How Vicious Can the Cycle Be?
The most important change agents in the future of orthodontics may well be the advertising dental franchises, the advertising retail chain store clinics, and the advertising referral agencies. The question is increasingly being asked whether individual practitioners--driven by the inroads into their practices of the advertising dental chains, dental franchises, and referral services--will be forced to retaliate by violating their own ethical value system and advertising. Unless an individual practitioner has developed a practice that is sustained by enthusiastic patient and dentist referrals, it is probably only a matter of time before he is forced to look for other ways of stimulating patients. If individual advertising is the way that is chosen, it will be a fruitless gesture in most instances because a little bit of unsophisticated radio and newspaper advertising cannot be expected to be effective against a lot of slick, sophisticated, well-financed advertising in TV, radio, and print media.
The orthodontist who cannot compete with the Tier II operations will inevitably be forced to join either a Tier I or a Tier II organization, as Avrom King has repeatedly predicted. In Tier I, he might be employed by a corporate clinic. In Tier II, he might be employed by a retail chain operation he might buy into a franchise; he might be associated with one of a number of closed-panel arrangements. There is some sentiment for forming cooperatives of "the good guys" through referral services or consortiums or practice associations in an effort to gain advertising dollars and clout approaching that of the franchises and retail chains. If too many well-heeled advertisers get into competition with one another, it seems likely that the competition will move from sophistication and quantity to price competition and, maybe, to appliance competition with simple appliances. In any event, the survival of the orthodontist may well depend on the strength of the management of the Tier II organization for which he works or with which he is associated.
The orthodontist who survives in private practice may very well benefit from an advertising war in which he is not a participant, because of increased public awareness and enhanced public appreciation for higher quality, individualized care. The franchise that advertises with a jingle "We care about you" must demonstrate that it does care about you. Otherwise, it has created the image and the desire without the substance, and "you" may go looking for a practice with both image and substance. There is nothing about a Tier II practice that precludes the practitioner from caring about his patients. However, the franchise and the retail chain and the referral services are operated by dentist and non-dentist businessmen whose main concern is the bottom line success of the enterprise. They may care more about profits than they care about "you".
Avrom King pointed out years ago that the advent of these new forms of delivery of care represent a threat to the traditional form of practice, but also opportunities for orthodontists to survive in an environment they had not anticipated, but in which they may be nonetheless happy with definite office hours, substantial pay and fringe benefits, and few or no managerial responsibilities. But one is tempted to think that this situation will also change in time, as the businessmen who operate these enterprises realize that they can hire technicians instead of orthodontists for much of the technical work, and organize their orthodontic service accordingly. The orthodontists may then only survive in Tier II environments doing the things that technicians cannot do--diagnosis and treatment planning, judgmental decisions about the course of treatment, TMJ and functional occlusion therapy, the biological and bioengineering aspects of orthodontic care, managing the technicians (hiring, training, and supervising), and the administrative management and marketing of the Tier II practices.
The irony in this cycle is that it could be postulated that the orthodontist's survival in Tier II operations may eventually depend on his being required to do all the things he didn't do, didn't want to do, or couldn't do in his private, solo, fee-for-service practice, and for want of which he got into Tier II practice in the first place.
With the burgeoning of various Tier II modes of operation in cities of 100,000 or more people, plus an echo effect in smaller communities in close proximity to these, relatively few orthodontists can feel immune to the effects of these enterprises on a basis of location. Immunity in almost any location will result from knowing how to manage and market a private, fee-for-service orthodontic practice. Many orthodontists know how to do this and are doing it very well. Many others could do it if they made the effort. Many others could not do it on their own, but could with the help of a practice consultant or consultants.
One of the important keys to successful practice is non-manipulative management of patients, parents, staff, and referrers, and non-manipulative selling of discretionary services. Those who possess these skills intuitively are truly blessed. With appropriate effort, others may be able to learn these skills through reading and training. The rewards will be great in terms of income, independence, and personal happiness and satisfaction.
