Does Diamond status make me better than you?
This guest post by Dr. Dhru Shah provides valuable insight into the incentives for providing specific treatments. While the focus is on periodontics, Dr. Shah’s comments are highly relevant to the current incentive systems in orthodontics based on “status”.
Dhru is a specialist periodontist based in the UK who operates the influential Dentinal Tubules education platform. His views are valuable and worth considering.
Introduction
I just achieved HuFriedy EverEdge Scaler Diamond Apex status! I’m truly thrilled about reaching this milestone. Just kidding! I haven’t achieved that status, but it would be pretty amazing if I did. While those instruments are impressive, I don’t rely solely on them.
Imagine if incentives were tied to a specific status for using a certain number of endodontic rotary files. What would happen? Would you still choose the most appropriate file system for the endodontic treatment, or would you be subtly enticed to use a particular file system just for the rewards? Would this influence your decision-making regarding patient care and treatment recommendations?
Orthodontics?
Let’s consider a different specialty – orthodontics. What if the treatment was considered a product, and you were incentivised to use that specific product? In that case, would you remain impartial in your treatment planning, or would you be inclined to use the treatment modality of the incentivised product? Would you prefer to approach the treatment from a problem-ideal solution perspective, or would you unconsciously be swayed by the influence of the product incentive?”
Rats?
Incentives matter. The right incentives matter even more. Do you disagree? Let’s go back over 100 years to Hanoi in 1902.
Back then, Hanoi was dealing with a severe rat problem. These weren’t just rats, but flea-infested rats causing all sorts of issues in the sewers. The government took action and hired rat hunters to get rid of them. To motivate the rat hunters, the government offered a reward for every rat caught, presenting the rat’s tail as evidence.
In April 1902, the ratcatchers killed 8000 rats within a week. Now, indeed that would have solved the problem? Instead, the problem worsened, and more rats infested the place.
What had happened?
Knowing the incentive, the rat catchers chose to benefit themselves rather than considering the greater good. They took advantage of the incentive.
Some people chopped off the rats’ tails and released them, while others started rat breeding farms. Regardless, the city was overrun with even more rats, most of which were missing tails. As I mentioned, incentives are important!
Incentives influence your behaviour.
Dentistry presents a unique healthcare situation where it’s crucial to remain unbiased. To be as objective as possible, we should strive to think impartially, although achieving complete objectivity is challenging.
Patients who seek treatment trust us to provide the best care possible. As Charles Feltman noted,
“Trust is when someone is risking making something very valuable to them vulnerable to the action of someone else.”
In this context, patients entrust us with something precious to them.
If incentives bias our actions, how will that pan out?
If the incentive is a discount or Diamond status, how will that influence your decision-making, both on a conscious and subconscious level? We all, indeed, need to earn a living. In healthcare, patients pay for the care and trust they receive. They appreciate when you act in their best interest, and they express their gratitude through payment. This value is not just described; it is felt. The act of paying a bill is emotional. But how would patients feel if they knew you were being incentivised by a product? What would that do to their trust?
Trust?
Imagine if you were a patient of a practice and needed dental care. Would you be happy with your physician or surgeon if they were using a product or prescribing a drug not because it was the best evidence-based solution for you but because they were getting a financial kickback or incentive to benefit them? What would your initial thoughts be?
Yes, the product company has to make sales, and offering incentives would be their way of doing this. They are not healthcare professionals and do this to increase sales.
Yet, as healthcare professionals, we should be the gatekeepers. We should put patient interest above these incentives and make decisions as free from influence as possible.
Instead, we leave the gate to follow the carrot serving us. We are celebrating receiving these incentives.
Just ask yourself:
- What impact do these incentives have on your decision-making?
- Is the incentive informing your treatment decision or is your treatment decision being guided independently? (Both on a conscious and subconscious level)
- Imagine if the solution is not even dental in certain cases.
- Would the dental solution solve a deeper problem?
- With the incentive shroud influencing you, would you be able to see the woods from the apex trees?
If a product is superior to others, it’s important to make decisions based on what’s best for the patient rather than being swayed by incentives. Unfortunately, marketers and educators actively encourage the pursuit of these incentives as a ‘win’. Their main goal is obtaining these incentives, and personal gain is being prioritised over providing care.
How does this affect the trust equation?
Healthcare is a unique profession in which the provider considers the care of the other first and the reward. As a consequence, incentives matter, but the person influenced by these incentives and their behaviour matters even more.
Nope. I want to be something other than a Diamond Apex HuFriedy Everedge Asia and Europe provider. They are fantastic instruments, and I use them.
However, I am a periodontist first. Patients’ care comes first, and decisions are guided by as much science as possible. The instruments are tools in my armamentarium.
I am focused on something other than being rewarded for using the tools more. I am focused on my patients and knowing which tools are appropriate for each case.
Because I am aware that incentives matter.
Dhru Shah, Specialist Periodontist.
Emeritus Professor of Orthodontics, University of Manchester, UK.
Ben Goldacre’s books would suggest that for valid consent information such as discounts, free lectures, products (you know, those free bracket cases) for Drs family and staff need to be disclosed to all patients. All dinners, lectures and overseas visits need to be revealed. In-house lectures at conferences….
Some doctors in my town refuse to see sales representatives.
There are many ethical issues with some of the companies and I don’t deal with those whose values clash with mine.
Again, as Ben Goldacre writes, our actions in colluding with companies whose behavior is questionable rewards companies for poor behavior, therefore part of the problem is us.
Well said. Your last 6 words resonate with me – “Part of the problem is us” . We are the gate keepers and should be exercising our responsibility with care, in the interest of the patient rather than the interest of the rewards and gains
EXCELLENT. Thank you!
Thank you
Excellent blog, thank you.
I think there needs to be more transparency for patients about what the status means. Often people don’t realise it’s due to numbers and they aren’t aware of the financial incentives offered to clinicians.
As someone with a small practice in one location plus a post in a corporate (where my cases don’t count for my status) I rarely qualify for higher status levels, and have resisted signing up for any packages as I want to recommend the best treatment on clinical merit.
Always respected your view Megan.
You are right – transparency is key. Particularly if a patient suddenly realises how the incentive will influence the dentist’s decision making. As healthcare professionals, we should be realising that we have decision making power and that with power comes responsibility.
Fantastic
I totally agree with Dr. Shah’s narrative.
Colin RIchman DMD (Periodontics)
Thank you Dr Richman.
I suppose similar incentives occur in the implant world.
Disagreeing with the idea that being a Diamond Invisalign provider makes you a better orthodontist . While the Diamond status does indicate a high volume of Invisalign cases, it doesn’t necessarily equate to superior skill or patient outcomes. Here are a few points to consider:
1️⃣ Experience vs. Skill: Being a Diamond provider means you’ve handled a large number of Invisalign cases, but quantity doesn’t always guarantee quality. An orthodontist with fewer cases but more personalized, high-quality care can achieve better results.
2️⃣Comprehensive Knowledge: Orthodontic expertise involves much more than just Invisalign. A well-rounded orthodontist needs to understand various treatment modalities and choose the best one for each patient, not just rely on Invisalign.
3️⃣Patient-Specific Care: The best orthodontists tailor their treatment plans to the individual needs of their patients. Being a high-volume Invisalign provider might suggest a one-size-fits-all approach, which isn’t always in the best interest of the patient.
4️⃣Broader Skill Set: Orthodontics includes managing complex cases that may not be suitable for Invisalign. An orthodontist’s ability to handle such cases effectively is a better indicator of their overall skill than just their Invisalign experience.
5️⃣Patient Satisfaction and Outcomes: Ultimately, what matters is the quality of care and patient outcomes. A good orthodontist is one who achieves the best possible results for their patients, regardless of how many Invisalign cases they handle.
In summary, while being a Diamond Invisalign provider can indicate experience with that specific product, it doesn’t necessarily make someone a better orthodontist overall. True orthodontic excellence comes from a combination of experience, skill, comprehensive knowledge, and patient-centered care.
Thank you. I really agree with Number 5. Patient centred outcome. That is the key. You have identified some very important points. History will judge this profession by its behaviours
I would like to commend Dhru Shah on his excellent post.
It is pervasive practice to chose a product and then find a patient, however it should be our resolve to refrain from this. A commercial company functions to produce the product, selling more is the commercial objective, however it is our clinical decision to decide, with the patient, how to achieve the clinical objectives.
In summary the companies have been doing their job very well, and we (including me) need to look at how we can do our job better.
it’s also great to see the collegiate concern and reflections shown by Dr Dhru (periodontist) of concerns in orthodontics, I hope we repay the favour, perhaps through creating less bone loss
With power comes responsibility
Thank you for the kind comment Farooq
The tragedy is that although we as professionals should be exercising these high standards of practice and care, the patients will never be aware of the deeper meaning behind a Diamond status provider ; that it is likely to be associated with not the best appliance system being used for the orthodontic problem. So the situation is fundamentally reduced to the problem “ Let the buyer be aware” . This places the burden of due diligence on the buyer of the service ie, the patient. The patient will have to do their own research and ask the clinician questions. However, the marketing engine for aligners is so strong, that it will mislead the patient as it does not offer a balanced view. An opposing marketing engine ( not for profit) needs to generated to educate patients and make them more critical of the services which are being offered.
I agree about educating patients. It is extremely important.
I also think we as professionals should be the ones carrying the responsibility. The due diligence is first on the healthcare professional and then second, on the buyer of the service – the patient.
What do you think?
Thankyou for the interesting post.
Incentives for product purchase have been around since the birth of the orthodontic specialty. I would encourage all fellow bloggers to read more about Edward H Angle, his patents, royalties, his passion for education and re-inventing orthodontic mechanical appliances.
As far as I am aware in my part of our wonderful world, status, as I believe Dr Shah is referring, does not intend or pretend to reflect quality or skill level, as is clearly discerned and accessible to those referring to such labels- please see below. I would be interested to know if this is not so clear to potential patients in other geographic areas.
Using only 1 such example, with the advent of the computer programmed aligner, Align Technology were obligated by law to allow any registered dental practitioner – including those from other dental specialties to use the appliance system. Many clinicians became “certified” (FDA regulation), subsequently using the “qualification” to market their practice. The status level was, I believe of great help for potential patients to determine at least some level of familiarity with the new appliance, as “certification / accreditation / training” did not reflect any experience whatsoever beyond the introductory class in treating patients with the new system. Fast forward 27 years and we have a tiered discount system in place for appliance purchase – just as Angle offered, just as bracket companies have done and continue to do so. Quantity does not guarantee quality, I’m not sure where that is implied for either brackets or aligners?
Totally agree with comments above, the responsibility is on the practitioner, on our specialty to treat all patients ethically, within local legal guidelines (and to be as periodontally friendly as we may be). Incentives influence behavior, KOL’s influence behavior, instructors and bloggers influence our behavior, there are endless influences on treatment decisions and practice. Surely our graduate education, including ethics and critical thinking skill prepares us for these ubiquitous factors?
VV- presents lectures, some may be sponsored by Align Technology
https://www.invisalign.com.au/find-a-doctor?
What do these icons mean?
The status levels and other designations used in this tool are not intended to reflect the quality or skill level of the dental practitioner or dental practice nor be viewed as an endorsement or recommendation by Invisalign of any dental practitioner or dental practice.
https://meridian.allenpress.com/angle-orthodontist/article/79/6/1028/58685/A-Biographical-Portrait-of-Edward-Hartley-Angle
“Through 1908, his last days in St Louis before his retirement from the active practice of orthodontia, Angle routinely gave 20% of his specialist’s fee to the referring general dentist as a commission…(this practice became outlawed)…
He also knew that the more orthodontists he trained to use his appliances, the better would be his chances for a lifetime annuity from appliance-sale royalties.
Well summarised on so many aspects. Thank you.
Unfortunately, there was not any orthodontist who could criticize this clear aligner treatment madness. Therefore, it was left to a periodontist to write this remarkable note. I congratulate him wholeheartedly. Thank you Dr. Shah
Unfortunately I see the same in the implant world. Is the profession now being led by the product industry?
This poses a bigger question too about education. Is our healthcare and CPD/CE being healthcare led or product led? I have written about it at https://www.dentinaltubules.com/content/is-cpd-and-ce-now-healthcare-led-or-product-care-led
Kevin I am happy for you to post that too
This post epitomises the disquiet I have had for teh direction our proffeion has been taking for many years now.
My job is to provide the best care for my patient – and being incentivised to sell more has to put a bias on my thinking. I am sad to see that Smilelign has joined in to this incentivised system. I was happy to support a UK business that didnt offer reduced prices for more sales. We are health care professionals first and foremost – not salesmen.
As always, an interesting dialogue. In the United States, the volume rebate/discount price model, as practiced by Align Technologies, is very common and frankly encouraged by large hospital systems, health insurance companies, medical and dental practices, consumer groups, and all levels of government. Encouraged? Yes, encouraged because of cost savings that could be passed on to the consumer. It is assumed that this is done ethically by appropriately evaluating treatment and prescription drug recommendations, supplies, and equipment purchases. For the USA, as long as a practitioner does not abuse their “designation,” the profession and specialties will live with this concept associated with volume purchases.
It is interesting that some USA medical groups and manufacturers use a different designation for their procedure or product, e.g., a Center of Excellence for Arthroscopic Knee Surgery. Does that sound pretty good to you? How about a Center of Excellence for Osseous Integrated Implants? It could be—you never know!!! I recommend fastening your seat belt.