THE EDITOR'S CORNER

Orthodontists are faced with a great economic challenge (see page 256 of this issue). It will require new efforts to extend orthodontic care to all segments of the population, especially adults; it will result in increased competition within the specialty, and between the specialist and others now doing orthodontic treatment; it will increase the importance of third party programs because a larger percentage of patients may be expected to have third party benefits.

It does not test one's sensitivity to observe a growing discontent on the part of the public with all the professions. It is on a basis of costs to be sure, but they also say that we have so tipped the balance of our occupations away from the image of learned professionals dedicated to public service and toward the image of entrepreneurs in search of a good livelihood, that we have virtually reduced a profession to a skilled craft, and that they will deal with us in those terms. The implications of this attitude are already visible in the inattention of government to the professions on professional matters and the growing inroads of third party programs on our professional prerogatives with mechanisms such as closed panels, prior authorization, fee schedules, lay review, professional coinsurance, service benefits, fee profiles, indexes of malocclusion and direct payment.

Economic pressures on orthodontists could easily accelerate a third party takeover of orthodontics and on the basis of all of those restrictive mechanisms which are not in the best interest of the public or the profession because they relate mainly to the feasibility of insurance and have little to do with health care.

So, in addition to the economic problems, we are faced with an image problem and a threat to our standing as a profession. Consumers and consumer advocates are questioning the old arrangements between producer and consumer, including their relationship to producers of professional services. Since consumerism is going to affect our lives and our mode of practice, we ought to be concerned about it, to understand it, and to work with it in constructive ways. If we do not, we will encourage antagonisms and voids that will work to our disadvantage.

Lack of communication breeds suspicion and suspicion may result in change for no substantial reason. Change alone is not always improvement. Therefore, it is in our mutual interest to establish a dialogue with consumers and consumer advocates which recognizes their legitimate right to question the old arrangements and our opportunity to work with them to try to see to it that mutual understanding will result in changes that will be improvements. There are signs that we are not aiming in the right direction.

One sign is that we have not yet found a means to establish such a dialogue. Instead, we see erosion of the relationship such as more and more civilian representation and control of third party health care arrangements. It is a sign of consumer distrust.

Another sign is that we are going along with the idea that any dentist is permitted to do orthodontics. The specialty should hold the position that no one who has not had full training in orthodontics should be permitted to perform orthodontic treatment on the public. He could be a pedodontist or a periodontist or a GP, but he must have full training. What is full training? At present it would be defined as a two-year university graduate course in orthodontics. That should be our opening dialogue with the consumer.

Others may try to say that it is self-serving, or that it is not true that education counts, or that in some remote areas there are no orthodontists. There are so many orthodontists so widely distributed and transportation has improved to such an extent, that lack of availability is no longer an excuse for acting against the public interest. Furthermore, I would rather be asked to make a special dispensation in hardship areas than to be in a position of accepting an idea in which I did not believe--namely, that a dentist untrained in orthodontics, or less than fully trained in orthodontics, can perform satisfactory orthodontic treatment.

Another sign is significant opposition among us to compulsory continuing education and reexamination. Most orthodontists I know are taking courses and attending meetings and continuing their education. The idea of reexamination is not to place the conscientious practitioner in some kind of jeopardy. It is to place the public interest first, which is the hallmark of a profession. You may say that we have been getting along just fine without either compulsory continuing education or reexamination, but the consumer is saying that dentists have been using this and our codes of ethics to protect incompetency. Here we are, a superior group of professionals, a large number of whom have submitted themselves for reexamination by the American Board, who have nothing to fear from similar reexamination, and yet are willing to be open to a charge of coverup of incompetence. I think the American Board examination is uplifting to the individual who is examined and to the level of competence of the specialty. We ought to make sure that reexamination is conducted on that same plane and with those same objectives in mind. The more that reexamination has to be forced upon us by laymen, the less likely it is to be to our mutual benefit.

Similarly with performance and quality control. Each professional has been his own judge of the service he produced and each consumer has been the judge of the service he received. The consumer wants to relinquish his judgeship and have some kind of review mechanism. The best kind of review for both the public and the profession would be what is called peer review, which is the profession policing itself. The more we delay in offering peer review, the less likely it is that the consumer will want to depend on us to review ourselves and the more likely it is that he will impose hired review with an ample amount of lay review. Peer review has an additional advantage that we ought to consider. Peer review in orthodontics should take the form of orthodontists reviewing orthodontics. That is in the public interest--to have the most knowledgeable professionals review the field in which they are expert for performance and quality of performance.

So, I think that there are various avenues of dialogue with consumers on the basis that it is in our mutual interest and that it will make sense to the American public if we come forth in their interest.

It makes sense that a well-trained person will perform better than an untrained or inadequately trained person 99 times out of 100. It makes sense that a trained person of good-will will be able to make a better review of his field of expertise for performance of a service and for the quality of that performance. It makes sense that, in a world in which the professions, including orthodontics, are changing very rapidly, that continuing education in various forms is necessary to keep up with the changes and the advancements, and that is in the public interest. To make it compulsory is to take it out of the realm of desire, just as did the graduate university program in the first place. It makes sense that the public is entitled to some evidence that the professional not only attended the continuing education courses and meetings and read the journals and texts, but that he learned what he needed to learn in order to keep up. Periodic reexamination of some kind is in line with that thinking.

There are those who will ask--Why in this year of the celebration of our country's freedom should we think of electively surrendering some of our freedom?

I think we ought to consider these moves because they are right, but also I believe that the future of orthodontics may well depend on how we face up to two issues. One is how much we are willing to put on the scale to tip our image back in the direction. of trusted professionals and away from being lumped with business, and how well we communicate that image to the public; and the other is whether we reverse the precedent in dentistry that any dentist can perform orthodontic treatment regardless of his training.