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Doctors

Dr. Bruce Peltier

Bruce Peltier, Ph.D., M.B.A.

July 18, 2009

Thank you very much, Dean Ferrillo. We are lucky to have such good leadership in times like these, and it is a real honor to speak at this very special event.

Members of the DDS and IDS classes of 2011, and the Hygiene class of 2010, welcome to your white coat ceremony. You have good reason to feel proud and afraid, both at the same time. You all have worked so hard to get here, and done so well!

This is indeed a big moment, for it marks the point where dental students and hygiene students make the big leap from rubber faces and plastic teeth to real people and dentin. We like to celebrate this moment and mark it as powerfully as we can, because you students sitting here in front of us are about to begin a long career that must be built on a foundation of trust.

I am going to talk for just a few minutes today about what it means to be a doctor, or for some of you, a professional hygienist. This is a very big deal. You know it is, otherwise you would not have put in all the work and time and expense and struggle necessary to be here today. You deserve to be congratulated for your hard work and your success. You should feel good.

But all that was preliminary. It only served to set you up for what is just around the corner next week, and that involves invasive procedures on the human body. Your work will produce great good or great harm, depending on how you perform. You can enhance people's health and self-esteem or you could cause them to have a permanent paresthesia or worse. Occasionally, your work even involves matters of life and death.

I want to talk to you today about the fact that doctors and health professionals are not like everyone else. You are special, and I want to explain why. You have already heard this explanation once during your first year, and it is so important that you will hear it again later this year in your ethics course.

The main point is this: doctors are not like regular business people, and dentistry is not just another business. There are essential and fundamental differences, and you need to grasp them and embrace them, for they benefit you at the same time they invoke a special responsibility. In the commercial marketplace in a capitalist economy, buyers and sellers interact in a competitive relationship. Each strives to make his or her best deal, and anyone who has ever used eBay knows this well. The buyer is trying to get as much as possible while paying as little as possible, while sellers do just the opposite. It's the seller's goal to give as little as necessary to get paid as much as they can.

This is no surprise, even though the exchange is typically conducted in a friendly way. You know that you might not be able to fully trust the other person, so you have to do your homework or risk getting burned. If you are a buyer, you must carefully research the product or service, you must study the seller as best you can, and you should shop around before you make your purchase. In the business world this is known as due diligence, and in economics it is called "caveat emptor," let the buyer beware. It is the buyer's duty to study the situation and look after their own interests.

As a buyer, you get burned once in a while, and you feel abused. Eventually you shrug your shoulders and move on, vowing never to let that happen again. Imagine, however, if this happened at the doctor's office. How would you feel if you found out that your orthopedic surgeon performed surgery on your knee primarily because he or she could make more profit by doing so?

This is such an important and timely issue that no less than the Supreme Pontiff, Pope Benedict the 16th weighed in with an encyclical just last month. He wrote:

Profit is useful if it serves as a means towards an end that provides a sense both of how to produce it and how to make good use of it. Once profit becomes the exclusive goal, if it is produced by improper means and without the common good as its ultimate end, it risks destroying wealth and creating poverty.

He goes on to write:

Economic activity cannot solve all social problems through the simple application of commercial logic. This needs to be directed towards the pursuit of the common good, for which the political community in particular must also take responsibility. Therefore, it must be borne in mind that grave imbalances are produced when economic action-- conceived merely as an engine for wealth creation-- is detached from political action which pursues justice through redistribution....

And finally:

There is nevertheless a growing conviction that business management cannot concern itself only with the interests of the proprietors, but must also assume responsibility for all the other stakeholders who contribute to the life of the business: that is, the workers, the clients, the suppliers, the community of reference.

What makes these comments so interesting, of course, is that they were written by someone hardly known as a wild-eyed socialist.

Health care is different from regular businesses for two essential reasons: First of all, there is typically much more at stake in health care, and second--unlike the buyer-seller relationship--the doctor-patient relationship does not consist of an exchange between equal parties. The conflict between the nature of health care and the nature of the commercial marketplace is one of the reasons we have such a hard time establishing a viable system of health care delivery in the United States.

In the first instance, there is much at stake for patients in the dental chair. What you young doctors and hygienists do is often irreversible. You can't take it back and exchange it or return the product and get your money back. When a tooth has been extracted, that's it. When a prep has been cut you can't put the tooth structure back on. When you give a child too much anesthesia, well, you know the story.... The consequences can be severe.

The second difference between business people and doctors is that of information asymmetry. Doctors know way more about the body than patients do, and since there are so many complex oral health conditions, it is unlikely that patients could ever catch up to doctors unless they decided to go to dental school. If you doctors tell me that I need a root canal, I cannot effectively evaluate your diagnosis and treatment recommendation.

This example is not an abstraction, because while you students were enjoying Cancun in June I was down at 450 Sutter Street getting a root canal. In my case, actually, I had decided that I did not need RCT, as the pain had disappeared as quickly as it had shown up. I figured that all was well until one of our colleagues urged me to get care. There was no real way for me to evaluate the situation other than to decide whether to trust a dentist and the profession of dentistry. The endodontist tapped on my tooth, put cold on it, and tapped on another tooth. He pointed to things on an X-ray, and I pretended to see what he was talking about. But, I couldn't tell. I had to make a big decision — a $2,000 decision based almost completely on trust. That's the way it is in health care. Patients do this every day.

The plot thickens, of course, when you throw money into this asymmetric equation. The need to trust doctors results in a fiduciary relationship where doctors become the agents of their patients. You young health care experts must help patients make decisions that are best for them. The problem is that you get paid more if they decide to have more work or more complicated procedures done. But, they don't know what is going on, so you have to make decisions for them and for yourself at the same time. You could easily make decisions that are better for you, and your patients would never know the difference.

In the marketing literature this is called "supplier-induced demand," and it is viewed as a good thing. Clothing manufacturers encourage new fashion trends because they can sell more clothes that way. You will come face-to-face with this situation next week in the clinic as you begin to work on your clinical goals or requirements or thresholds. It is tempting to do more work on a patient if that work will move you forward towards graduation, and who could blame you. But, sometimes your goals will not align with your patient's goals. In those cases we are counting on you to be trustworthy and to make decisions based first on the needs of your unsuspecting patient.

As you may have already discerned from your observations in the clinic, there is really no way for our faculty to monitor you closely enough to completely eliminate these kinds of problems. As a matter of fact, we are not all that interested in such close supervision. We want to demonstrate that we trust you, so that you will incorporate trustworthiness into your own professional identity. It would be hard to overemphasize the importance of this part of your value structure, as your professional autonomy depends upon it. If integrity and your patient's interests are not central from now on, the profession will be in deep trouble. Your colleagues as well as your patients depend upon you, because bad things happen when the public loses faith.

So when you get into the clinic next week remember four other quick points:

  1. You are there to serve your patients, not the other way around.
  2. Your patients will be scared of you, and fear causes all kinds of inexplicable behavior, including tardiness, missed appointments, too much talking, silence, dumb jokes, and grumpiness.
  3. Manage the rapport, for it is all important. You will not succeed without solid doctor-patient rapport.
    and finally,
  4. Tell the truth, even when it is difficult and embarrassing.

Here's one last bit of advice, while I'm at it:

Celebrate. You can start this in just a few minutes. Take time to appreciate what you have accomplished, and do this continuously throughout your career. You've gotten through the first year of dental school at the University of the Pacific, a world-class accomplishment. You've made it into the clinic and you've put yourself into a very good spot in life. Congratulations.