by David W. Chambers, EdM, MBA, PhD
Part 1: The new model
Evidence-based dentistry probably won't work. It doesn't put the emphasis where it belongs - on the individual dentist providing care to individual patients. The same can be said for the CE circuit and for many consultant groups. Trial-and-error sounds a bit scary, especially that part about "error." Insurance companies, specialty groups, and even organized dentistry would be happy to offer "guidelines" to get every dentist doing the same thing. Quite a bit of advice is free for the asking if you are interested in buying some equipment, materials, systems, or other products.
Dentistry can be improved, and some patients are becoming pretty insistent about that. A lot of new voices are out there, each with an opinion about what should be done in dental offices. Researchers, agencies, organizations, and experts for rent all have something to say. But the chief role has always and still does belong to the individual dental practitioner. Outcomes-Based Practice (OBP) is an effort to find that individual voice.
The high-speed handpiece, matrix bands, many dental materials, a large number of orthodontic techniques, patient-management protocols, and computer software all have been developed by practicing dentists. And those are just the headline grabbers. With the exception of a few who are merely going through the motions, dentists everywhere are making adjustments, testing alternatives, verifying product claims, and finding a better way to serve their patients. These changes are not flashy nor are they for everyone - but they do add up. Think of what your own practice was like 10 years ago. Did you import every improvement? Doesn't it also reflect your unique touch in a thousand small innovations, specially suited to your needs and those of your patients?
It is inherent in dental practice to make constant improvements. Although it is becoming a big business for folks to tell dentists how to practice, whose business is it really? When all dentists and practices are the same, there will be one correct answer for every important question. Meanwhile, individual practitioners bear the ultimate responsibility for bettering the profession ... one office at a time.
The fundamental unit in dentistry is the practice. Dental schools, initial licensure examinations, and partial prepayment plans (there is no such thing as dental insurance) have it wrong because they deal with procedures, not practices. Capitation is wide of the mark because the basic unit for third parties is populations and the opportunity for care - not the actual care of individuals. Researchers explore the theoretical underpinnings of practice that they find interesting or can get funded. Manufacturers make better tools, but they have no control over how those tools are used. It is only at the practice level where we can understand the relationship between the dentist's work and the patient's health. Education, organized dentistry, research, industry, the continuing-education enterprise, and others can help practitioners in this work. But it should never be the other way around, as we sometimes hear today.
I tend to use the word practice as a noun - something you have, rather than as a verb signifying repetitive and somehow not-quite-adequate activity. Think of a dental practice as a structured opportunity that has two purposes: to provide care for patients and to offer a way for dentists and staff to grow and become more completely fulfilled. Dental practice is earning while learning. Practice is like an option in business. It is an asset and an opportunity to invest in one's own future. Practicing does not automatically lead to either income or improvement, but it is a unique opportunity for both. It is one of the characteristics that sets professionals apart from salaried workers.
The residual value of owning a practice comes when it is sold to someone else who wants an opportunity to treat patients and fulfill themselves. Not everyone can have a practice. Dentists' practices are licensed, capitalized, and uniquely invested with the mind and personality of the dentist.
Outcomes-Based Practice depends on one critical assumption. I cannot prove this is true, and I know several dentists and many others whose miserable lives prove my assumption is not universal. For the most part, however, it is human nature to grow - not just as a defensive reaction to our changing world, but as an intrinsic desire to reach our full potential.
Dentists manifest the perpetual self-improvement principal through their practices. Some see themselves as artists; others as care-givers. Some measure success in monetary terms; some prize admiration. For some, practice is a manifestation of a spiritual calling or community service; for others, it's just "the thing they do best and get the most satisfaction from." For most dentists, practice is a rich blending of these motives. Only a few have stopped trying to improve; no one has maxed out.
How do dentists feed their intrinsic desire for self-improvement? Everybody besides dentists seems to have the answer for this one. Because so much "success" fuel has been thrown on the fire, we are in danger of smothering the flame. The dogmatic didactics of dental education too often have left a bad taste in dentists' mouths. Most research is aloof and esoteric. Mandatory CE sounds too much like having to take our medicine. The gurus and manufacturers have a faint odor of commercialism about what they recommend.
The most powerful engine for self-improvement in dentistry is the dentist. There's simply no alternative. Most of what dentists learn over their careers they learned by observing outcomes of what happens in their practices. The need today is not for more information or opinions, nor for professional groups that screen information, only allowing "authorized truth" to reach wet-gloved dentists. What we need is a reaffirmation that dentists learn continuously in their practices, and we could use a few tools to help us do this better. This is what I call Outcomes-Based Practice - continuous improvement of individual dental practices through reflection on outcomes (assessed practice goals).
This is the first in a 12-part series. Next month, we will look at OBP alternatives - why evidence-based dentistry won't work and the terrors of policy-based dentistry.
