Dear Editor:

Since I am no longer in active clinical practice, after more than five decades of practice, I have the opportunity in my “new life style” to take part in activities that are important to me. I am actively engaged, both locally and nationally, in fighting managed care. But as part of the fight, I am concerned about how psychologists interact with the community at large.

Recently, our APA announced a program to combat violence in school settings. I was deeply interested and contacted the local school authorities and received an enthusiastic response. My next step was to contact psychologists in the area to enlist their cooperation.

What I encountered, after attempts to enlist three psychologists, was bitterness about our APA not recognizing that time was the only commodity that was part of the psychologist’s livelihood and why was the APA so willing to ask psychologists to donate their time. The anger that was expressed made me thoughtful. Two psychologists said: “I would give time in an emergency or hurricane and would do that freely. But aren’t my services professionally part of what school taxes cover?” It was the anger that was expressed that concerned me. Statements such as: “They are sitting there in D.C. on salary and benefits. What about us?” After discussion with my wife, I decided to call Ray Fowler directly. I have been a member of APA since World War II. He was courteous but stated that these were the rough times that private practitioners would have to go through.

I am feeding this into the “hopper” because there is something radically wrong when three psychologists who have been active workers in the field of clinical practice and strong advocates of professionalism and professional organizations, are so negative to our central APA.

Max Rosenbaum, PhD.
Palm Beach, Florida

Dear Editor:

I have recently had the opportunity to begin knowing some dentists who are doing some really interesting work. Their goal is to establish dental practices, as one put it to me, on the principles of Carl Rogers. At first, such a statement stunned and confused me, so I listened carefully.
Basically, they are interested in a high quality, relationship oriented practice. In this relationship, both parties are of equal importance, rather than assuming that the "doctor" is in charge. Rather than seeing the doctor as knowing more, the doctor and client, as these dentists call consumers of their services, are co-experts. The goal of the relationship is to create a lifetime plan for the individual's teeth. The teeth are seen as a part of a human being, rather than a disembodied mouth. Therefore, they strive to take the whole person into account.

They reject symptom based dentistry as endorsed by dental insurance plans and insist on offering the highest quality approach they know how to provide. The initial evaluation of the individual's dental situation is unlike what most of us have experienced. The first step is an interview, done by a dental assistant and then with the dentist. It is designed to develop some real understanding of this new client - their goals, fears etc. Mutually acceptable goals are begun to be negotiated. The new client then gets into the chair but not for anything intrusive. Instead, pictures are taken of each tooth with an interoral camera. The pictures are instantly shown on a video screen visible to the client and dentist. The client is beginning to see his/her teeth in ways they probably have not before. The goal is for the client and dentist to co-discover what issues exist, rather than the dentist being solely responsible for this process.

Next, full mouth x-rays are taken, then 35 mm pictures are taken, and finally impressions are taken. In the next appointment, all the information gathered is reviewed by dentist and client together in the office, not in the chair. Then the dentist does the traditional oral exam, sharing findings along the way. By the time that the initial evaluation is complete, the dentist hopes that the client knows the problems and issues that will be reviewed, so that there are no surprises when they have their next interview and a treatment plan is suggested. The goal in this is that the client comes to own the problems rather than trying to place responsibility on the dentist to "fix me." The dentist knows that in the long run, the quality of results will largely depend on whether the client has come to own the problem rather than perceiving the dentist dependently as the one who will fix the problem.

This is a highly time consuming approach. It is different from the manufacturing approach that most dentists, reacting to insurance company restrictions, have taken. (Managed care has also demanded that we take a manufacturing approach with our consumers as well.) Gregory Tarantola, DDS, writing in Dental Economics (1997) said it this way: "What will it take for your practice to thrive and prosper into the 21st century in a managed-care environment? You can begin by clarifying the real issue, which, by the way, is plainly not private-fee-for-service vs. managed care. The real controversy is a much more fundamental, global issue: comprehensive care in a relationship-based practice vs. limited care in a manufacturing based practice."

Tarantola is talking about practicing on the basis of one's values, rather than on the basis of where the money comes from. If one can practice within one's values under a managed care system, then there is no conflict. If, however, one cannot practice within one's value system, there is serious trouble ahead.

I went to a seminar run by another dentist working to learn how to practice according to these principles. He said it exceptionally well when he asked the group if they have a money centered practice or a values centered practice. A money centered practice is indicated if we have altered what we do because the funding source told us we had to. Such behavior, it seems to me, is consistent with addiction - the term I have often used to describe our relationship with third party reimbursement. Those who are addicted to something often alter their value based behaviors in order to satisfy their addiction. A values centered practice is indicated when you offer what you believe to be the best quality care you know how to provide, allowing the client to make his/her own choices. Ironically, both for dentists and psychologists, it seems quite clear that those who create values centered practices are making more money than those who have money centered practices.

I know that I have inadequately presented the approach of this group of dentists. However, I find their attitudes and approach so exciting that I wanted to share it. I found that I had things to learn from them that help me in what I am trying to do with my own practice. Hope you find this useful.

Dana Ackley, Ph.D.
Author of Breaking Free of Managed Care
3635 Manassas Drive, Roanoke, VA 24018
540-774-1927 danaackley@juno.com

Editor's Note: Dr. Ackley’s letter originally appeared on the Division 42 Listserv. It was reprinted with permission at the editor's request.

Letters