The Trade-offs Inherent in Dental Practice Reentry

Last week I responded to an email from a dentist who practices within my CDA component, the Redwood Empire Dental Society. He/she is an associate employed by a doctor I’ve never met. Her/his boss announced their practice will be reopening May 12. She/he was feeling nervous and unsure about what is the right thing to do.

My reply:
“I’m very sorry you’re facing this dilemma. My opinion is your employer is being unreasonable, unsafe and unethical.
What will ultimately be necessary for safety is largely unknown at this point. For now, we have to rely on our trusted sources: ADA, CDA, & CaDPH.All 3 of these entities strongly recommend delaying routine dental services and limiting current treatment to emergencies. I don’t believe a dentist can be cited for violations, but the ethical boundaries are clear.
In my opinion, safety must always start with the individual doctor… You can’t take care of anyone unless you take care of yourself. I don’t know what your personal financial situation is, but unless you feel compelled to return to a state of productive income, I would communicate to your employer that you have decided that it would be unsafe and unethical for you to do the procedures demanded. Like most dentists, you intend to return to routine care when the PPE listed in the ADA Toolkit is available. This will hopefully occur in the next few weeks.
Good luck and be well!”

I’ll show the specifics of his/her initial communication, but before I do, I’ll state that I think she/he is facing the same dilemma that all dentists in private practice are struggling with: How can I act responsibly within the context of my financial reality?

Last week I was reading a series of social media posts by 2 dentists who are longtime friends. The gist was a moralization that dentists should NOT reopen their practices until “we have the go-ahead from CDA.”

CDA has tremendous credibility and I for one take advice from their experts very seriously. I don’t, however, think that my friends’ shared opinion deals with the realities inherent in the dilemma. First of all, these 2 are long time practice owners in my age cohort (65+). They are strongly branded in Santa Rosa, near the end of their careers, and have hopefully saved well for their retirements. Based upon age alone they are several orders of magnitude more likely to die from COVID-19 than practice owners who are 30 years younger who may be facing large debts from their education and practice procurement.

I could be mistaken, but I don’t think the CDA, ADA, nor Governor Newsom is going to announce that it’s time for dental practices to “go ahead”, partly because dental practices never closed in the first place. Throughout the lockdown dental services have been defined as “essential.” I think the decision to return to routine services will be made by each individual practice owner. Each will weigh the legal imperative of shelter-in-place, the ethical standards created by organized dentistry, and their own economic reality. Each will then choose a time and methodology for their own return.

In my previous blogs I recommended that all dentists assume that adequate PPE will become available in a timely manner. Each should set a tentative date for return to routine services and communicate now with individual staff members to determine if each will be at work on that date. Study carefully the ADA Toolkit, the CDA Back to Practice Resources, and the CA Dept of Public Health “Guidance for Resuming Deferred and Preventive Dental Care.” Implement the steps indicated in a “soft reopening” … A series of team meetings prior to initiating services on patients. If PPE doesn’t appear by the chosen return date, delay as necessary, but remain ready.

The initial communication from the ambivalent doctor:
“Hi Dr Perry,
It was great to watch your webinar this Monday!“
I’m working for ______________ on ________________.
The owner has me scheduled to start next Tuesday.
So far there’s no safety protocol and no staff training despite my numerous requests.
I don’t even know what PPE is in the office. I’m not sure if we have N95 masks. We just had an all doctors meeting where he recommended doing crown preps without water to minimize aerosol production.
After the meeting the owner called me to ask how I feel about going to work.
I stated I don’t feel safe working under the circumstances. He pretty much threatened to report me to the EDD for declining employment.
And if I’m to go to work, but do not do productive procedures, I won’t get paid asI’m 100% paid on production now.
He wants us to do surgical extractions, root canals and crown preps, calling them emergency procedures.
Your advice?
Thank you.

After my reply, this doctor later emailed that he/she gave the boss an ultimatum, and he agreed that he/she will have full control of all clinical decisions. I don’t know the details, but it’s likely the practice’s launch strategy doesn’t line up with my recommendations, nor would it receive the approval of my old friends, but she/he intends to start seeing patients this Tuesday. I have no intention of posting anything on social media about the decision.I

remain confident we’ll be OK! Let’s lead our patients and practices back to health… Let’s do it together!

Call me if you need to talk.
Stay Well,