The Relationship of the Profession to Society

“What Model or Metaphor Can We Use to Best Understand the Relationship of Dentistry to Society?” What are the Tensions that Exist Between Understanding Dentistry as a Profession and Dentistry as a Business?”

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In What Ways Is Dentistry Like A Business?

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In What Ways Is Dentistry Not Like A Business?

Are These Ways In Which Dentistry Not Like A Business Consistent With the Characteristics of a Profession?

Is The Nature of These Transactions Substantively Different

?

• Buying gas at Super America • Buying a suit at Dillards • Buying a Mercedes at James Motors • Minister performing my wedding • Lawyer preparing my will • Dermatologist “Freezing” my actinic lesion • ENT M.D. prescribing drug for my tonsillitis • Pharmacist filling my prescription • Internist doing my annual physical • Preventive medicine doctor discussing with me precautions for travel to China

Dentistry as a Business Conference: Money, Management, Marketing, and Technology

Sponsored by the ADA’s Council on Dental Practice “ADA News,” August 23, 1999

Culture

Understanding culture is our way of understanding people. Acknowledging the existence of different cultures is affirming that different people have different understandings about life and the world. We hold different ways of measuring and evaluating our existence.

Culture Defined

“Culture is the collective, mutually shaping patterns of norms, values, assumptions, beliefs, standards, and attitudes that guide the behavior of individuals and groups, whether those groups be families, colleagues, religions, races, geographic regions, nations, or professions..”

• • • • • • •

Culture provides a construct for understanding behavior.

Culture serves as an interpretive framework to determine what is valued and what is not.

Culture establishes the moral imperatives that bind us together, order our behavior and determine rewards and punishments.

Culture provides contextual clues to interpret words and actions.

Culture gives actions and events meaning.

Culture enhances stability in that it permits predictability and enhances our sense of certainty. Culture permits introductions to and socialization of individuals who would become members of a cultural community.

• • • • • •

Norms

-what the culture understands as normal; that which should occur naturally; the cultures guiding rules or principles.

Values

-what the culture desires; desires create purpose- purpose provides meaning.

Assumptions

-what the culture takes for granted; what it presupposes, takes for granted.

Beliefs

-that in which the culture places its trust and confidence.

Standards

-the uniform referents of the culture; the touchstones used in measuring and evaluating.

Attitudes

-the emotional intentions of the culture; what it feels and wills.

Culture and Ethics • To describe differences between cultures

is not necessarily to draw moral conclusions

; only to characterize differences.

• Of course, one can

prefer

the characteristics of one culture over another. Preferences are not morality.

• Kentucky/California; French/Chinese; African/European; Arabs/Jews

The Culture of Profession

“

Professions are organs contrived for the achievement of social ends rather than as bodies formed to stand together for the assertion of rights or the protection of interests and privileges of their members.” “The organizational component of the profession is explicitly meant to emphasize the advancement of common social interests through the professional association.”

Abraham Flexner

“The core criterion of a full fledged profession is that it must have means of ensuring that its competencies are put to socially responsible uses … professionals are not capitalists, and they are certainly not independent proprietors or members of proprietary groups.”

Talcott Parsons, professor Harvard University

“Dean”

of American Sociology

“Is Social Work A Profession?”

Abraham Flexner School and Society 1915

Characteristics Of A Profession(al)

• Work is primarily intellectual • Work is based in science and learning • Work is practical • Work can be taught and learned • Organized in democratic collegial units • Exist to achieve societally defined goals rather than self interest of its members.

Characteristically professionals

‘profess’

(promise, avow) a technical competency based on a tradition of advanced learning/education for which they will be morally accountable in placing this expertise at the service of society. The concept of profession is deeply rooted in the notion if

“making a promise”

to‘another.

“Knowledge Is Power”

Baruch Spinoza Dutch philosopher

•

Law

: Power over

Property

•

Medicine

: Power over

Person

•

Clergy

: Power over

Providence (Ultimate Destiny)

The extraordinary ethical responsibilities of the professional flow from the

“power differential”

existent between the professional and the person they serve.

Professional Relationship is Fiduciary

• To be a fiduciary means to stand is a special relationship of trust, confidence or responsibility to another.

• Professionals are in a fiduciary relationship due to the power they hold over others; power based in knowledge. They

“know”

when others do not.

• Therefore, others must trust them to use the knowledge they have in their best interest.

“The patient-physician (dentist) relationship is the center of medicine(dentistry). As described in the patient-physician (dentist) covenant, it should be a ‘moral enterprise grounded in the covenant of trust.’ This trust is threatened by the lack of empathy and compassion that often accompany an uncritical reliance on technology and by present economic considerations. The integrity of medicine (dentistry) demands that physicians (dentists), individually and collectively, recognize the centrality of the patient-physician (dentist) relationship and resist any compromises of the trust this relationship requires.”

Richard M. Glass Journal of American Medical Association, January 10, 1996

The Culture of Dentistry As A Profession

• • • • • •

Norm

- Oral health is a primary good; an end in itself.

Value

- Care and concern for all people and their oral health.

Assumption

- Societal good

Belief

- Cooperation and reciprocity with society can result good for all.

Standard

- Justice/Fairness

Attitude

- Egalitarianism

The Culture of Dentistry As A Business

• •

Norm

- Oral health as a means

Value

- Entrepreneurial; building a successful enterprise; profits • • • •

Assumption

- Private good to be maximized

Belief

- Dentistry as a part of the free enterprise system

Standard Attitude

- Marketplace - Social Darwinism

Norms Values Assumptions

Profession Business (Proprietary)

Oral Health a Primary Good … an End Building a Successful Enterprise … Oral Health as Means Care and Concern for Patient Selling Therapies Social Good Individual Good Beliefs Standards Cooperation Leads to Good for All Social Justice Free Enterprise, Competitively Providing Dentistry as Commodity Market Place Attitudes Egalitarianism Social Darwinism Fittest Economically Gain Good of Oral Health

“A new language has infected the culture of American health care. It is the language of the marketplace, of the tradesman, and of the cost accountant. It is a language that depersonalizes both patients and health professionals and treats health care as just another commodity. It is a language that is dangerous.”

Rashi Fein, professor Health Economics Harvard University

Do Any Groups Exist Today in Contemporary America That Are Professions In the Traditional Sense?

*****

Is the Concept of Profession Viable Today?

Has The Business Community Usurped the Concept of Profession By Its Commitment to Product Quality and Customer Satisfaction?

Enlightened Self Interest

• 18th Century thinking bought new social and political understandings, among them the appreciation and valuing of self interest.

• Realization that our private good is ultimately grounded in the larger public good.

• Or, that our success as dentists depends on how we treat our patients.

Short Term versus Longer Term

• Another way of expressing it is we must distinguish between what appears to be in our best interest at the moment from what is in our longer term self interest.

• Sacrificing of quantity of care issues today with monetary implications for quality concerns, in exchange for longer term value of reputation for quality care.

Short Term versus Longer Term

• Interestingly, this is what American business has decided is good business.

• Our business will ultimately make more money, if we provide quality products at fair prices and gain customer loyalty, than if we sell a less than quality product one time at a large profit margin.

What Factors Are Erasing the Distinctions Between The Concepts Of Profession and the Proprietary?

• Power differential going away.

(Education of the populace, Internet) • Increasingly traditional professionals are working in corporate/business settings.

• Business has adopted traditional professional standards of putting the client/customer good first. The former warning of the marketplace,

“caveat emptor” (“let the buyer beware”)

is no longer applicable, due to customer guarantees.

A Lingering Question

Is a visit to the dentist or cardiologist for care in no way substantively different than a visit to the Toyota dealership to buy a new car, or to Lazarus department store to purchase a new suit?