Merit pay for dentists.

The federal government wants to bring in merit pay for teachers. It sounds like a really great idea. Until you think about it. Politicians are very keen on the idea because they believe it resonates with the voting public. Funny thing is, you never hear politicians talking about merit pay for parliamentarians. Now, why is that? Or dentists for that matter.

My dentist is great! He sends me reminders so I don't forget checkups. He uses the latest techniques based on research. He never hurts me, and I've still got most of my teeth.  When I ran into him the other day, I was eager to see if he'd heard about the Federal Government's latest program for improving the dental health of our children by introducing merit pay for dentists.

"Did you hear about the new federal program to measure the effectiveness of dentists with their young patients?" I asked.

"No," he said. He didn't seem too thrilled. "How will they do that?"

"It's quite simple," I answered. "They will just count the number of cavities each patient has at Grades 3, 5, 7, 9, and average that to determine a dentist's rating. Dentists will be rated as excellent, good, average, below average, and unsatisfactory. That way parents will know which are the best dentists. They check the results on the government's Myteeth website and make wise choices."

"The plan will also encourage the less effective dentists to get better," I said. "It will improve the entire dental system because poor dentists who don't improve will lose their licenses to practice."

"That's terrible," he replied.

"What? That's not a good attitude," I said. "Don't you think we should try to improve children's dental health in this country?"

"Sure I do, but that's not a fair way to determine who is practising good dentistry."

"Why not?" I asked. "It makes perfect sense to me."

"Well, it's so obvious," he said. "Don't you see that dentists don't all work with the same clientele, and that much depends on things we can't control? For example, I do a lot of my work in a rural areas with a high percentage of patients from deprived homes, while some of my colleagues work exclusively in upper middle-class neighbourhoods. 

"Many of the parents I work with don't bring their children to see me until there is some kind of problem, and I don't get to do much preventive work. Also, many of the parents I serve let their kids eat way too much sweet food from an early age, unlike more educated parents who understand the relationship between sugar and decay. To top it all off, so many of my clients use rainwater tanks which are untreated and have no fluoride in it. Do you have any idea how much difference the early use of fluoride can make to dental cavities?"

"It sounds like you're making excuses," I said. "I can't believe that you are being so defensive. After all, you do a great job, and you needn't fear a little accountability."

"I am not being defensive!" he replied forcefully. "My best patients are as good as anyone's, my work is as good as anyone's, but my average cavity count is going to be higher than a lot of other dentists' because I chose to do some work where I am needed most."

"Don't' get touchy," I said.

"Touchy? I'm furious." His face had turned red, and from the way he was clenching and unclenching his jaws, I was afraid he was going to damage to his own dental work.

"In a system like this, I will end up being rated below average, or worse. The few educated patients I have who see these ratings will believe this so-called rating scheme is an actual measure of my ability and proficiency as a dentist. They may leave me, and I'll be left with only the most needy patients. And my cavity average score will get even worse. On top of that, how will I attract good dental hygienists and other excellent dentists to my practice if it is labelled below average?"

"I think you are overreacting," I said. "'Complaining, excuse-making and stonewalling won't improve dental health'... I am quoting from a leading member of the DOC," I noted.

"What's the DOC?" he asked.

"It's the Dental Oversight Committee; a group, made up mostly of carpenters, plumbers and hair stylists, to make sure dentistry in this state improves."

"Spare me! I can't believe this. Reasonable people won't buy it," he said hopefully.

The program sounded reasonable to me, so I asked, "How else would you measure good dentistry?"

"Come and watch me work," he said. "Observe my processes. Considering what I have to work with, I add considerable value."

"That's too complicated, expensive and time-consuming," I said. "Cavities are the bottom line, and you can't argue with the bottom line. It's an absolute measure."

"That's what I'm afraid my parents and prospective patients will think. This can't be happening," he said despairingly.

"Now, now," I said, "don't despair. The Federal government will help you."

"How?" he asked.

“If you receive a poor rating, they'll send a dentist who is rated excellent to help straighten you out," I said brightly.

"You mean," he said, "they'll send a dentist with a wealthy clientele to show me how to work on severe juvenile dental problems with which I have probably had much more experience? BIG HELP!"

"There you go again," I said. "You aren't acting professionally at all."

"You don't get it," he said. "Doing this would be like grading schools and teachers on an average score made on a test of children's progress with no regard to influences outside the school, the home, the language background, the community's socio-economic status and important factors like that. Why would they do something so unfair to dentists? No one would ever think of doing that to schools."

I shook my head sadly, but he had brightened.

"I'm going to write to my parliamentary representatives and senators," he said. "I'll use that school analogy. Surely they will see the point.”

Sadly, I walked away.