Interview: Increased commercialism and overtreatment in dentistry
Overtreatment, as the word suggests, is excessive or unnecessary care provided to patients for a variety of reasons, such as malpractice, pressure from management or financial gain. In a recent interview, Dental Tribune International had the opportunity to discuss the topic with Dr Alexander C. L. Holden, a specialist in public health dentistry and a senior lecturer at the University of Sydney. Holden co-authored a study that explored overtreatment in Australian private dentistry. He found that some dental professionals are no strangers to commercialism and that the pursuit of profit often prompted them to provide more dental treatments than were necessary.
Dr Holden, how did you become interested in this topic and what was the main issue you wanted to address in your study?
When I was newly qualified in the UK, I worked at a practice where the professional culture was all wrong. All the clinicians were pressured by the practice management to focus on meeting financial and activity-based targets. I didn’t work there for long, but the experience very much stayed with me and has shaped the direction of my career ever since. When I moved into an academic career, I was able to investigate the issue of how commercial pressures might impact clinician behaviour—an area in which I had long had an interest.
Based on your findings, what factors prompted the dental professionals in the study to engage in overtreatment?
None of our participants reported engaging in overtreatment themselves, but they reported that they had commonly encountered this phenomenon in the practice of their colleagues. Some participants suggested that they felt the pursuit of greater financial gain and profit growth was a major influence on their colleagues’ behaviour. The culture of “selling” treatment and the proliferation of courses that purport to teach dentists how to increase their acceptance rates also influenced their professional conduct.
Participants also reported noticing that some colleagues would actively look for treatment to carry out in order to sell more treatment. Alternatively, they would try to create additional needs and wants for patients by suggesting that they undergo cosmetic care that they had not asked about.
In your study, you talk about the link between professionalism and commercialism in dentistry. Could you elaborate on that and explain what impact the commercialisation of dentistry could have on professionalism?
It is probably important to acknowledge that increased commercialism in dentistry is not necessarily an isolated phenomenon in society, as the same commercial influences have an impact to a greater or lesser degree on the rest of healthcare and on life in general. Despite this, the healthcare arena and dentistry hold a special status, since clinicians deal with vulnerable patients who do not typically have the same knowledge and skill as their treating practitioner and cannot assess their own condition.
“Increased commercialism in dentistry is not necessarily an isolated phenomenon in society”
The dentist–patient relationship needs to be resistant to influences which diminish professional duty, and dentists need to place patient interest before financial gain. When we buy other goods and services, we know that the person we are transacting with has no obligation to give us a fair price or to make sure that we can make an informed choice about our purchase. Dentistry is different. The profession should be robust in preserving the special nature of the dentist–patient relationship, which is an essential part of being a professional group of skilled people.
In that case, do you think that overtreatment is detrimental to professionalism?
Absolutely! Dentists are highly dependent on public trust, and cases of proved or suspected overtreatment tarnish the whole profession. We should engage in sincere and mature conversations about how we might protect the public from overtreatment occurring in dentistry. Presently, a lack of data about diagnoses, as well as having a lack of linked data systems, prevents us from being able to holistically understand how important an issue overtreatment might be. What our research provides is an understanding of the nature of the problem.
“Dentists are highly dependent on public trust, and cases of proved or suspected overtreatment tarnish the whole profession”
How could the commercialisation of dentistry empower patients to access dental care?
The commercialisation of dentistry could deliver patients greater choice through enhanced competition, which may encourage greater self-regulation in the profession. In a competitive marketplace, unethical behaviour becomes more visible to both colleagues and the public. Whereas an increase in commercialisation might offer the public superficial promises of greater choice and lower cost through competition, this benefit can only be actualised through the preservation of the dentist–patient relationship, where patients do not have to apply a “let the buyer beware” attitude.
Editorial note: The study, titled “Overtreatment as an ethical dilemma in Australian private dentistry: A qualitative exploration”, was published online on 1 November 2020 in Community Dentistry and Oral Epidemiology, ahead of inclusion in an issue.