toward improving quality and the ethical tone of an office. But by its self, it is not enough. There is still the job of creating a culture of quality. Office climate is addressed in the next exercise.

  1. The structure for honestly addressing ethical bumps in the office, as an issue for the whole office, can, however, be formalized in the office mission, ethics code, and manual.
  2. Two team members should be deputized to review the mission, ethical code, and office manual to identify any language or practices that might serve as barriers to an open culture of quality. There should also be an explicit statement encouraging an open office environment. You will want to create your own, but a starting point might be something like this:

“It is expected that every team members will identify opportunities to improve the patient experience and work with the entire team to bring about improvements. No team member will be blamed for voicing concern about improving the quality of oral health care in the office.”

 Resources 

  1. Mark Graban (2009). Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction. ISBN 978-1-4200-8380-4. There is a year’s worth of training activities in this book.
  2. Mimi Swartz (with Sherron Watkins) (2003) Power Failure: The Inside Story of the Collapse of Enron ISBN 0-7679-1368-x. The story of how a dysfunctional ethical climate led to the collapse of a large corporation and damage to so many, as told by the chief whistle blower.

Return to Practice Culture

Office Climate

Core Concept

Many business researchers argue that it matters more how organizations treat their employees than how they treat their customers. The thinking is that employees threat customers the way they feel they are treated, and organizations cannot expect employees to be open and helpful unless they experience that climate themselves. Patients are very good at picking up clues about the office environment and adjusting their expectations accordingly. An office team that is together in projecting a strong, supportive, and ethical image goes a long ways toward making patients feel well cared for.

Activity

Have everyone in the office take the Organizational Climate Inventory (C4). This is an activity for everyone and it can be taken manually or online using the button link below..

Individuals score their own inventories by totaling the marks in each of the 12 columns. On anonymous slips of paper, the tallies are given to a designated team member who transfers them onto a master tally sheet. (It will look like a “bell-shaped curve” of tally marks centered on a point somewhere along the range and overlapping across several office climate types.

Office Climate Inventory Form

Reflection

There are four primary types of organizational climate.

  1. In the Leader-Centric style, the boss makes all the decisions, and tends to make them for his or her own benefit. This may result from a personal need to be in control or wanting to maximize ego or financial rewards. In the management literature, this is often referred to as Type I leadership. A large number of tally marks in the first three columns on the left of the Office Climate Inventory signals this type.
  2. Paternalistic practices look and feel much like leader-centric offices, except for the assumption that the dentist is making all the right calls on behalf of the patients and the employees. The dentist’s voice is the one that matters. He or she is playing the role of father or mother. This is known as Tyle II leadership, and a predominance of tally marks in the fourth through sixth columns would reflect this type.
  3. Consultative practices are honestly open to input from patients and staff. The dentists ask out of a sense of true concern and listen to suggestions, but always retain veto authority. A piling up of tally marks just to the right of the center on the Office Climate Inventory would be indicative of Type III leadership.
  4. Team organizational climates are unusual in American business. They involve all individuals concerned with the outcome of a decision helping to frame the decision. Each group participant may bring something different to the discussion and each must be able to live with the decision. Type IV leadership would be evidenced by tally marks being most numerous on the right-hand side of the inventory.

There is no one best organizational climate. Consider the necessary differences that must exist among a military dental assignment, work in a nursing home or community clinic, a family practice in a rural community, and a high-end cosmetic practice. What always causes problems, however, is when there is a bad alignment between the climate the dentist expects, what the staff assumes as the appropriate climate, and what is projected to patients. Talking one climate and acting another makes the practice appear phony. It is also not very ethical.

Closing the Gap

  1. Have the office interpret the Office Climate Inventory
  1. Ask each staff member, including the dentist, to prepare answers to these questions in preparation for a team meeting:
  • Is the type of climate described in the inventory a good fit for the type of patients treated and the type of dentistry performed by the office?
  • There any aspects of the statement of practice philosophy or any applicable ethical codes that conflict with any parts of the climate of the office?
  • Are there any policies in the office manual or traditional patterns of office behavior that conflict with any parts of the climate of the office?
  1. Discuss these potential discrepancies in a series of staff meetings.
  2. Also discuss what changes can be made to achieve better consistency.
  1. Consider changing the climate of the office
  1. If there is strong sentiment that the office climate does not match the expectations of patients or the vision of the dentist or the team, a meeting can be called to discuss changing the office climate.
  2. Make a list of the reasons why a climate change is necessary: what are the hoped-for outcomes that you would like to see replace the current unsatisfactory outcomes in patient care, office efficiency and protocol, interpersonal relations?
  3. Make a list of the policies and behaviors that need to be changed.
  4. Make a list of how you will check in two months to see whether you are making progress (this step may have to be repeated several times).
  5. This is a high-risk/high-reward activity, and it may be useful to get help from a colleague, someone from a local college business school, a church member, or other neutral party.

 Resources 

  1. Dental Leadership Course 27 is an online, anonymous, computer scored inventory of how meaningful individuals find their work. Note that www.dentalleadership.org is a computer-based set of resources for dentists sponsored by the American College of Dentists that is a companion to www.dentalethics.org.
  2. Morton, J. C., Clark, J., Adelson, R., & Hornsby, J. L. (1980) Dental Teamwork Strategies: Interpersonal and Organizational ApproachesISBN 0-8016-0979-8. Goals, teamwork, staff meetings, group decision making. Very sad to say, nothing like this has been written in the past 40 years!

Return to Practice Culture

Power Talk

Core Concept

It is impossible to avoid communicating. The hygienist appears in the dentist’s private office door as he looks at a study model to say that the prophy patient is finished and is late for a personal appointment. The dentist looks up, scowls, and goes back to pondering the difficult restorative case. Not only did the dentist communicate pretty bluntly, he communicated the same four things that we all communicate every time we interact with others:

  • Information (“just wait a minute”)
  • Emotion (“I am annoyed, perhaps with you”)
  • Status (“I am the one in charge here”)
  • Personality (“I am a controlling type, and I prefer not to have to fight to maintain control”)

There is no way to avoid broadcasting on all four channels simultaneously, and all day long. Some people have the knack for making agreeable impressions. They sparkle. Every office wants at least one. But this program will not try to teach this wonderful skill. Dental offices take it for granted that they are in the information business, and often also assume that they are not in the emotion business. Probably there is less information and more emotion flying around that we believe.

This exercise is about status. The definition of a patient is not someone who needs oral health care. Some who attend the office regularly need virtually none; most who stay away need a lot of care. A patient is an individual who has agreed to the terms of the dental care giving relationship in a particular office. Most of these status relationships are negotiated subtly. Offices develop routines that create these status relationships. Offices discharge patients who do not understand office power structures. It starts with waiting, then asking questions of the patient but frowning on the patient asking questions, lying on one’s back, being given a close range of options, etc.

But the most controlling person in the office may not be the dentist. Freedom from control is being able to do what you think you need to do, the way you want to do it, and when you what to do it. By this definition, dentists often surrender a great deal of control to the “office routine.”

Patients and others outside the office often have surprising control.

Activity

Have members of the office team read the case of Power Talk. It is best if this is done individually and each team member makes his or her own notes.

Power Talk Example

Reflection

Devote a staff meeting to analyzing this case. It would be good to encourage telling personal stories about patients who have attempted to manipulate the status rules of the office. Gradually, you will find the stories shifting to those about things that are done in the office to manipulate the status of patients, or even co-workers.

  1. How many of the following status-manipulating tactics did you pick out in the case? (a) speak first, (b) seldom interrupted, (c) initiate personal topics, (d) make requests, (e) ask questions, (f) more eye contact when talking and less with listening, (g) addressed by title, (h) address others informally, (i) make more and larger gestures, (j) initiate touching, close distance.
  2. Make a list of some of the office routines that have the effect, intended or not, of reducing patient autonomy.
  3. Review the list of routines in the office that affect patients. Here is the key question: what kind of person is attracted to this office and what kind is repelled by it based on the way status and power are conveyed? Does any of this “status steering” interfere with some patients getting the oral health care they need?

Closing the Gap

Either as a desk exercise for the dentist or in a staff meeting, review the office mission statement, the office code of ethics, and the office manual. Does it match the environment you want in the practice?

Make the changes in the office routine that are necessary to create the right balance of status.

Caution: This exercise has the potential for bringing personality issues to the surface. It has even led to personal changes, but where that has occurred, it has been achieved by mutual consent.

 Resources 

Chambers, D. W., & Abrams, R. G. (1992) Dental Communication ISBN 0-9632599-0-3. See especially Chapter 4. Power and chauvinism.

Return to Practice Culture

All of the ethical elements of personal orientation and practice characteristics come together in patient care. This is the “moment of truth” when all the fundamentals are brought to bear.

This Block assumes that dentists know how to provide excellent dental care and they strive to do so. The vast majority of the dental ethics literature addresses these concerns.

The focus here is on excellent care from the perspective of the practice and the patient. Is the practice meeting all of the patient’s expectations? Informed consent also is given a great deal of attention in the largest single exercise in this program. This is an ethical question—to what extent are the patient and the practice satisfied that they would not make any other choice about what should be done, even if everything possible were known about the choices being made? This is a slightly different perspective than some dentists are used to. The paternalistic view of dental ethics is that dentists have done well when they have done the best they can judged by their personal standards of what is ethical.

The concept of the Four Cs is also introduced. Good oral health care is more than a succession of top-quality technical work. It shows up in a pattern of care that can be read from a chart audit. The highest ethical standards are achieved by practices that provide care that is comprehensive, continuous, competent, and compassionate.

Trust and Loyalty

Core Concept

You and your office have a contract with your patients. You expect certain things from them and they expect certain things in return. Ethical relationships are built on trust that each will honor their part of the contract. Sometimes relationships continue in form despite their being imbalanced or even when based on duplicity. Patients, for example, may tall their friends about disappointed expectations with their dentist—even when the expectation is unrealistic or they have not told the office about their dissatisfaction. Offices may subconsciously disrespect patients in the name of efficiency or superior dental knowledge. It is not the stability of patient-dentist relationships that counts: it is the quality.

Activity

Gather data using a Patient Satisfaction Survey instrument that appears at the end of this Block.

The best way to find out what patients think about their experience in your office is to ask them. But, of course, some approaches are nice but not so helpful replies. To help get good feedback, you can use the attached Patient Satisfaction Survey form.

The form should be used anonymously and precautions for protecting patient identity are valuable. For example, a covered box for returning the forms or even the opportunity to complete the form on the Internet would help. The reasons given for the survey are also important. Use of the results to improvement the practice should be stressed. You may also want to mention that the form has been approved by the ADA [which, in fact, it has] or is being used by many dentists across the country [which we hope will be the case]. Obviously, any abuse of confidentiality is a deal breaker for that patient and all others.

It matters how the surveys are distributed. You want an honest, representative sample of your patients. If you only give it to your favorite patients, you are in effect lying to yourself. A rolling block sampling plan works best. On a given week, all Monday morning patients get the survey with a strong emphasis on getting 100% returns. Small blocks of 100% compliance are much less biased than large samples of selective compliance. On Tuesday, all afternoon patients are queried, Wednesday morning, Thursday afternoon, and Friday morning. Of course, if you are open fewer days during the week, those times will be skipped. Wait three weeks and then repeat the process, but start with Monday afternoon, Tuesday morning, etc. Wait three week and repeat, etc. This approach minimizes bias due to targeting patients and provides a nice, even sampling across days of the week, times of the year, and other potentially confounding factors.

How many survey forms are necessary? A hundred would be a good start. And it is suggested below that periods of gathering information, then stopping to analyze results and make changes, then sampling again work very well. The better the office is, the larger the needed sample. This may seem paradoxical, but it is not. The best offices will have momentously positive responses that suggest no needed changes. They will have to ask a lot of patients before they find an actionable prospect for improvement. The offices that are just starting on their path to more ethical patient relationships will find chances on many survey forms.

The Patient Satisfaction Survey form is available online using the buttom immediately below. It is available as a PDF document, which can be printed or copied into a new text document. If the latter it is possible to customize the form. For example, the name of the dentist or the office can be added and other personalizing touches would be welcome. The office may wish to modify some questions or add new ones. This is fine, but it is urged that the existing questions be tried first because they are based on the literature regarding customer satisfaction. Remember the “one-page rule.”

Satisfaction Survey

Reflection

  1. A staff member should be designated to review all forms returned each day. If there is a need for immediate action (the toilet in the bathroom is broken), respond in a timely fashion. But avoid the temptation to respond reflexively to a single negative response—you are looking for trends.
  2. A staff member should be designated to summarize the set of responses from each sampling period.
  • The Patient Satisfaction Survey form asks about both what the patient expected and whether they got it. The scoring combines these two dimensions so there is a single number for each question. The table below shows how to combine the importance and performance side of each question into a single value. For example, delivering on an important aspect of care is worth 4 points to the good. But is it five times as bad to disappoint a patient on something they feel is vital.
ExceedMeetDisappoint
Vital  8  6  -20
Important  6  4  -12
Nice  2  0  -4
  1. With all due respect to the merchants of sizzle on the CE circuit, they are wrong. One cannot make up for failing to meet patients’ needs by vastly exceeding them in some other area. Research shows that a well satisfied customer tells one friend and a disappointed one tells seven. The scoring table gives disproportionate weight to the vital needs of patients and to failing to meet their expectations. There is relatively little weight attached to nice features of the practice and to exceeding expectations.
  2. A total score per patient and an average score for the office for each particular survey period can also be calculated. When the surveys have been scored, they should be arranged in order by score with the lowest scores on top.
  3. The survey results for each sampling should be discussed by the entire office staff. Patterns are more important than isolated results. The most important focus for the analysis is trends at the negative end of the score scale. They direct attention to the greatest opportunities for improvement.
  1. Make a list of the most important problems—the items that tend to have the lowest scores. These concerns should be anchored by reference to your practice philosophy and your office code and standards. The whole office team should review these documents. It would also be valuable to review the Office Climate Inventory exercise C4 from the previous block. Avoid ad hoc reactions to isolated patient concerns. Changes should be driven by your ethical standards. Differences between what you want your office to accomplish and the Disappointed ratings of patients are called your “office ethical adequacy gap.”
  1. Offices that are ethically mature will have few or scattered patient concerns. (Everyone has an off day now and then, including patients.) Striving for excellence should be attempted after problems are fixed and not as a means of compensating for problems that remain uncorrected. Excellence should be guided by the practice philosophy. What are the essential elements of the practice? These were identified in Block A in the Practice Values Survey exercise. Because you have said these are critical to your office philosophy, you will want to see if what matters most to you is matched by positive patient responses. For each of the key factors you identified determine whether patients agree with you by rating these factors as Vital. Then look to see whether patients feel that the office is exceeding expectations on the factors that are most important to you. Differences between meeting and exceeding patient expectations on what matters most to the office are called your “office ethical excellence gap.”
  2. The two questions about length of time patients have been in the community and in the practice are designed to show differences between established and new patients. The responses of long-term patients in the practice get special attention. Any problems here signal that something is slipping. Patients who are new to the community will have the freshest eyes, and their responses should be given careful attention. Patients who have been in the community for some time but are new to the office might be expected to pay more critical attention to the features of the office since they either do not have a regular dentist or are switching dentists.
  3. The question about ethical standards of the practice is exactly the item that has appeared on the Gallop Poll survey of professionals for many years. It may be of more general interest than it is of diagnostic value. Over the past 25 years, the percentage of the general adult population that rates dentists as “very high” or “high” on ethical standards has increased from 52% in 1981 to 62% in 2006. The Chicken Little rhetoric of some in the profession comes from the fact that new professions, such as nurses and firemen, have been added to the survey. Because these are high-trust professions, the rank of dentistry has gone down while the level of trust has actually gone up. Dentists should expect to see the proportion of “agree” and “strongly agree” responses in their practices to be in the high 90% range since patients have chosen the office and there is a positive bias of completing the form while sitting in the office they have chosen.

Closing the Gap

The “office ethical adequacy gap” should be addressed first. Resist the temptation to work in two directions at the same time because that will lead to confusion. There is always time to advance excellence; there is very little time to achieve adequacy.

The following steps are useful in addressing performance gaps:

  1. First, make certain that each pattern of problem is relevant to your practice philosophy and that it is covered in your Office Code and Standards. You may have gaps because you overlooked or assumed something that matters to your patients. Add whatever is needed to the Office Code and Standards and to your existing office manual.
  2. Next, explore the office routines, scheduling, assignments of responsibility, and reward structure that may be interfering with meeting patient’s expectations that are important to your office. Change the office manual to remove barriers to meeting these needs.
  3. Set a goal. The only way to know whether the adjustments you have made have been effective is to compare patient responses before and after the changes. A new round of surveys will be needed, and the office should agree on the types of ratings they expect. Often it is more helpful to express the goal as no or a small number of “disappointed” ratings rather than an average that can mask lingering problems.
  4. A note on the psychology of self-improvement: All experts would not agree with the approach suggested here. Some feel that changes can be made and even sustained by will power. Promising to try harder or even “reaching an understanding that things will change” are common approaches to workplace improvement, as well as weight loss and marriages that are having difficulties. Good intentions that are not supported by structural changes in policy and routine tend to fade quickly. In extreme cases, any member of the office may be ill-fitted for the philosophy of the practice, and, following appropriate attempts at adjustments, a personnel change may be the best approach. That is a structural change.

For ethically mature offices, the four steps for addressing “adequacy gaps” can also be used to promote excellence. In this case, it would be unusual to make large modifications in the office Statement of Philosophy or Code, or even in the office manual since these are the touchstones that are driving excellence. When setting a goal for excellence, the proportion of “exceeds” or “meets” ratings is the appropriate outcome, in contrast to number of “disappointed” ratings. (It is expected that there will be no “disappointed” ratings since those were taken care of in previous cycles with this system.)

This is also the place to consider modifying the Patient Satisfaction Survey instrument. It may be the case that the six standard items that comprise the basic survey fail to register the unique ethical strengths of your practice. The items that are already received strong ratings from patients can now be replaced by special items constructed to test for special goals that come from the Practice Philosophy. (An alternative is to use multiple forms that add new items to all forms and use patient samples for standard, already well-covered items. In this system, the new items appear on every form and two or three established items would show up on every second or every third survey form.)

  1. Obtain another sample of Patient Satisfaction survey.

Wait several months after agreeing on the measures that should be taken to address identified adequacy or excellence gaps in order to allow the changes that have been made in office routine to become habit. Then take a new sample of patient satisfaction.

The process can be repeated as often as it is useful in prompting improvements. Each cycle can be expected to require about six months to complete.

 Resources 

  1. Maister, D. H. (1993). Managing the Professional Service Firm. ISBN 0-02-919782-1.
  2. Zeithaml, V. A., Parasuraman, A., and Berry, L. L. (1990), Delivering Quality Service: Balancing Customer Perceptions and Expectations.ISBN 0-02-935701-2.
  3. The Agency for Healthcare Research and Quality maintains a collection of measures of quality in medicine. The Consumer Assessment of Healthcare Providers and Systems (CAHPS) is a standardized instrument very similar to the Patient Satisfaction Survey form presented here. It is required of physicians and surgeons who receive Medicare reimbursement.

Return to Patient Care

Informed Consent

Core Concept

Informed consent is the cornerstone of the ethical relationships between patients and dentists. Almost everything else rests on this.

The legal conception of informed consent is obtaining documented permission to perform certain procedures as a defense against accusations of committing a battery. Precise requirements differ from state to state, and usually having an assistant get a signature from a patient on a standard form or having the dentists run through the standard presentation and making a note in the chart is sufficient.

The ethical requirement for informed consent is different. It certainly does not differ by state. The ethical goal of the informed consent process is to reach an understanding about what the dentist and patient expect of each other, an understanding that is durable enough to withstand the vicissitudes of unanticipated events. A patient who has given informed consent knows what to expect under normal circumstances and agrees to go forward on that understanding. So does the dentist and the office staff.

Activities

  1. Review all written and all “standard verbal script” informed consent protocols and reflect on the normal fashion in which large cases are presented. Identify the factors that seem to be significant in these situations and write them down.

If the office does not have scripts for common situations, it will be useful to take a few minutes at various points in the day and make notes about the “typical things that are said” in commonly recurring situations. A useful list might include at least 15 items in three or more informed consent situations.

  1. Perform an audit of your informed consent process. Partner with another dentist you trust (perhaps one who is participating in this Practice Ethics Assessment and Development program). Set aside an hour to review a stack of informed consent forms and charts from each office. The challenge for each record is for your partner in the task to determine what the patient has agreed to base on the documentation you provide. Your partner is not looking for “got ya’s” like a plaintiff’s lawyer would be in a malpractice trial, but for patterns in the types of treatment offered and the way case presentations are constructed.
  • Are all alternatives being presented?
  • Does the documentation create an overall impression that patients participated in choosing their treatment?
  • Is there any way to determine from the documentation how you and patients come to a joint decision?

For those who feel confident about this process and want to up the stakes, invite your spouse to sit in on the discussion.

  1. Take the other view. On a piece of paper, write down every detail you can recall regarding your mortgage. Typically, such documents run 30 or more pages and you will have signed every one of them, so there should be lots a very important detail that you have consented to. Check what you wrote down against the actual mortgage agreement.
  2. Perform a reality check. The literature shows that patients are poor at accurately recalling what has been presented in informed consent. Frequently they will deny knowledge of things continued in documents they signed or information they were told in conversations. They will often deny that that is the type of thing they would have agreed to if they had been asked. Find out for yourself. Assign several staff members to follow up with patients regarding what they recall about informed consent and how they participated in decisions. The staff members can ask patients who are in active treatment (not at the appointment where the decision was made) for a few minutes to discuss how the office presented information to patients. Office team members would identify a decision that was made previously, and, in an open-ended format, ask the patient to describe what they recall about:
  • The benefits and risks they recall being part of the decision
  • What mattered most to the patient?
  • Are they still satisfied with the decision?
  • Are there any new questions now?

Informed Consent Presentation Example

Reflection

  1. Scripts: Consider a sampling of scripts for the verbal presentation of standard decisions you ask patients to make in the office. Scripts are commonly used in treatment plan presentations (which is part of informed consent). These are ubiquitous: what does the hygienist say to patients in explanation for the dentist’s reviewing the case? How does the dentist explain what the patient can expect in the first few days following a deep restoration? The front desk is an incredibly scripted position.
  1. Do a little introspecting to determine whether there would be any factors that you, if you were the patient, would like to know about before agreeing to a joint decision. One way to monitor your introspection is to recognize any piece of information you normally avoid that might make you just the slightest bit uncomfortable if you were to include it.
  2. Continue your introspection by asking whether you give the same, standard presentation of risks and benefits to all patients or for expected behavior. What would it mean if you never varied your presentation? What would it mean if you regularly withheld information from some types of patients, such as alternative treatment or cost? Is the presentation of benefits, especially for the approaches you favor, much heavier than the presentation of risks?
  1. Formal Informed consent: What did you find out about the formal process of gathering informed consent. How far beyond being a mere tissue of legal protection is your process?

Reflect on the outcome of this process in light of your Statement of Philosophy and your Office Ethics Code.

  1. Do patients really understand? There is a saying that patients give informed consent, dentists do not. What was learned by putting yourself in the position of someone overwhelmed by “legal requirements” that are as difficult to actually comprehend as your mortgage agreement?. Sometimes, “consent” can be roughly translated as “Please stop talking, I quit paying attention a while back, can’t we just proceed?” That is more than a practical statement: it has ethical overtones.
  1. Typically, individuals will recall only a small fraction of the conditions of their agreement, and some of these will be partially misconstrued.
  2. If you are still not convince about the difference between signing a document and understanding a joint decision, try this with your last rental car agreement or the disclaimer you click on the computer screen before you make a purchase that says you have read and agree to the terms.

Closing the Gap

  1. First as an office exercise for the dentist alone, write down a set of standards that should be met whenever a patient makes a decision about his or her dental care. Perhaps it would look something like this:

“Whenever I ask a patient to make a decision, in order to ensure that this is a choice that fully respects the patient’s autonomy, I will take steps to make sure that…“

(Examples might include: “The patient can repeat in his or her own words what they expect will happen” or “The patient is very unlikely to alter his or her decision if given more information.”

Repeat this exercise with the office team, since many of them also ask patients to make decisions.

  1. Write down a set of changes you could make based on this introspection to increase the chances that joint decision making between you and patients is more likely to be in equilibrium and less vulnerable to future regret.
  2. Make changes as indicated in your Office Ethics Code and in your Office Manual.
  3. Redesign your informed consent documents and the way they are presented in line with what you have learned about this process.
  4. It might be advisable to meet with a representative of your malpractice carrier or you society’s Peer Review Committee and the question would be whether your documentation could stand legal challenges. But be careful not to substitute this legal review of informed consent for the ethical review and doubly careful not to change your process so as to provide more legal protection for you and less ethical consideration for your patients—for example by increasing formality and technicality.
  5. Make a list of four things you do or could do to demonstrate to patients that the trust they place in you as a professional (much higher Gallop Poll rating than salesmen) is justified. Saying that patients should just trust you because you are an ethical professional is begging the question. What behavior can patients see that allows them to draw the conclusion that you are trustworthy? Add this to your Office Manual.
  6. Informed Decision Script
  1. In a team meeting, create a master informed consent script. The purpose of the script is to ensure that the essential general elements for reaching a stable joint understanding are covered in each situation, regardless of the details of the choice to be made. A template to guide your efforts appears below:
  • All reasonable alternatives presented, including “do nothing”
  • Material risks and benefits discussed
  • Patient asked for a tentative decision
  • Question: “Is there any information you could think of that might change your mind?”
  • Question: “Now that we have agreed on a course of action, please summarize what you are expecting of me and I will summarize what I expect of you so we know we are on the same page.”
  1. Rehearse the master script you agree to in a team meeting.
  2. Practice the script on several patients
  3. Modify the script and add it to the Office Manual

 Resources 

  1. Wright, R. (1997) Tough Questions, Great Answers: Responding to Patient Concerns about Today’s Dentistry. ISBN: 0-86715-320-2. Excellent advice and examples of script writing.
  2. Graskemper, J. P. (2011) Professional Responsibility in Dentistry: A Practical Guide to Law and Ethics. ISBN: 978-0-4709-5977-0. See Chapter 8: Informed Consent.

Return to Patient Care

The Four C’s

Core Concept

The ideal for the general dental practice has for years been captured in the four Cs: (a) comprehensive care, (b) continuous care, (c) competent care, and (c) compassionate care. Obviously, this model takes a different form in the office of a specialist, a public health clinic, or on a mission trip to an underdeveloped country. But the goal of the profession as a whole, through the articulation of its parts, is to meet all of the oral health needs of all individuals by providing care that meets the standards of the four Cs. Dentists can tell the difference between their best days and their worst; and perhaps patients can too.

Concerns have been raised recently regarding practices moving away from one or another of these goals and of increased fragmentation within the profession. These are ethical concerns with economic side effects. There is concern when patients are offered only pre-set, high-value treatment options, when elective procedures are marketed over procedures needed for sound health, and when patients pick dentists based on economic considerations and vice versa.

The next three sets of exercises are built around a practice audit of the types of care your office actually provides. The intent is to furnish a tool individual practitioners can use to compare their practices to the own goals and to monitor changes taking place in their practices. There are no national norms for what an ideal practice should look like; at the moment, there are not even any descriptive standards for how the “typical” practiced is conducted along these lines.

Activity

Basic Approach: completion of the Practice Procedure Profile survey

  1. Begin by deciding on a sample size. Forty to fifty charts is a recommended number.
  2. Complete the “Norm” column on the right of the Practice Procedure Profile before beginning the audit. The first time this inventory is completed, you will be expressing your hopes for the procedure profile of your practice. You are noting the proportion of the 40 or 50 charts to be reviewed that you would like to see in each category. For example, the target proportion of patients who are in comprehensive care following their initial emergency or exploratory visits might be 40 patients out of a sample of 50 or 80%. For some practices, this would be unrealistically high because of the type of patient served; other dentists would be disappointed to see anything this low. A proportion should be entered for each category—a proportion that the dentist would find acceptable or appropriate for the practice.
  3. A good sampling system helps to ensure that unbiased data are available to the dentist to guide practice decisions. The office manager is the natural choice for pulling the sample of charts. Begin by taking the date on which the sample is drawn as the birthday of the first chart to be drawn. Draw the chart the falls on today’s date or the first following it, and select the next 20 or 25 charts in order (one half of the sample). Now add six months to today’s date, and draw the remainder of the sample in the same fashion.

The dentist (or perhaps a hygienist or office manager) reviews each chart, making tally marks on a working Practice Procedure Profile sheet. A patient will often be in several categories. Total the tally marks in each category and convert to proportions by dividing by the sample size (total number of charts reviewed).

The dentist would certainly find it helpful to make general notes on any patterns or important general findings.

Three C’s Practice Procedure Profile

Reflection

It is the dentist’s responsibility to determine the meaning of these patterns. There is no overall numerical score; there are no correct answers. What matters is the difference between what was expected and what was observed to actually be the case. On a separate piece of paper, the dentist should make notes about the gap between the “norm” proportions established as an expectation before the sample was drawn and the observed proportions. The goal is to understand or explain the differences.

  1. An obvious explanation for differences between expected and observed proportions is that the “norm” was not an accurate guess. That will certainly be a contributing factor the first time this exercise is conducted. But two follow-up questions also need to be addressed: (a) is it acceptable that the dentists should be uninformed about the proportion of patients in the practice receiving in various kinds of treatment? and (b) which is the better number: the theoretically chosen norm or the actual proportion?
  2. A second type of explanation centers on characteristics of the patients served. It is more difficult to maintain continuity of care in an urban and poor community. An honest use of this explanation for the gap between norm and actual properties requires that the dentist distinguish between patient characteristics and practice characteristics. If the practice advertises boutique services, it will naturally attract a distinct type of patient—but that is a characteristic of the practice. If patients have difficulty getting appointments because the office is only open four days a week and not in the evenings or on weekends, that is a practice characteristic and not a characteristic of patients.
  3. A third type of explanation involves practice characteristics. Consider office location, staffing patterns, types of procedures the dentist prefers to perform, referral for procedures that general practitioners could perform, etc.
  4. A final group of explanations for gaps between norm and observed proportions is that the dentist has set the standards without giving full thought to his or her own ethical values. The dentist may want (or even believe he or she has) a certain kind of ideal practice, but circumstances, drifting attention, or convenience for the dentist or office team may have deflected achievement of this goal. This is the interesting category of understanding because it points in the direction of action that can be taken to create a more ethical practice.

NB: technically, there is a fifth reason for differences between norm proportions and observed proportions: random error. For a sample of 40 to 50 patient records, the error range would be about 6%. For example, an observed proportion of 70% patients who have visited the office in the past nine months would more accurately be an estimate of between 63% and 76%. A sample of 20 records almost doubles the error range (twice as uncertain); while increasing the sample to 100 records only decreases the likely error to 2%. Efficiency and accuracy considerations are the reason for suggesting a sample size of 40 to 50 records in this exercise.

Prudence dictates that dentists should not be overly concerned with gaps between norm and observed proportions that are in the 5% range or smaller.

Closing the Gap

The driving principle of the exercise is the ethical principle of self-honesty. Gaps between the professed and the actual Practice Procedure Profiles of an office violate the principle of veracity, one of the five principles in the ADA Code of Professional Conduct. When this gap is unknown to the dentist or is rationalized away, there is an ethical issue deep within the practice. There are two ways to address the ethical gap of procedure profiles: (a) be honest about the profile in the practice or (b) change it to approximate the ideal. (Realistically, there will likely be a combination of changing the goals, changing the outcomes, and living with discrepancies.)

  1. Review the practice Statement of Practice Philosophy and the Office Ethics Code you developed in exercises C1 and C2. If there is a gap between what is promoted and what is provided, the Statement of Practice Philosophy and the Office Ethics Code must be rewritten on penalty of maintaining a deception. These documents should be changed to accurately and publicly reflect the way the practice actually functions. The office team might very usefully be involved in this process.
  2. Contrariwise, if there are gaps and the dentist wants to maintain the ethical ideal image of the practice, changes must be made in office routine and habits. The focus in this case is on the Office Manual rather than the Statement of Practice Philosophy and the Office Ethics Code. The reasons why there is a gap between ideal and actual is that there are structural routines and habits embedded in the Office Manual that preclude reaching ideal. Examples of changes that might be considered include changes in the following:
  • Treatment plan presentation script
  • Staff configuration (duties of assistants or number of hygienists)
  • Patient management practices
  • CE attended by the dentist and the office
  • Weight given various practice outcomes in determining monthly success
  • The “face” of the office: what team members talk about
  • Relationships with other practitioners in the community
  • Attention to patient satisfaction surveys
  • Means of obtaining informed consent

 Resources 

Dentistry has a rich supply of ethics cases that concern clinical judgment. Perhaps the best collections are

  1. The American College of Dentists’ set of 52 ethical dilemmas collected by Dr. Tom Hasegawa.
  2. Rule, J.T., & Veatch, R. M. (2004) Ethical Questions in Dentistry ISBN: 0-86715-443-8. Eighty-eight dilemmas arranged by category of ethical challenge, with analyses.

Return to Patient Care

The four Blocks you have now completed are designed to integrate with each other and inevitably result in a better ethical climate in your practice and creation of a stronger ethical foundation for patient care.

This self-assessment and self-development program is rigorous and intended to engage the entire office at a deep level. If successful, it will have been transformative rather than offering a few new phrases and acquaintance with best practices. It will also be unique to your practice. No two offices start from the same place and face the same combination of challenges.

The aspirational nature of this program and the detailed self-development activities are important. There is no objective test that can be applied across practices to neatly classify them as “ethical” or “unethical.” The goal is to encourage and guide each practice to become better. There is only one person who can determine whether that has happened: you.

The final Block is easy because all of the heavy lifting has already been done. You are invited to verify that each activity has been completed and to reflect on the results of these activities. How has each changed your practice; what difference do you see in patient care?

You are invited to submit PEAD Reflection form. Upon receipt and verification that the program was completed, you will be issued an appropriate number of hours of CE credit and will receive recognition of your accomplishment.

Thank you for your contribution to the profession!