Joe Ingham explains why some practice owners and associates don’t always agree during their professional relationship.
Imagine the scene: a young associate is sitting on a stool next to their patient who is now comfortably numb following the expert administration of local anaesthetic.
The pleasantries and explanations have taken place, the dental nurse is ready to assist and the patient has opened their mouth.
The associate picks up the air-turbine and before putting bur to tooth s/he presses the pedal to check that (a) the bur rotates and is safely locked in and (b) the water spray is working.
On this occasion neither of the above happens. The handpiece is replaced in its holder before being picked up again and the pedal-pressing routine repeated - not surprisingly with the same result. This time the associate closely inspects the business end of the handpiece, looking just like an actor in an old slapstick movie peering down the end of a hosepipe which resolutely refuses to emit any water. Pressing the foot pedal, this time more in hope than expectation, the bur remains both motionless and dry.
If a cross infection policy ever allowed it, the associate would in all probability scratch their head, and then depress the pedal again! Einstein said that the definition of insanity is to keep on repeating the same action and expecting to get a different result. Whilst the associate's sanity is not in question here, it is probably fair to assume that his or her stress level is rising by the second.
Equipment breakdown
Dentistry is stressful enough when everything goes according to plan and any equipment malfunction has the potential to affect the whole team as well as the patients.
Most equipment breakdowns are thankfully rarely serious or catastrophic. It is worth remembering that common things are likely to occur most commonly. Our colleague in this example might want to consider checking to ensure that the compressor has been switched on and that the slow hand piece hasn't inadvertently been placed in the wrong holder thereby depressing the micro-switch that controls the high-speed handpiece.
Who's responsible?
It is likely that in the associate/practice owner contract there will be a clause stating that the practice owner is responsible for the provision and maintenance of surgery equipment.
In much the same way that a car which has been leased frees the driver from the hassle and expense involved in the event of a breakdown, it would still be incumbent on the driver to ensure that relatively minor maintenance such as ensuring that the tyres are inflated to the correct pressure or that the right sort of fuel is put in the tank.
Realistically, if we use the car analogy again, not every associate's surgery will be fitted out like a brand new sports car with all the latest gadgets and built to the highest specification. In fact, it is more likely that a new associate will be given the smallest surgery with the oldest equipment whilst the practice owner has the most spacious room fitted out with the newest.
This hierarchical system can be found across the business and commercial world and it should come as no surprise that it is also prevalent in the world of general dental practice.
Degrees of responsibility
The onus is on the associate to ensure that simple maintenance of the surgery equipment is performed - for example lubricating the hand pieces. This may well form part of the dental assistant's duties, but once again the associate will have a certain amount of responsibility to ensure that they are actually carrying out the agreed tasks.
The associate's surgery should contain all the essential equipment and materials necessary to provide a reasonable standard of care. Access to a working x-ray machine that meets the prevailing standards would be considered mandatory whereas the provision of an operating microscope may be extending the wish list a little too far.
The longer term
The majority of associates aspire to owning their own practice, in much the same way that most people would like to eventually own their own home rather than live in rented accommodation. Circumstances usually dictate that until such time as one has become established and settled both in a professional sense and also geographically, undertaking such a huge commitment is not feasible.
The period after Foundation Training can provide an invaluable opportunity to learn about the mechanisms of running a general practice. It should be possible to observe at arm's length how to manage employment issues such as persistent lateness, under performance and the like, as well as dealing with equipment issues and deciding whether to effect repairs oneself rather than relying on the more expensive option of a specialist engineer.
The contract
The associate employment model is a working arrangement between two parties which seems exclusive to dental practice. The practice owner and associate have equal professional status - both are after all qualified dentists - but they do not necessarily have an equal business status.
Perhaps the biggest advantage of working under an associate arrangement is the ability to claim self-employed status for taxation purposes. As with most agreements though there is a trade off: a self-employed associate would not be eligible for certain benefits conferred by law to employees such as holiday pay and statutory sick pay. Income tax is a complex area and members should always seek professional advice from an accountant who is familiar with the business of dentistry.
Will it last?
Like many marriages an associate agreement usually begins with the partners hopeful and optimistic about the future in which a long lasting and fruitful relationship is envisaged. However, many such partnerships all too soon come apart and end in acrimony, distrust and financial wrangling. It is important to bear in mind that no matter what professional disputes might be going on, the needs of the patient should always be given priority.
From a patient's perspective, they are largely unconcerned with how their fees are apportioned between those who have contributed to their treatment. It is of no consequence to them how much goes to the practice owner, the laboratory or the associate. When paying for a meal in a restaurant, the consumer is only concerned with the price on the menu and not really interested in how much goes to the waiter, chef, cleaner, restaurant owner or the purchase of the raw materials.
Points of view
"Always try and see things from the other person's perspective". This simple yet in many ways rather profound statement can be found in Dale Carnegie's book How to Win Friends and Influence People. Although first published in the 1930's, many of today's dental associates might consider applying this advice to their relationship with their practice colleagues.
Remember that many dentists consider their practice to be as dear to them as a family member, particularly if they have spent many years investing time, money and emotional energy into developing it as a business. Any criticism coming from a relatively junior and inexperienced colleague is unlikely to be well received unless the process is approached with great tact.
Depending on the seriousness of the deficiencies the associate may have to consider the possibility of moving practices. Each registrant is responsible for their own clinical standards and the General Dental Council is unlikely to accept any shortcomings accompanied by the plea that, 'I only work here, don't blame me'. Like any relationship success depends on the ability of the two parties to get along.
Moving on
The longer an associate remains in post at a particular practice, the more likely it is that s/he will develop a loyal core of regular patients who will consider that individual to be 'their dentist'. Many patients baulk at the idea of seeing someone unfamiliar during a dental appointment. Once they have formed a relationship with someone whom they know and trust, some patients will go to extraordinary lengths to maintain that relationship. Problems often arise when the associate decides to move on.
Patients are autonomous and are not 'owned' by any particular practice or practitioner. They are free to attend any practice of their choosing with the obvious caveat that the practice is accepting new patients. Persuading patients that they are somehow contractually bound to attend a specific practice would be inappropriate however, soliciting patients away from say your old practice to a new one you are setting up may be legally challenged as the goodwill has financial value. Contracts often contain 'binding out' clauses and advice should be take-in reality, if a patient wants to find a particular dentist they have ample opportunity to do so. A popular dentist will find that the good old 'word of mouth' form of advertising is by far the most effective - and cheapest - option in these circumstances!
Finally
Working as an associate can be a useful way for dentists at varying stages of their career to engage in a mutually beneficial relationship. In order to succeed however they need both parties to be open, trustworthy and tolerant of each other's needs.
Joe Ingham works in general practice as well as working as a tutor at the School of Hygiene and Therapy at The Eastman Hosptial, London. He is also a part-time dento-legal adviser for
Dental Protection.