Article
Once upon a time, long, long ago, patients formed judgements about dentists after meeting them and, in most cases, after receiving treatment from them. Advertising was not permitted by the General Dental Council (GDC) in those days, the signage outside dental practices was strictly limited in scale, size (and even the size of any lettering) and the choice of wording of anything resembling patient information or promotional material was very tightly controlled and policed. The GDC's guidance in those days (the equivalent of Standards for the Dental Team1 today) warned against making claims that were ‘grandiose or flamboyant’, exaggerated or ‘not capable of substantiation’.
Those ancient readers who are still able to explain what a ‘telephone directory’ was, may also remember that dentists were permitted only standard entries with no bold text or highlighting, and certainly no ‘feature’ advertisements in panels alongside the main directory. After all, it was essential to avoid the cardinal sin of drawing attention to yourself in any way. In fact, this dystopian vision describes the status quo barely 20 years ago.
Fast forward to 2022 and even the most cursory journey on that magical mystery tour that is also still known in some old-fashioned circles as ‘the internet’, will introduce you to what seems a very different virtual dental profession with a staggering range of virtual skills and other claims to virtual fame. You don't even need to meet these dentists to know how brilliant they are. Before you get close to crossing their exalted threshold, these virtual dentists can convince you of things that are virtually wrong with your teeth, your gums, your oral and general health – and especially your smile and facial appearance – that you never even realized. Moreover, they can persuade you that they are the perfect choice of dentist to fix it.
The well burnished egos of the star performers in the dental practices whose wares are marketed in these slick online promotions are impressive indeed, and in many cases they are complemented with an equally compelling social media profile. Self-doubt and humility are scarce commodities. Patients seemingly queue to deliver rave reviews and must be close to running out of superlatives when singing the praises of the dentists and their extra-special skills.
Against this dizzying background one might reasonably ask whether there is still a place for professionalism (or even truth) in an increasingly commercial, consumerist and competitive healthcare market. If there is, perhaps it needs to be a different kind of professionalism – a modern professionalism, fit for the reality of a very different modern world? Or has the whole idea of professionalism simply become an embarrassing anachronism? Interestingly, all this hyperbole is much more a feature of primary care dentistry than it is of medical GPs, or of opticians, chiropody, osteopaths etc – and we can all ponder the reasons for that.
Professional regulators in any field, but perhaps especially so in conservative fields like the law and healthcare, will always struggle to keep up, and inevitably there will always be some who will be quick to take full advantage of that fact. In Standards for the Dental Team1 the GDC devotes a generic four sentences (Para 1.3) to a very high-level exhortation to act honestly and with integrity and not to mislead, although in fairness the GDC's current supplementary guidance does make a further more targeted effort. However, it all seems rather quaint and out of touch: the guidance on social media2 seems blissfully unaware of how these channels are being used as a powerful marketing tool, and offers no effective direction or warnings in this regard. Meanwhile the guidance on advertising3 suggests that while patients can check (on the GDC website) whether you are registered and whether you are on a specialist list, they are ‘more likely to rely on information that you provide such as practice leaflets or certificates on the practice wall’. On the practice wall? Beam me up Scotty before we run out of Sellotape or Blu-tack.
In some parts of the world, however, a few dental regulators are well ahead of the curve: for example, the Dental Board of Australia and the Australian Health Practitioner Regulation Agency that supports it, produce comprehensive guidance4,5 for all registrants on what is and is not acceptable advertising, patient information and promotional material – even anticipating and answering the question of what is (and isn't) a testimonial or ‘purported’ testimonial. And before you ask, in Australia, testimonials are not allowed anyway if they make any reference to clinical treatment provided, or the clinical skills of the provider. I should add that most of this guidance has been around for at least 10–15 years.
Significantly, National Law in Australia also prohibits any advertising of a regulated healthcare service that directly or indirectly encourages the indiscriminate or unnecessary use of regulated health services.3 In short, you can't advertise in a way which encourages patients to seek the provision of dental treatment that isn't strictly necessary, or which will not benefit them, or which might harm them in some way. Australia may be located on the other side of the world from the UK, but in this respect, it might as well be in a different universe. In the UK, if you want some kind of dental procedure badly enough – however crazy or ill-advised – you will have no difficulty in finding someone willing and able to provide it, and more than happy to advertise that fact.
Another illuminating aspect of the Australian guidelines is that when promoting one's services or allowing such promotion by others, one cannot use images that have been altered or enhanced in any way, or where the lighting, contrast, make-up or framing is designed to create an expectation of an outcome that may be more favourable than is likely to be achieved in the circumstances of an individual patient or prospective patient looking at that advertising. What you showcase on your website or in social media must be realistically achievable in the mouth of any and every patient who might view those images – concentrates the mind doesn't it?
If on reading this you are already in shock, and thinking that such constraints are draconian and ridiculous in this day and age, you certainly won't like the even stricter prohibitions currently imposed by the Dental Council of Hong Kong6 where any information, communicated in any way to patients or the wider public, must be objectively verifiable and presented in a balanced manner. As in Australia, patient testimonials are forbidden, but so also are testimonials from colleagues, and dentists who teach/train other dentists can't seek and share any adulation from that direction either in order to impress patients. When referring to the efficacy of any particular type of treatment, both the advantages and disadvantages must be set out with equivalent detail and clarity. Such information must not be laudatory, sensational, exaggerated or misleading, nor make comparisons with other dentists or claim/imply undue superiority over them. Most strikingly, it must never aim to solicit or canvass for patients, nor be persuasive or capable of generating unrealistic expectations.
In the UK, most marketing consultants would give you a very strange look if you asked them to design a website or social media strategy that would not attract patients or stimulate demand, would not make you and your practice appear more attractive than any other practice and, above all, would not be ‘persuasive’. Among the very long and comprehensive list of restrictions in Hong Kong is the following extract:
‘Any web component or technology in any form that invites or solicits contact with the dental practice, or may lead to invitation or solicitation of contact with the dental practice, or may amount to touting or leading to any unfair advantage over other dentists is strictly prohibited.’
The overall approach of the Dental Council of Hong Kong is conveniently summarized by the following extract from their Guidance, which provides much food for thought:
‘Promotion of dentists' services as if the provision of dental care were no more than a commercial activity is likely both to undermine public trust in the dental profession and, over time, to diminish the standard of dental care’.
There are further echoes of some of this in the ethical code and guidelines published by the Singapore Dental Council,7 which similarly bans not only testimonials (whether from patients or third parties), but also the use of ‘before and after’ pictures – or even ‘after’ images alone on the grounds that ‘anecdotal cases create unjustified expectations of the results of treatment, which may vary’. Dentists in Singapore pledge to honour the ethical code, in the preamble to which the following text appears:
‘The dental profession has traditionally been held in high esteem by patients and the public at large… The public image of the profession as a whole is greatly dependent on the impression created by individual practitioners… In modern dental practice, the public not only expects dental practitioners to have the necessary knowledge, skill and experience of dental practice but to maintain the highest standards of moral integrity and intellectual honesty.’
With this in mind, the guidance strictly prohibits ‘soliciting’ or ‘touting’ for patients by any means, and speaks a lot about ‘dignity’, ‘professionalism’ and ‘collegiality’ (especially in relation to activity designed to entice patients away from other dentists). It proactively shuns the cult of celebrity and reminds dentists that they are part of a healthcare profession, not of the beauty industry, thereby putting a firm brake on the whole ‘cosmetic dentistry’ bandwagon. For example, ‘Advertising must not seek to induce ill-founded fear or insecurity about health or longevity, nor play on the public's sense of self-esteem or generate overly critical perceptions or dissatisfaction with self, body image or physical attractiveness. Dental practitioners must not advertise using elements of glitz, glamour, style, famous locations, associations with celebrities and the entertainment or fashion world’.
This is all a far cry from the current free-for-all here in the UK where it is a dangerously short walk to companies who, for a fee, will happily create and disseminate fictitious testimonials and online feedback – as glowing as you want, as many as you want – to be posted on social media and on practice and other websites. When coupled with grotesquely self-aggrandizing descriptions of dentists and their skills, training and even qualifications, and heavily photoshopped ‘before and after’ illustrations of past successes (or even, borrowed or library pictures of other dentists' past successes) it is little wonder that patients are lured in. And these patients come along with very clear ideas of what they want and which ‘celeb’ smile they want to emulate. One often hears from clinicians that a patient wanted, insisted upon or even ‘demanded’ x, or that they flatly refused to consider y (often a simpler or more conservative approach). This may even be so, but it can also be the result of what the patients have been told or led to understand or believe in the process of forming those views. The outcome is self-fulfilling – precisely as it is designed to be.
Which brings me back to professionalism. A salesperson is trained to explain the benefits of a particular product or course of action, to stress those benefits and tone down the volume on any limitations or downside aspects for fear of introducing doubt and/or losing the sale altogether. And salespersons are also taught how to counter and meet any objections or hesitation by re-stressing the benefits and playing down any risks or disadvantages. However, the proper role of a genuine professional, whether a lawyer or in healthcare and other fields, is to explain to patients/clients what is and isn't in their best interests, and why. A clear, honest and balanced explanation with no bias or coercion, however subtle. The biggest no-no of all is deliberately steering a patient towards the course of treatment that delivers the most money or profit to the dentist, and then clutching at spurious straws to justify that on pseudo-scientific, quasi-clinical and ersatz-evidential grounds. There is no difference between this and the mis-selling of financial products such as PPI or investments to generate maximum commission for the so-called ‘professional adviser’ making the recommendation. And we all know what happened there.
So why are the controls so weak here in the UK and so out of step with other countries? Some years ago, under relentless pressure from the consumer lobby and the tabloid media, as well as some politicians, the GDC opened the floodgates and allowed advertising – initially within certain limits. The stated aim was to provide members of the public with more information, and thereby allow them to make better informed choices and decisions. In theory this made reasonable sense, but in reality it was the next step on the slipperiest of all slippery slopes. I remember from my youth that my driving instructor had sensibly devoted my first lesson to ensuring that I could control and stop the vehicle. By the time the GDC thought about that, it was already too late, and the ‘limits’ – to the meagre extent that they exist at all – have become incredibly light-touch, so it is small wonder that many believe that they effectively don't exist at all, and consequently anything goes.
A few months ago, Primary Dental Journal published an article I had written on the topic of professionalism, viewed from a medico-legal perspective.8 In that article, I expressed my personal view that dental patients don't want our technical skills alone (however good they are): they want, expect and deserve the rounded totality of our professionalism. By this I mean a suitably balanced combination of the following that characterize the members of a given profession and distinguish them from others who can't or won't commit to and adhere to those standards.:
Those who wish to explore these and related issues more closely may wish to refer to the article in question. However, another point I made in that article is directly relevant here, and I wish to expand on that. It concerns the issue of quality – our own perceptions of the quality of care provided, the perceptions of patients receiving the care and treatment, and the perceptions of third parties, such as professional colleagues and/or bodies such as the GDC. It would be naïve to expect all those perspectives to coincide, but having spent more than 30 years of my career in and around the dento-legal field, I can readily confirm that they very often don't. That fact keeps the indemnity providers busy and many law firms in gainful occupation. Rather too gainful for my taste… but I digress.
Dentists might tend to measure the quality of the treatment they provide by inwardly focused and relatively narrow, technical and objective criteria. Patients, on the other hand, are more likely to apply subjective criteria – what matters to them, how they feel about the overall experience and whether their expectations were met.
Patients assume, when they visit a dentist, that they are in a protected environment where they can be confident not only that acceptable standards of care will be provided, but also that someone somewhere is in charge of regular checks and balances to make sure it stays that way. That is why patients feel so let down when something goes wrong. Dentists, on the other hand, will usually consider that they are delivering an acceptable standard of care and many will go further, genuinely believing that they deliver an above-average or even excellent standard of care. Mathematicians and statisticians will no doubt be intrigued to learn how and why the majority of dentists, being intelligent people, after all, could possibly believe that they are all above average, but my advice would be for the mathematicians to try to persuade those dentists otherwise. They will soon appreciate what they are up against. Dentists view clinical standards as an integral part of their professional status; a challenge to or criticism of those standards cuts deep into the psyche and sense of identity as a professional.
In the above-mentioned article, I made the further point that it matters little how excellent the treatment happens to be in a technical, clinical sense (and how amazingly gifted the treating dentist is, or believes themselves to be) if the treatment is not necessary in the first place, or has been provided under false pretences on the strength of misleading and deceptive information having been given to the patient (or more balanced information withheld), or if the treatment is not in the patient's best interests. In those circumstances the treatment cannot, by any definition, be excellent: the dentist has committed the dental equivalent of a ‘professional foul’ (sic) and yet, no referee is on hand to wave a yellow card, nor any VAR available to publicize the felony.
Another complication is that other dentists may well have a very different opinion to the treating clinician (and a perspective that may or may not be wholly neutral). The fact that they weren't there when the original treatment was provided, and weren't privy to any of the key communications, has the potential to render their views more (or less) charitable. Such a view is inherently less informed, but most of the time, it is also more independent and less heavily invested in a particular outcome. I do accept that there are exceptions when some professional ‘baggage’ exists between the parties.
Bodies such as the GDC, the NHS or an employer are viewing things through yet another, different lens, and will often pick up on and criticize things that nobody else has raised – least of all, the patient. Compared to quite a few of the things that the GDC waves through without comment, some of the trivia that preoccupies them and their advisers is a regular source of wonderment.
Summary
The whole point of professionalism is that each aspect of it facilitates and enhances the next. It solves so many of the other potential problems associated with clinical dentistry, while the absence of professionalism creates or exacerbates them. It does the profession, and its most admirable, unsung members, a disservice when dentistry descends to the healthcare equivalent of the Wild West with no effective constraints over the claims of expertise that can be made, the promotion and provision of ill-advised and perhaps harmful treatment at the expense of the best interests of the patient and the trashing of the profession's position and reputation in the eyes of the public.
I certainly don't yearn for ‘the good old days’ if that means a blanket prohibition on practice promotion – it is not particularly ‘good’ when patients have no information at all, and indeed poor or unethical practices can in some respects even benefit from the resulting anonymity. I fully accept that policing modern media is not easy, but it is a nonsense for the GDC to continue to suggest that members of the public are better off for having so much misinformation and disinformation available to them. They are colluding in the consumerist shambles of patients being put in the position of having to choose their dentist on highly questionable grounds – the more you are prepared to exaggerate and misinform, the more attractive, profitable and successful you become. Meanwhile, those who simply get on quietly with their lives and career, care for their patients conscientiously and do a great, ethical and professional job find themselves diminished and eclipsed by virtual reality on all sides. They cannot compete equitably in this virtual professional environment with colleagues who play by different rules.
And nor do I accept for one moment the argument so often levelled at those who don't support the current tsunami of electronic deception, which is that such reactionary views are hopelessly outdated and that you can't hold back the tide of ‘progress’. When the search engines stop searching, social media stops twittering, TikTok stops ticking and reality finally replaces fiction and illusion, patients still want and expect us to demonstrate all those same ‘old fashioned’ professional and ethical values, just as much as they ever did.
Other regulators around the world are having to wrestle with the same challenges made possible by developments in information and communications technology, and many of them are showing leadership and innovation in their approach to reminding healthcare professionals of their obligations, and holding them to account. It is entirely possible to work with change rather than turning a blind eye to it. Here in the UK the GDC's outdated and laissez-faire approach is failing in its statutory duty to protect the public, while at the same time failing in its less obvious moral duty to maintain public confidence in the reputation of the profession it regulates, upon whose shoulders the entire cost of the GDC regulatory burden falls.