THE EDITOR'S CORNER
Most orthodontists survived the Seventies more or less intact, but worried about what the future may bring. What can we expect from the Eighties?
While a substantial number of orthodontists can be expected to continue to practice in a more or less traditional manner through the Eighties, it seems obvious that we have lost control of a major portion of those factors that influence our destiny with regard to economic, social, and political events, and that we will be carried along on a tide of consumerism, traditionalism, anti-professionalism, experimentation, and change. The Eighties will undoubtedly see growth of advertising, merchandising, and marketing in orthodontics. We will see more closed panel health care facilities, some of which will have an orthodontic department. We will see more vertical and horizontal group practices, and associations of practices in franchises and consortia. We will see many referral relationships between specialty practices and closed panel clinics, open panel clinics, unions, corporations, and retail dental facilities. Many more practices will be located in stores, in clinics owned and operated by the store or as concessions leased out to individuals, groups, or dental chains, each of which may not necessarily be owned by a dentist or dentists.
Orthodontists have been in the forefront of training and using expanded duty auxiliaries and can be expected to relinquish mechanical tasks to an increasing extent in the Eighties and to assume the role of diagnostician and supervisor of the tooth-straightening process, while paying much more attention to those factors which will enhance the success of the treatment and the value of successful treatment to the whole person and to his well-being.
On the technical side, one can see the Eighties as a time of consolidation and perfection of what we now have. This could mean more accurate methods of bracket placement, less visible appliances, more use of bonding and better methods of debonding; more understanding of forces and more precise control of forces. We can expect more attention to be paid to the human side of treatment--patient profiling and patient management for the side problems that could interfere with the efficient completion of optimum treatment. It would not be rash to predict that by the end of this decade, most orthodontic offices will have one or more computers and that these will be used for diagnosis, practice management, practice research, monitoring of treatment, storing a great deal more data than we are accustomed to think we need or want.
On the economic side, the trends that contributed to the decline in patient starts in the average practice are still with us as we enter the Eighties. Any increase in birth rate that we are now seeing will not appreciably affect child patient case starts in the Eighties. We will definitely see an increase in the number of adult patients.
We also will have the impetus on the part of single working adults and, especially, married and unmarried women in the work force, to seek improvement in their appearance and self-image, and in their sense of wholeness. Nevertheless, a good part of the increase in adult interest in orthodontic treatment will be balanced by a steady decline in the numbers of 7-17-year-olds in the next decade. The economics of orthodontic practice should be helped by this shift, however, because adult orthodontic treatment should command fees that are one-third to one-half higher than child patient fees, and orthodontists are paying more attention to raising child patient fees on a regular basis to keep up with increased costs and inflation. At the same time, the presence of larger numbers of adults may cause changes in treatment and adminstrative procedures.
Increased costs and inflation are continuing at a rate that is not encouraging for the economy in general and for orthodontists.
It is important for orthodontists to understand the rationale of the consumerists, legislators, Sunset committees, public health officials, educators, and various bureaucratic agencies (FTC, HEW, Council of State Governments) who are moving dentistry away from traditional care and delivery of care. Their view is that a majority of people are not receiving adequate dental care and that the chief barrier is price. Dentists point in vain to the fact that dental fees have not gone up to the extent of other goods and services and, indeed, have not kept up with inflation. The adversary group believes that dental fees ought to be lower than they are and that they have been held artificially high by lack of competition, by monopolistic control of entry into the profession, and by the fact that dentists are overtrained for the mechanical tasks that they perform. They believe that dentists for the most part only want to do the finest quality work for people who can afford it.
How would they solve all the problems? To create the competition that will lower the price, rescind the ADA Principle of Ethics which prohibited advertising. To break the monopolistic control over entry into the profession, change dental practice acts to permit ownership of dental practices by non-dentists, and move to federalize dental practice acts and controls. To replace dentists in tasks for which they are deemed to be overtrained, promote the use of expanded duty auxiliaries for most of the mechanical tasks in dentistry, to some extent without dentist supervision. To get dentists to substitute minimum satisfactory alternatives to the highest quality choices of treatment, depend on price competition, the alternative work force of auxiliaries, and alternate forms of delivery of care.
It would be an apt metaphor to describe the dentist as a peach tree from whom the government and others would like to get apples. Failing that, they will plant their own apple trees.
How many dentists survive under these circumstances depends on how many people prefer peaches to apples and are willing to pay the price. Most people who cannot afford peaches also will be unable to afford apples. Ultimately, it may be found that apples cost just as much as peaches, and then you will see the government move to socialize dentistry completely. Even then, there will be some people who prefer private practice and are willing to pay the price.
How long do you think it will be before the same forces that are changing dentistry in general today turn their attention to specialty dental services?
The same reasoning which was applied to dentistry in general will be applied to specialties. The price is too high. Less well paid professionals can perform satisfactory lower quality treatment for more people at a lower price. In addition to extensive use of auxiliary personnel, we will see advocacy of the supergeneralist. General practitioners whose traditional role will largely be handed to expanded duty dental auxiliaries will be encouraged to assume the role that traditionally has been served by specialists. How many specialists survive under these circumstances again will depend on how many people prefer high quality treatment and are willing to pay for it.
Traditionalists like ourselves are angered by external forces which are contrary to our beliefs and value systems, and occasionally we cry out that "someone ought to be fighting against these wrongful changes". We hope that somehow people will see the light and return to the old values and the old ways. From evidences that we have seen in other areas such as education, professions are weak institutions and do not have the ways and means to withstand external change and, while dissatisfactions may arise even in the minds of the protagonists of change, questioning the wisdom or effectiveness of the changes, this process may take 30 to 50 years and in the end, the environment may no longer be relevent to the past or served by a return to it.
This does not mean that the individual orthodontist who desires to continue in private practice is doomed. Certainly he should be able to do so in the Eighties, but how successful he is will depend to a much greater extent than in the past on how well he is able to offer a service which enough people perceive to be beyond the ordinary.
