Thursday, January 09, 2014

Dr. Chris Salierno: Good Dentists Can Make Bad Decisions

Interview with Dr. Chris Salierno

Dr. Michael DavisBy Michael W. Davis, DDS | January 9, 2013



Dr. Chris Salierno Introduction


Dr. Salierno received his B.S. from Muhlenberg College and his D.D.S. from SUNY Stony Brook School of Dental Medicine. He completed his formal training at Stony Brook Hospital’s General Practice Residency program where he focused on implant prosthetics. Dr. Salierno practices general dentistry in Melville, New York. 

Early in his career Dr. Salierno served as president of the American Student Dental Association. He has continued to lend his leadership skills to serve his colleagues, as well as the public, by serving on a variety of committees that promotes enhanced professional ethics for the dental profession—including advocacy for new dentists.

His published professional papers and educational lectures have elevated quality care in dentistry. He writes and lectures internationally on a variety of subjects including, implants, occlusion, TMJ disorders, and practice management.

Much of his lecture content is available on his blog, The Curious Dentist, which also features candid discussions about everyday dentistry. Dr. Salierno is  co-editor of The Surgical-Restorative Resource, which focuses on the team approach to complex dental care. He is a past Chair of the ADA New Dentist Committee, and is currently the President of the Suffolk County Dental Society.


Interview Questions

Dr. Davis: Dr. Salierno, your blog, “The Curious Dentist”—directed at our Dr. Chris Salierno pull quote 2junior colleagues— is very eye opening. It is troubling to see the minefield recent dental  graduates often must navigate. Senior doctors like myself often have no idea what challenges our next generation of doctors are facing with future employers.

One example, of course, is transferring the tax burden of federal FICA taxes from the employer, to the employee dentist, therefore increasing the employer’s bottoms line. Employers habitually misclassifying “employees”, as “independent contractors”. This, of course, is illegal and in direct contradiction to well established and routinely enforced IRS Guidelines.  

We have seen employers configure employee dentist compensation, using a convoluted structure of percentage of collections or billable services which would require a doctorate degree in economics and quantum mechanics to decipher. In numbers of cases, employee dentists are not getting a fair deal. 

There is also indisputable evidence of the pressure experienced by our junior colleagues to provide high-skill services, such as molar endodontic therapy in a rapid cut-rate manner. None of this serves the best interest of the patient, nor the dental profession.

Dr. Salierno, could you please highlight a few of these problem areas for dentist employees. In fact, I’d love for you to publish a paper specific to these issues, and give a lecture to every senior dental school class, prior to graduation.

Dr. Salierno: I’ve actually participated in an initiative just like you’ve suggested. The ADA’s Success Program brings leaders into dental schools to give presentations on subjects like ethics, practice management, and career choices. Programs are offered for first through fourth year and I’m happy to say that the majority of schools take us up on it. The main message to students is that they are not alone, no matter what challenges may face them in the years to come.

And I’ve heard about challenges from our colleagues that would make your skin crawl. Lying, cheating, and stealing come in all forms. I think the worst area right now is non-dentists influencing treatment decisions, which is more prevalent in the corporate setting. Dental schools and programs like the ADA Success seminars try to keep up with the myriad of ways that the rules can be broken.

I also hate when corporate recruiters make owning a business sound like rocket science. They play on young dentists’ anxieties and financial hardships by offering a “safe” way to just focus on clinical dentistry. Owning a business is a privilege of our profession and it keeps control in the right hands… ours.

We should focus on teaching the core principles of ethics and critical thinking to help protect the next generation. I advise my audiences to always trust their instincts and keep an active dialogue with their peers. Regardless of the practice setting, corporate or private, employee dentists need to keep talking to each other. The more we talk, the less they can deceive.


Dr. Davis: Unlike in my earlier time, numbers of dental programs are graduating a fair number of doctors, who are foreign nationals. We often focus on how certain employers take advantage of low-skilled low-pay foreign nationals in the workplace. However, today we have examples where some unscrupulous dental clinic employers hire foreign nationals as dentists, and sponsor their work visas. They sometimes hold power over these doctors, to follow company directives (often unwritten), no matter how unethical. How can these doctors be better protected, as well the patients they serve?

Dr. Salierno: That is truly unfortunate. I know some talented individuals who came to this country to be honest and productive members of the dental community. An employer can use their visa status as leverage to keep them overworked, underpaid, and practicing unethically. I don’t believe this is a widespread problem at this time, fortunately.

I think this is a matter that we should police ourselves. If we suspect that a clinic is engaging in this behavior they should be reported to the proper authorities, namely Office of Professional Discipline (OPD). But the investigation should not be limited to the clinical work of the dentist; it should also inquire as to the management practices of the business. Educational programs that accept foreign-trained dentists should teach them about their rights to practice in this country.


Dr. Chris Salierno pull quote

Dr. Davis: You have been a vocal and prominent advocate for protection of the doctor/patient relationship, especially from intrusions of outside third parties, like the insurance industry and unlicensed corporate clinic employers. Why is protection of the doctor/patient relationship of such importance and benefit to the public welfare? Can you give an example or two, where violation of the doctor/patient relationship, by a corporate third party harms patients? How can this be averted?

Dr. Salierno:  When the dentist-patient relationship is disrupted, both the dentist and the patient lose; only the disruptor benefits. A young employee is susceptible to influence since they are still forming their own clinical decision-making philosophy. Some of us are more aggressive or more conservative than others and that’s fine. But where we fall on that spectrum should be based on our sound clinical judgment and respect for the patient’s needs. An employer dentist or non-dentist employee may influence that young dentist based upon the desire to make more money and nothing else. When that happens, the patient is a victim because they were over-treated.

But the young dentist is also a victim. Their treatment philosophy may begin to change. They drink the Kool Aid, so to speak. They start to think, “Well, all fillings eventually become crowns, so I might as well save the patient time and money and just do a crown now.” The only people who win are the non-dentist employees who make their quota and the employers who sell more dentistry.

This influence comes in sneaky ways. Corporate employees won’t directly tell a dentist what to do in a given clinical situation, which would be illegal. But they will subtly influence in other ways. I’ve heard of office managers telling dentists that they have to write a narrative to explain why they want to use a certain lab instead of milling the crown on-site. I’ve heard of territory managers publicly rewarding dentists who make certain quotas and chastising dentists who don’t.

How do we stop these practices? There will always be ways for cheaters to cheat the system. But I do believe we can curb this behavior. Quotas should be illegal, plain and simple. Non-dentists should never be allowed to discuss treatment with dentists, either specifically or generally. The ADA recently adopted a “Statement Regarding Employment of a Dentist”  which is a great step towards informing young dentists of their rights. Let’s continue to find ways to educate dentists about being an employee. Good dentists can make bad decisions when put under pressure by their employers. Let’s help remove the gray areas of ethics and give them the confidence to say “NO” when being negatively influenced.


Dr. Davis: Every few weeks, someone from the public approaches me, and advises me they would like to be my patient, but because I’m not participating with their insurance plan, they will seek dental services with a provider on a list given by their employer. Too frequently, these low-end plans attract only the “rogues gallery” of the dental profession. The person next wants me to review the list, and offer suggestions for their family’s dental care. Since I serve on peer–review and provide expert legal case services, I am privy to a great deal of information, much of which is very disturbing for the public interest. My ethics often requires non-disclosure of material not in the public record. Yet, on these “provider lists”, I often recognize doctors who have problems with drugs and/or alcohol. Some are sex perverts. Some, especially with the corporate clinics, play unethical games with consumer bait-and-switch, and high-pressure sales for unnecessary services. Some are only employed with unethical dental clinics for a few months, before they leave that revolving door employment. Thus, I decline to make any recommendations.

I’m certain you’ve faced the same or very similar situations. How can we elevate the public’s understandings, that the dentist providers on some of these “preferred provider” lists are employed at clinics, where the public can be frequently be taken advantage of?

State dental boards are generally doing an inadequate job of weeding out problematic doctors and problematic clinics, as demonstrated in the US Senate joint committee report on corporate dentistry, of July 2013. Civil malpractice cases are settled and sealed in over 95% of cases prior to trial, and little makes it into the public record. Unlike New York State, most states’ dental peer review is strictly voluntary for the doctors, and they retained ADA membership regardless of peer-review participation. Violators seem to have free will, to continue business as usual. For the benefit of the public and the majority of ethical dental practitioners, how can we better clamp down on the “bad apples”? How can the public make reasonable choices, for the health and safety of their family’s dental care?

Dr. Salierno: I think there are unethical and illegal practices made by dentists who are fee-for-service as well. We should be careful not to state that dentists who choose to become “preferred providers” are ipso facto prone to being unethical.

I don’t think the public believes that dentists who participate in plans are actually “preferred” by some altruistic third party insurance company. I think they understand what they’re signing up for or they just don’t care.

The real deceivers out there are the paid services advertising that they carefully screen the dentists in the area to find the best of the best. They advertise that friends and family can’t be trusted for referrals. I think you know exactly the company I’m talking about and they make me sick. They deceive the public into thinking they are providing a service (which they aren’t) and contribute to the degradation of our professional image.

But I digress. I think bad dentists should be disciplined by their peers, before it affects the public. Ethical hearings should be standardized across local and state dental societies. Dental students who exhibit unethical behavior should be reprimanded or even expelled.

But punishment is only part of the strategy; we also need to promote best practices. Let’s reverse the commoditization of oral health. Let’s promote the dentist who’s a positive member of his/her community. The dentist who travels to donate care to those in desperate need. The dentist who is a proud member of professional organizations, which hold their members to a higher standard of ethical conduct. My hope is for the public to be inspired by seeing us at our best, not shocked by seeing us at our worst.


Dr. Davis: Dr. Salierno, I want to thank you for your efforts with this interview. It takes courage to face hardball questions, and generate informative answers. Your works gives me great hope for the future of our dental profession, and the concept of placing the patient’s interest to the fore.

Dr. Salierno: Thank you, Dr. Davis. It was my pleasure.