What's Happening to Dentistry?By Dr. David Carsten“The vast population of this earth, and indeed nations themselves, may readily be divided into three groups. There are the few who make things happen, the many more who watch things happen, and the overwhelming majority who have no notion of what happens. Every human being is born into this third and largest group; it is for himself, his environment and his education to determine whether he shall rise to the second group or even to the first.” -Nicholas Murray Butler, President of Columbia University, 1931 My experience is broad and from that I have perspective. Rural, urban, private practice, group practice, hospital, university, academic, regulatory, local, regional, and national are all places or situations I have worked. I have observed what is happening in health care and dentistry from “on high” and “on the ground”. The high debt of graduating students and how that guides their decisions is very concerning. These high debt new doctors are reluctant to specialize for the reason of taking on more debt. I worry about the expansion of dental service organizations and the disappearance of small practices. I wonder about the disappearance of small dental laboratories and schools that teach technicians. The low reimbursements from dental insurance companies and how that affects the quality of care is disturbing. I strongly object to dentistry being paid almost entirely by surgical procedures and not by diagnosis and prevention that get at the cause. Our aging and gradually sicker population is more challenging to treat and has greater needs. I wonder about the push for midlevel providers gradually becoming providers for more and more patients. I strongly support evidence-based practice and despair how little dentistry is evidence-based. The advent of artificial intelligence systems is welcomed since that will focus on evidence but there is a lack of understanding of artificial intelligence systems and a tendency to always believe the black box. Robotic providers are arriving now. The doubling of biological scientific knowledge happens roughly annually and I know that the increasing knowledge of the disease process and treatments will outmode current practice. Primary care in medicine is woefully short and I wonder who will pick up the reins and how. I am disappointed in seeing the number of healthcare educators decrease when we need many more to work through all these changes. The changes are numerous, increasing, and accelerating. What are stakeholders thinking? From my perspective as a state commissioner that conducts public hearings regarding infection control, anesthesia, and other topics, I have a very good sense of what dentists are thinking. They want change to happen slowly if at all. They fear rapid change. As a professor, I have a pretty good idea of what students and faculty are thinking. Faculty and students are trying their best to satisfy requirements. As someone connected to national ADA efforts, the JCNDE, and other organizations, I have a pretty good idea of what they are thinking. The ADA, ADEA, CODA, and the JCNDE, groups I know, are planning for change but it is difficult to be too far ahead of your constituents and many decisions reflect what constituents want. It is difficult for constituents to be future-focused when the present has many challenges. What can we expect? The traditional solo dental practice is fading in favor of groups that can take advantage of corporate power and consistency. The continuing push for both efficiency and access to care will increase pressure to add midlevel providers and automation. People with the Dr title will be more and more removed from technical procedures. There will be polarization. Dentists will be forced to decide to focus on high-end dentistry (a small proportion), become a manager of DSO systems, become a dental specialist with high-level skills, or become an Oral Physician with primary care responsibility and capability. As the standards shift to overall health, the definition of competence will shift. A closer collaboration with medicine is being baked into education, expectations, and standards of care right now. Speaking the language of medicine becomes imperative along with a broad understanding of health care. Technology needs to be embraced but the limitations understood. The changes are coming faster than people expect, perhaps like climate change, the consequences are arriving today. The tipping point is long past. There is no going back. The essential problems are complacency, fear, the willingness to wait to respond, and even Pollyanna optimism. There are choices. What drives those choices? Our emotions drive our choices, fear, compassion, greed, anxiety, curiosity, gratitude, and generosity to name just a few. What drives you? Will you be meta-cognitive, understand your thinking and feelings, be able to look at the evidence objectively, and make the best decision for you, your family, and your practice? Many newly graduated dentists feel driven to join corporate practices for economic concerns as well as lifestyle. More than thirty percent were choosing that direction in 2020. What will be the outcome? Better access to care? Greater evidence basis? Will quality increase or decrease? Will there be an alternative to selling to a DSO? Specialization will be increasingly attractive but without more programs and more educators, that is very limited. Moving towards collaborative care with medicine, the Oral Physician specialist, is attractive and programs may well develop. They do not exist yet. There are currently many barriers, not just in insurance but in knowing medicine, knowing the language of medicine, and having the confidence to stand and collaborate with other healthcare providers as a full partner. The demand for “high-end” dentistry will likely increase. There will be fewer laboratories to support the few dentists that can provide the highest quality. To travel that path will take increasing sacrifice, education, and determination. Costs will increase. The trend now includes far too few technicians that will remain in practice for the demand. With very few highly skilled technicians, high-end dentistry will be an aspiration attainable for very few. What about solo or small group practices? We can see that this group is getting squeezed. Being neither high-end nor corporate, their costs are higher than corporate and their fees are lower than high-end. Can this stabilize or will many be forced to make unattractive choices? A heavy dose of truth and honest self-reflection is required for each dentist. Being fearful of change won’t help. Ignoring it is worse. We all have to ask ourselves what our mission is and how best to get there. What action will I take to shape my future and the future of oral health care? The changes will be coming quickly over the next 10 years. Change is already in motion, a tsunami is approaching. Those of us close to retirement have little to worry about. Those of us in our early careers will have some flexibility. Those of us in the middle will have hard decisions to make. What will be the key characteristics of the successful healthcare provider of the future? I am certain that followers of the 2500-year-old Hippocratic oath will survive and perhaps thrive. Let me be pithy and summarize the spirit of that promise. 1. Be compassionate, ethical, and prosocially moral. Do what is in the best interest of the patient. Be truthful. 2. Practice critical thinking. Read and understand scientific literature and know how to determine truth from fiction. 3. Always be sharpening clinical judgment. Have and maintain a high level of expertise. 4. Have solid relationships with colleagues, auxiliaries, and patients. Forty years ago when I saw my first patient, it was a very different world. There have been too many changes to list. There will be more change in the next ten years than in the last forty. There is a saying in politics that the rules are made by those that show up. It applies to much more than politics. Showing up for continuing competence, initial competence, state licensure, interstate licensure, interprofessional collaboration, interprofessional knowledge, and infection control has been important and productive for me. I have made friends on these projects that work on many other projects. There is much to do, the tasks of many. I have chosen to be part of the guidance to a better outcome, working with talented people. It requires doing your homework and following through to be an effective part of a state dental board, to volunteer through the ADA, to teach at a dental school, to lobby your legislature, and to seek opportunities to guide the future. Action cannot wait or dentists will be asking themselves, “What happened?” “As our knowledge expands…The perimeter of our ignorance increases.” - Neil deGrasse Tyson, 2022  David Carsten, DDS is a dentist anesthesiologist.
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