The personal touch

Most readers will have been aware of the rise in corporate ownership of UK dental practices, be that because they have read the press announcements of burgeoning numbers of corporate purchases of dental practices, and also the mushrooming numbers of corporate chains. What I was not aware of is that this has been happening increasingly in GP medicine, with one in 20 GP practices now being owned by chains.¹ There has also been a rise in corporate ownership over the past decade, with firms that own at least five different GP practices now running 6.1% of all surgeries in England, this figure rising by 2.1% over the past 10 years. The Chief Executive of one chain has stated that single-doctor practices are no longer viable, and, while patients feel secure with the idea of a trusted family doctor who has known them for years, such a model is no longer fit for purpose. Those who have visited a GP doctor in recent years will be all too aware of the difficulties in obtaining an appointment with a named doctor. The personal touch is being lost.

Readers will also be aware that medical (and dental) practices have to operate at a profit so that the practice owner and his/her team can have security for their practice outgoings, and personal mortgages, everyday living expenses, etc, but, the corporate model necessarily includes another financial tier, namely the need to pay shareholder/corporate owners and all parties with a financial interest. In that regard, Dr Steve Taylor, a GP and spokesman for the Doctors' Association UK has stated that ‘larger practices can have advantages of economies and scale and that some GPs have moved in this direction’, but ‘not necessarily because it is good for patient care but out of financial expediency’.¹ Recalling my time in the medicolegal world, the GP subscriptions were the financial foundation of at least one indemnity organization, but probably all of them, given that few patients sued their ‘named’ GP who provided a personal touch, but when the model changed to larger group practices, this changed because patients no longer had continuity of care with a named GP, and no longer had a relationship with one doctor and certainly not to a group practice.

Is there a lesson for dentistry from all of this? Certainly. Patients do not want to see a different dentist each time they visit a practice, be it corporate or not. As I wrote, two Comments back,² we still need dentists in the UK who are prepared to sort out mouths that are in freefall. By doing so, practices and reputations are built – and the freefall patient who has his/her dentition sorted will remain a patient, or even a friend, for life. This could not happen without continuity of care. I feel that establishing a continuing (and hopefully longstanding) relationship with a patient will reduce the risk of adverse medicolegal occurrences. In that regard, I listened to a great talk by Dr Tif Qureshi at the BDIA Conference. His theme was ‘new patients sue dentists’ (these being principally the patients who are attracted by pretty pictures on Instagram), while ‘longstanding patients don't’. In that regard, if readers have the chance, Tif's webinar on ‘The lifetime patient vs the cosmetic patient’ is well worth a watch. I am aware that research has started on this. Len D'Cruz, Head of Indemnity at BDA Indemnity recently advised me: ‘From our early data on this, we can see the following trends: firstly, new patients or patients who have not been in for more than two to three appointments to the practice are more likely to complain or raise a claim or leave a negative on-line review. Secondly, the relationship appears to be with the individual dentist rather than the practice, i.e. the patient may have been to the practice a few times, but when they see a new dentist in the practice, the bond of trust may not be as strong unless that dentist is a longstanding dentist in the practice, i.e. experience/’seniority’ counts (Len D'Cruz, personal communication, June 2023). The personal touch is therefore important.

In a dental practice, the arrival of a new patient who has been introduced by a longstanding patient starts the clinician accepting the patient with an advantage, because they attend, having already heard good news about what the practice provides: that patient will have confidence that they will have a good experience. The ‘Instagram patient’ does not have that advantage, because all that those patients will have seen are photographs and perhaps testimonials. And, also worth remembering is that a smile is joined onto a patient and that before starting any ‘smile, bleaching, veneering’ treatment, there is a patient who the clinician must get to know. Makeover patients are not immune from suing dentists. ‘Never treat a stranger’ is a comment variously attributed to Sir William Osler (a Canadian physician, said to be the founder of modern medicine), but also to LD Pankey. This ubiquitous quotation is worth remembering, however simple the treatment might seem. There is more to it, insofar that William Osler advocated spending substantial time with a patient on the first, or an early, visit, stating, as he did, that ‘the accomplished clinician must, therefore, not only master the science of inquiry and the art of observation but must also establish the rapport that precedes the unguarded flow of pertinent information from the patient’.³

Another famous ‘Oslerism’ was ‘Listen to the patient (s)he is giving you the diagnosis’.³ The personal touch, by which the dentist takes time to listen to a patient before treatment commences must surely be a worthwhile investment in a clinician's time. In that regard, LD Pankey (himself an advocate of comprehensive, patient-centred dentistry who spent much of his life helping other dentists understand the happiness and fulfilment to be had in closer relationships with patients) stated ‘The pre-clinical interview is important.’ And, as an aside, in dentistry, corporate or otherwise, let's not have ‘the vanishing GDP’, in the way that ‘the vanishing GP’ appears to be forthcoming in the UK. That would be deleterious for the personal touch.

PS Readers may be interested to read other ‘Oslerisms’. Here are three examples:⁴

• One finger in the throat and one in the rectum makes a good diagnostician.
• The very first step towards success in any occupation is to become interested in it.
• The good physician treats the disease; the great physician treats the patient who has the disease.