Private Dentists' Experiences Working in Corporate Dentistry

OPEN RESEARCH

Rationalisation and ‘McDonaldisation’ in dental care: private dentists’ experiences working in corporate dentistry

Alexander C. L. Holden,*1,2 Lee Adam3 and William M. Thomson3

Key points This research highlights how corporatised The implications for patients and dentists of While the values and interests of consumers dentistry has encapsulated the principles increased efciency, predictability, calculability may be well served through the corporatisation of hyper-rationality, or McDonaldisation, in and control, characterised by McDonaldisation, are of dentistry, this should not detract or diminish providing dental healthcare services. considered. the nature of the caring relationship between patients and their dentists.

Abstract Introduction This study examines how dentists experience the corporatisation of dentistry and the impacts of rationalisation. The emergence of corporate dentistry in the early twenty-frst century has introduced greater competition into the dental marketplace. Ritzer’s theory of ‘McDonaldisation’ explores the rationalisation of services through corporatisation and provides an apt framework with which to understand the qualitative insights gathered through this project. Methods Semi-structured interviews and refective journals were used to collect insights from dentists who were working in private practice. Data were then subjected to thematic analysis. Results A total of 20 private dentist participants provided 22 separate interviews and multiple refective accounts. Following analysis, three key themes emerged: 1) opportunities provided by corporate dentistry; 2) balance between professionalism and commercialism in corporate dentistry; and 3) competition between independent and corporate dentistry. Conclusions The participants’ insights demonstrate how Ritzer’s four dimensions of rationalisation – efciency, predictability, calculability and control – have been encapsulated by corporate dentistry in Australia. Corporate interests in Australian dentistry are perceived to improve competition and ofer opportunities for younger and less experienced dentists, but the fndings also suggest that those leading corporate dentistry need to ensure that rationalisation does not diminish the caring relationship between dentists and patients.

Introduction establishment of corporate-owned dental Australia at the time were owned and operated practices was facilitated by a legal precedent by corporate entities.2 Te corporatisation of dentistry has arisen that removed the barrier to non-dentists Dental care in Australia is provided as a phenomenon in many countries during owning practices. In New South Wales predominantly through the private sector, the early years of the twenty-frst century.1 In (NSW), a landmark case in 1996 quashed an with around 85% of care being provided by Australia, the frst corporate dental practice appeal from the (now defunct and superseded) practitioners in community-based private group was founded in 2001, with fve large Dental Board of NSW, determining that the practice.4 Public dental services are provided by corporate groups in operation by 2012.2 Te Board had erred in preventing a corporation the individual state and territory governments, from opening a dental clinic.3 Te Board’s with the local states and territories as well as decision was based partly upon a belief that the Commonwealth (federal) government 1The University of Sydney School of Dentistry, Faculty of Medicine and Health, Australia; 2 Sydney Dental Hospital a health fund opening a dental clinic might providing funding for these services. Eligibility and Oral Health Services, Sydney Local Health District, NSW, cause future hardship to private dentists. Te for public dental care in Australia is means- Australia; 3The University of Otago Faculty of Dentistry, Division of Health Sciences, New Zealand. court held that this consideration, based on tested, with around a third of the public being *Correspondence to: Alexander Holden professional protectionism, was impermissible. eligible to receive care.5 Te capacity of the Email address: [email protected] In the decade since the establishment of the public dental services means that only around Refereed Paper. first incorporated dental practice group, 20% of those eligible may access state-funded Accepted 23 September 2020 data from 2012 suggested that around 6% of care.6 While Australia operates a universal https://doi.org/10.1038/s41415-021-3071-3 the approximately 6,000 dental practices in healthcare scheme called Medicare, most

dentistry and oral healthcare is excluded, was defined as one that is owned (either Methods with only the Child Dental Benefts Schedule wholly or predominantly) by non-dental ofering eligible children dental care in either professionals and that incorporates non- Ethical approval was obtained from the public or private practice settings through this dental management as a core part of the University of Sydney’s Human Research Commonwealth-funded scheme. Te cost of business’s operations. The American Dental Ethics Committee (project: 2019/687). dental care is a major barrier for Australians, Association’s Health Policy Institute has Participants were recruited through a with 23% of adults aged 15 years and above attempted to define different classifications multifaceted strategy of advertising: 1) reporting that cost prevented them from of dental group practices.12 This classification on social media; 2) to the leadership of accepting recommend treatment and 24% is difficult to transport into the Australian the NSW branch of the Australian Dental stating that they would have difculty paying context, given that some American states Association; and 3) to the participants of a a $200 bill for dental treatment.7 have continued prohibition of practice graduate scheme run by a corporate dental The health professions have traditionally ownership by non-dentists. practice group. Only those participants been anti-competitive, both in the sense In endeavouring to understand the context, who held a current clinical role in private of their relationships with the laity and operation and impact of corporate dentistry, practice and who had full licence to practise within the professions themselves. This can Ritzer’s theory of ‘McDonaldisation’ offers dentistry in Australia were included in this be seen in the inaugural codes of ethics of a useful framework. It comprises four study. Participants provided consent to both the American Medical Association8 components: 1) efficiency; 2) predictability; participate and were interviewed using a and the American Dental Association,9 3) calculability; and 4) control.13 These semi-structured interview format which both documents decrying the practice of components of Ritzer’s theory provide allowed for participants to express their professionals competing against each other insight into the phenomenon of ‘hyper- thoughts around core topics of relevance. or engaging in commercially competitive rationality’. Ritzer’s theory used the example The interview questions were developed behaviours. The profession’s desire for of the fast food industry as a grounding with reference to a scoping review of control over the practice of dentistry and example, demonstrating how the principles the tensions between commercial and autonomy of the way they chose to provide of rationalism have been translated into professional obligations in dentistry that we care meant that members were expected other sectors, including healthcare. Ritzer’s conducted before this research.15 Interviews to behave in a courteous fashion towards theory effectively encapsulated how social were conducted by one researcher (ACLH), each other, this professional expectation activity and organisational logics are guided being recorded and transcribed verbatim. stemming from the profession’s enjoyment by the pursuit of hyper-rationality. The Participants were invited to provide written of exclusivity in providing services. The concept of McDonaldisation demonstrates reflections using an online journalling attrition of dentists’ professional monopoly how this hyper-rationality offers producers, platform and were also invited to participate through the deregulation of practice consumers and managers more efficient, in a follow-up interview around one month ownership has disrupted the model of how predictable, calculable and controlled after their initial interview. The textual data private practice dentists operate and work. ways of achieving set objectives in a were explored using thematic analysis as In the UK, the profession supported world characterised by an ever-increasing articulated by Braun and Clarke,16 through lifting restrictions on corporate entities from dynamism.14 a process of iterative coding to reveal owning and operating dental practices.10 There is a lack of research investigating irreducible and linked themes and categories In the Australian context, the Australian the role of corporate dental services within within the data.17 Dental Association Inc. displays a sceptical the Australian oral healthcare context. perspective on the role of corporate-owned The insights provided in this qualitative Results dental practices, noting a tension of purposes examination will help to situate the role in its current position statement that the of corporate dentistry within the context In total, 20 dentists engaged in private dentistry primary responsibility of a corporate owner of dentistry existing as a commercial in diferent practice environments took part in ‘is to maximise the return to shareholders’, endeavour in healthcare provision. In this research. All participants were interviewed, while the primary responsibility of a dentist understanding how corporate practices in with several providing follow-up written ‘is the duty of care to a patient’. The document dentistry have impacted service provision refections and two participating in follow-up goes on to state: ‘There is a potential conflict and the experiences of dentists working in interviews. Te demographic characteristics of interest between the responsibilities of an private practice, we will apply the theory of the participants are summarised in Table 1. employed dentist and corporate owners of of ‘McDonaldisation’ proposed by George To illustrate the definitional challenge dental practices’.11 Ritzer.13 Through applying Ritzer’s work presented by corporate dentistry in the There is a definitional issue with in this research, we will explore how the Australian context, one participant who understanding what constitutes a corporate application of McDonaldisation to oral worked part-time at a particular practice as a dental business and how this is separate healthcare may create what Waring and locum was not sure whether that business was and distinct from a non-corporate dental Bishop14 refer to as ‘irrationalities’, whereby corporate-owned or independent, being aware business. Many independently owned the process of corporatisation and hyper- only that the owner did not work on-site, if practices are strictly corporate businesses rationality may conflict with the essence of indeed they were a dentist. Participants were due to their structure. For the purposes of healthcare provision, and how these possible asked for their perspectives on corporate dental this research, a corporate dental business impacts upon practice might be managed. practices and how these entities ftted within

Table 1 Participant demographic characteristics primarily driven by commercial ideals and principles. Number of Characteristic Participants also suggested that, in some participants instances, corporate dental practices were able Sex to provide more support to clinicians: Male 12 • ‘I think [...] they probably bring some aspects into dentistry that improve patient safety if Female 8 anything around organising things like HR Years since qualifcation (average: 17) a little bit better. Tey do a lot of things well 0–1 1 which I think has a flter through efect into other parts of the profession’ 1–10 6 • ‘Corporates, or well-organised corporates, 11–20 7 will provide better services to the clinicians 21–30 2 to do their work by removing all the hassles of staf management, equipment management, 31–40 4 patient management, I would argue that Type of practice (role) what the corporates are doing [...] is that we are giving the dentists more resources to do Principal/owner 7 Private (independent) a better job and to do more of it’. Self-employed associate 9

Clinical director 1 Balance between professionalism and Corporate commercialism in corporate dentistry Self-employed associate 3 Participants also commented that both Scope of practice independently owned and corporate General dentist 17 dental practices may impose targets on the practitioners who work there; in both groups, Specialist dentist 3 some use targets to measure the productivity Current location of practice in Australia* of dentists and others do not: New South Wales 15 • ‘I have colleagues who have mentioned similar targets being imposed by more private Victoria 3 solo or run dental practices. I don’t think it’s South Australia 1 exclusively a corporate issue. I think it’s one

Queensland 2 that is evident throughout dentistry’ • ‘If you’re an associate dentist, I’ve worked Key: * = one participant practised in multiple states. under some bosses where they’re actually not corporates, these are private owned centres, that do push us and it was a little the wider cultural and professional milieu of now, realistically, there is more job ofers bit uncomfortable for me’. dentistry. Tree themes emerged from this from corporates [...] it depends where you research that related to the role and impact of are of course, location, than from other Participants also addressed their perceptions of corporate bodies in Australian dentistry: practitioners. So it’s a real option for a lot whether corporate dentistry was solely focused 1. Opportunities provided by corporate of students, so we can be as negative as we on making proft, rather than patient care: dentistry want, or we can be supportive’ • ‘So the fallacy seems to say that the corporate 2. Balance between professionalism and • ‘I guess they [corporates] have a place in is only interested in profts because private commercialism in corporate dentistry that they provide jobs for perhaps the less practice is interested in profits too, they 3. Competition between independent and experienced dentists. Tey seem to, I mean wouldn’t do it if there wasn’t something at the corporate dentistry. they say you do very much run a very strict end of the day for the risk and investment’. numbers game in terms of they have a strong Opportunities provided by corporate push towards meeting targets and things, but There was appreciation that profit was an dentistry I guess it’s just like any industry’. important consideration for any practice Many participants acknowledged that owner, whether a corporate or an independent, corporate dental practices ofered opportunities It is noteworthy that this participant classifed and that in itself the making of a proft from to dentists, especially those who were new to dentistry as being ‘just like any industry’, dentistry is not problematic. As discussed the oral health workforce: suggesting that the dental profession may be in earlier themes, it is when the commercial • ‘It’s alright, there is a lot of negativity, but conficted about whether it is a profession aspects of running a practice as a business begin really what’s the point of all that negativity, – driven by professional values – or more to be favoured over providing a professional we just have to move forward [...] right appropriately termed an industry, which is healthcare service. There was acceptance

from all participants that this could happen will fail eventually, ‘cause I think people want • ‘I don’t think they’re all bad but I think they’re in any practice environment. Participants to go in and see the same dentist, or the same bad for the dentists. I think they sort of help who worked in independent private practice face behind the counter, and they want to encourage this feeling of fearmongering which recognised that corporate practices have a have that relationship, regardless of whether should’ve been present with an oversupply, particular niche in Australian dentistry: they live in a city or live in the country, they which is what drives people to want to push • ‘I feel that perhaps the corporates provide want that familiarity’ higher, like, treatment because you feel like slightly more afordable dentistry to a wider • ‘So I think they do get comfort in knowing a corporate’s coming’. number of people’ that it’s a family, that I’m going to be here for • ‘It’s not great for the dentist but I think there 30 years, or you’ve got the same faces there all Tis fear of competition could contribute to are definitely benefits for patients. And the time. I think people get comfort in that, some of the dubious practices described earlier, corporates, despite what we say about the and know that there’s a continuity of care’ whereby dentists found themselves being 100% recall rate, it makes sure that patients • ‘Te practice has always been run as more or pressured to engage in ‘fnding’ treatments and to actually show up regularly and actually do less that personal relationship, which is what increase their acceptance rate for treatments. Tis get their clean and they do ofer incentives’. we were doing, we have a personal relationship. may be one of the negative impacts of perceived So, putting a name on it was the whole idea threats from competition within dentistry. Participants suggested that the bureaucracy that people knew who they were dealing with and management of corporate dental practices and they would be the same people and so Discussion were more problematic than the dentists on. But, you know, that was almost, not who work there, with dentists seeking to necessarily a direct reaction, but a reaction to The study set out to show how private behave professionally and appropriately, the way that more or less corporatisation was practitioners either experienced or perceived but the business itself working outside these going where the dentist becomes more or less the corporatised dental environment in boundaries of professionalism: irrelevant within a brand’. Australia. It has found that the participants • ‘I saw this side of them where they seemed to involved in this research have varying be perfectly happy as a corporation to deceive It is evident from the statements above that perceptions of the corporatisation of dentistry, the public [through false advertising] to dentists are heavily invested in a belief that with practitioners reporting both positive advance their aims. Te dentists inside that patients value continuity of care very highly. and negative perceptions and experiences of were very diferent. I can’t say that I’ve ever However, this may be true only for dental corporate dental entities. In interpreting and met, we’ve certainly seen some of the stuf procedures and treatments that have not lost understanding those observations, it is useful coming out of there that hasn’t been done their therapeutic association. It may be that to apply Ritzer’s McDonaldisation model, with really in good faith, but I’ve never met a patients will happily visit the cheapest or most its four components of McDonaldisation: 1) dentist who wasn’t trying to act professionally convenient provider when seeking services efciency; 2) predictability; 3) calculability; within that group’. that are not linked to health (such as teeth and 4) control.13 whitening) but would take an entirely diferent Competition between independent and approach when considering treatments that Efciency corporate dentistry were essential to health. One participant Te participants noted how corporate bodies One of the challenges for corporates in dentistry suggested that dentists were wrong to assume in dentistry sought efficiency by providing is addressing how patient loyalty to a corporate that loyalty to a particular practitioner was effective supportive services to clinicians in brand may be encouraged over loyalty to a foremost in patients’ minds: order to maximise focus on clinical practice, particular dentist. Independent practices rely • ‘Patients were no longer loyal to an individual supporting prior observations that the drive on this loyalty to practitioners, towards both practitioner. Tey are loyal to availability, for efficiency provides corporates with the associates and practice owners, to sustain the accessibility, afordability [...] So, the choices ability to expand services while cutting costs.18 patient fow of the practice and ensure that are being made by the patient now, not by the The participants specifically referenced how patients attend regularly. Corporate dental practitioner. I think maybe a lot of [dentists] this allowed a greater amount of dentistry to practices must try to mitigate any damage that think that the patients are here for their be provided by practitioners within corporate might be done by having turnover of dentists, beneft, and I think the opposite’. dental practices, suggesting that corporate with patients associating their loyalty to the practices were very focused upon a ‘numbers corporate entity itself. Participants were aware Several participants suggested that their game’. A contradiction of perspectives arose from of this challenge and cited this as a weakness of colleagues disliked corporate business models the participants’ commentaries; some reported the corporate model of dental practice: in dentistry because those threatened the that they perceived corporate dental practices • ‘I think it comes down to the personal viability and sustainability of their own to be primarily concerned with the pursuit of relationship that the dentist has with the businesses: productivity and proft, while others suggested patients, and if you’ve got a corporate model • ‘I guess a lot of the adversity to corporatisation that this was no diferent to the motivations and there seems to be a lot of turnover of dentists is really from independent practices that are considerations of independent, dentist-owned within those models. Now I’m sure there’s afraid of being swept away or having all their practices. Te professional rhetoric that some of exceptions and all, but I would say as a rule, patients taken away from them into preferred the participants displayed, which is evident within you know they churn through quite a lot of provider practices, which is happening at the the earlier discussed position statement from the dentists. And I just see that as something that moment’ Australian Dental Association Inc.,11 asserts that

dentists who own practices have more virtuous relationship, specifcally relating to continuity worked in independent practices.21 O’Selmo intent than corporate businesses which are only of care and patient loyalty. Some of the et al. attribute this diference to the efects of driven by profts. One participant’s example of participants advocated that one of the key rationalism within corporate practices. One of the practitioners within a corporate practice weaknesses of the corporate model in dentistry the concerns about the loss of dentist autonomy working sincerely to provide good care, but being was a perceived lack of value being placed on is how professional obligations may be swept thwarted by the corporate’s culture, illustrates the patient loyalty to practitioners, with corporate away in favour of the business goals and strategy assumptive dichotomy that dentists are solely practices instead seeking loyalty to their brand. of the corporate entity.22 Traditionally, the concerned with professionalism, and corporate Te dichotomy presented by the participants medical professions have been able to avoid businesses with profit and commercialism. between patient loyalty to a particular clinician the increasing bureaucracy of healthcare due Another participant acknowledged the reality and patient loyalty to consumerist ideals also to the high levels of autonomy bestowed upon that all dental businesses, whether corporate or speaks to a professional anxiety relating to a them within health systems.23 However, the independently owned, needed to be cognisant perception of many practitioners that dentistry ‘creeping bureaucratisation of healthcare work’14 of proft. is not a fungible service. Despite this, one has started to address the perception of a lack Efficiency is also concerned with how of the participants did refer to dentistry of political accountability in healthcare, with services might be extended so that a larger as being ‘like any industry’ which would rationalism being used to curb the monopoly proportion of the population might access support the corporate strategy of valuing interests of professionals.24 care. Tis is achievable through lowering the consumer-centric considerations over those cost of services through efciency savings. which assume that all patients fnd intrinsic Irrationalities Participants were of the view that rather than value within personalised, continuity-driven Te irrationalities created by the application of solely competing against the established private, dental care. McDonaldisation to oral healthcare are twofold, professionally owned dental sector, corporate as evidenced within the participants’ narratives. dentistry was able to ofer more afordable Calculability First, the tension between the nature of dentistry care to a demographic of patients who would In Ritzer’s theory, calculability (whereby existing as a profession and as a business needs otherwise be unable to aford routine dentistry accounting and quantitative measurement to be considered. A risk that has been observed in private practice. Participants also suggested become intrinsic features of services) is a with corporatised dentistry is the establishment that corporate dental environments were ideal core element of corporatisation. A key aspect of patients as commodities to the business, for younger and more inexperienced dentists of calculability in hyper-rationality is how with their worth being attributable to their to work in. This could be suggestive of a practitioner activity is closely monitored, ofen value as paying consumers, not as patients who belief that the standard or grade of corporate publicly displayed and may be incentivised.14 may be experiencing dental disease.25 Second, dentistry is expected to be lower and/or that Te participants expressed that calculability was participants alluded to corporate environments corporate practices offer more supportive apparent in both independent and corporate being better suited to less experienced environments for less experienced clinicians. dental practice, and that the behaviours of practitioners, suggesting that the nature of setting targets and placing pressure on dentists the dentistry carried out in these practice Predictability to be productive that are ofen solely associated environments could lead to de-skilling. Tis Considering predictability within Ritzer’s with corporate dentistry also occurred in assertion is consistent with similar observations thesis is oriented towards the standardisation of independent dentist-owned practices. This made by Waring and Bishop.14 Ritzer suggested services, ofen through the use of best practice fnding is unsurprising given that most dental that ‘McDentists’ (from a phraseology coined by and evidence-based guidelines. While the use practices, both corporate and independent, are Ritzer using the prefx ‘Mc’ to denote the impacts of clinical guidelines in dentistry is not habitual funded based on activity, encouraging a focus of McDonaldisation upon that industry) ofered within the professional culture of Australian upon the production of treatments which have simplifed services: ‘McDentists [...] may be dentistry, another component of predictability a payment value associated with them.20 replied on for simple dental procedures, but is the use of common branding and common patients are ill advised to have root canal work experience to create brand afnity and loyalty. Control done by one’.13 Tis assertion may hold truth for Using Ritzer’s key example of a multinational Many of the participants suggested that both corporatised and independently operated fast food restaurant chain, consumers can corporate dental practice was good for services; if a service predominantly focuses access a restaurant anywhere around the patients and the public, but bad for dentists. upon the provision of routine care (exam and globe and experience the service that they Te elements of efciency, predictability and simple cleaning) for the majority of patients, would expect at home. Mottram notes that calculability all feed into control, the fourth then practitioners may become de-skilled the mechanistic, rapid nature of corporatised component of Ritzer’s McDonaldisation theory. in providing more complex care. Tis is not healthcare met patients’ expectations of a Corporatised dental practice, as with any ostensibly an issue with corporatised care, convenient, modern-day health service.19 corporatised model of business, is concerned instead being an indication of a lack of efective Considering how the participants’ viewpoints with hyper-rationality – how costs and expenses utilisation of skill mix in practice with the contribute to the predictability of corporate can be minimised, profits increased and appropriate dental professionals providing care. dental care revealed a tension between consumers enticed. In a 2018 study, O’Selmo The rationalisation of dental care was diametrically opposed beliefs surrounding et al. found that associates within UK corporate acknowledged by many of the participants how corporate practices and independent practice environments reported lower levels as being a beneficial development for the practices view and value the patient-dentist of control and autonomy than those who patient-consumer of oral healthcare. Trough

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